This is a series I’ve been thinking about starting for months. I thought it might be interesting to try and promote regular discussions about mental health. I know I’m biased toward the topic, but it strikes me as something we could all benefit from learning more about. Additionally, the more mental health issues are publicly discussed and explored in a rational manner, the less likely people will be to stigmatize and demean those with mental health concerns. I don’t think any of our regular moose have issues with prejudice against the mentally ill, but it can’t hurt to bring the topic up here. Each installment (written very sporadically I’m sure) will spotlight a different mental health condition. DSM criteria will be provided, and I will give a brief review of current literature. I thought it would be good to start with a lesser-known disorder, so maybe this diary can provide you with some information about a condition with which you are not completely familiar: Intermittent Explosive Disorder. Please hit me with any thoughts you have, and feel free as always to wander off topic. 😉
Intermittent Explosive Disorder (IED) is a condition which is distinguished by seemingly abrupt, unmediated displays of verbal and/or physical aggression. The most salient factor about these episodes of affective (anger-based) aggression is that they are disproportionate to any provocation, real or imagined, that the client may have endured. Violent displays of “temper” are frequently characterized by physical assaults against others or destruction of property. The degree of destructive impulse varies by the individual and the scenario. The aggressive impulse may begin from minutes to hours before the actual “acting out,” and the sufferer may experience a building of tension leading up to an incident. The individual engaged in an “outburst” may experience temporary relief from tension and even brief gratification, but generally finds him- or herself plagued with feelings of shame and remorse following an episode. Some individuals have also reported subsequent feelings of exhaustion in addition to a general deflation of mood. These episodes tend to be brief, typically lasting less than one hour, and may be accompanied by an assortment of physical symptoms, such as heart palpitations, perspiration, chest discomfort, and psychomotor agitation. The condition is more frequently diagnosed in males than females and usually has an age of onset between late childhood and early adulthood. Some studies have found a higher incidence of the disorder in White males as compared with African American, Asian American, and Hispanic American populations.
According to Coccaro et al. (2007), IED confers functional impairment equal to or greater than most other Axis I and Axis II disorders. The high degree of explicit aggression is out of proportion to precipitating stressors, and other mental disorders or physiological effects of a substance or medical condition does not account for the extensive explosive behavior (Koelsch, Sammler, Jentschke, & Siebel, 2008). Recent epidemiological studies further suggested that IED is highly prevalent in the United States population (Coccaro et al., 2005). IED begins as early as childhood, peaks in the teen years, and diminishes in new cases after the age of 30 (Coccaro et al., 2005). Males typically meet the criteria for IED approximately six years earlier than females, which is consistent with other data regarding higher rates of male aggression. (Paone & Douma, p. 33)
The condition is coded on Axis I and belongs to a larger group of impulse control disorders listed in the Diagnostic and Statistical Manual of Mental Disorders Fourth Edition-Text Revision (DSM-IV-TR), the primary diagnostic tool for mental health professionals in the United States. According to Grant and Odlaug, “Impulse control disorders (ICDs) are characterized by the engagement in a rewarding behavior that is difficult to resist even though it may ultimately result in negative consequences. The formal ICDs include pathological gambling, trichotillomania, kleptomania, Intermittent Explosive Disorder, and pyromania” (p. 231). Formal diagnoses are formulated according to the following multi-axial model:
Axis I: Clinical Disorders
Axis II: Personality Disorders and Mental Retardation
Axis III: General Medical Conditions
Axis IV: Psychosocial and environmental stressors potentially related to the disorder
Axis V: Global Assessment of Functioning (GAF), a scale of 1-100 designed to describe the client’s current functioning
The DSM-IV-TR criteria for a diagnosis of Intermittent Explosive Disorder are as follows:
- several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
- the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
- the episodic violence cannot be better accounted for by another mental or physical medical condition.
IED is a highly disruptive disorder, which can prove extremely damaging both to the sufferer and those around him.
Though initially believed to be rare (APA, 2000), recent epidemiological studies indicate the prevalence of IED is about 4-7% (Coccaro, Posternak, & Zimmerman, 2005; Kessler et al., 2006; Ortega, Canino, & Alegria, 2008). Prototypically, IED tends to run a chronic course, lasting on average 12-20 years. Over this time, the IED patients will engage in ~55 acts of physical aggression, several of which require medical attention (Kessler et al., 2006; McElroy, Soutullo, Beckman, Taylor, & Keck, 1998). Not surprisingly, the limited research suggests that IED is associated with considerable social and occupational impairment that can include loss of work, relationship problems, and legal difficulties (McCloskey, Berman, Noblett, & Coccaro, 2006; McElroy et al., 1998). (McCloskey, Berman, Kleabir & Coccaro, 2010, p. 324)
In addition to short-term adverse effects, IED may also pose long-term health risks. Longitudinal studies indicate that high levels of hostility and anger predict the onset of coronary heart disease (CHD); additional studies indicate that these two factors correlate positively with hypertension, stroke, and Type 2 diabetes, and may eventually compromise lung function (McCloskey et al). In a 2010 study relating to IED and adverse health effects, McCloskey and colleagues found that individuals diagnosed with IED were more likely to be current smokers, less likely to never have been regular smokers, more likely to have life-histories of depression, and more likely to have histories of moderate abuse or severe dependence problems with both alcohol and other drugs; the study showed that “IED participants were also more likely to have most kinds of pain including ulcers, neck/back pain, headaches, and other chronic pain” (p. 326-327).
Aggression and even explosive outbursts are indicated in a number of disorders, and IED should not be diagnosed for cases in which displays of anger or aggression are better explained by another condition such as schizophrenia or bipolar disorder. Intermittent Explosive Disorder is sometimes comorbid with other conditions, however, particularly other impulse control disorders and Obsessive-Compulsive Disorder, to which some aspects of IED bear a slight resemblance:
The irresistible and uncontrollable behaviors characteristic of ICDs suggest a similarity to the frequently excessive, unnecessary, and unwanted rituals of obsessive-compulsive disorder (OCD). There are, however some clear differences between ICDs and OCD. For example, people with ICDs may report an urge or craving state prior to engaging in the problematic behavior and a hedonic quality during the performance of the behavior (Grant & Potenza, 2007). Individuals with OCD are also generally harm avoidant with a compulsive risk-aversive end point to their behaviors (Hollander, 1993), whereas individuals with ICDs are generally sensation seeking (Kim & St Grant, 2001). The pleasurable or rewarding aspects of ICDs, as well as the sensation-seeking personality of individuals with ICDs, have necessitated cognitive-behavioral strategies for ICDs that are distinct from those used in OCD. (Grant & Odlaug, p. 232)
The precise causes of IED remain unknown, and the literature is still sparse. The disorder may be related to neurological abnormalities, particularly a dysfunctional prefrontal circuit in individuals with IED. Comparisons have been made between individuals with a diagnosis of Intermittent Explosive Disorder and the neurobiology of patients with specific localized brain lesions to the orbital and medial prefrontal cortex which have been linked with aggressive impulses and behaviors. Though no evidence has been discovered that those with IED are suffering from brain lesions, their behaviors correlate highly with patients with acquired aggression due to neurological damage (Williams & Coccaro, p. 8848).
Research indicates that several treatment options may prove efficacious. Pharmacological interventions have proven effective in some cases. The atypical antipsychotic Clozapine has been used to ameliorate symptoms of mood lability, explosive hostility, and self-mutilation behaviors in patients with IED (Grant & Odlaug, p. 231). Tegretol, an anti-seizure medication, and Inderal, a heart medication that moderates blood pressure, have shown therapeutic value. In children, play therapy is indicated in some instances. In terms of psychotherapy for adults, cognitive-behavioral techniques, including cognitive restructuring, self-inoculation training, relaxation techniques, and multicomponent treatments, seem to be most effective. With the most aggressive individuals, however, psychotherapeutic techniques are less empirically indicated. McCloskey and his associates noted that, while the pool of IED sufferers and aggressive offenders may in some cases overlap, very few diagnosed with Intermittent Explosive Disorder have histories of domestic violence.
. . .[P]sychosocial interventions had only “small” effects on reducing aggression (Babcock, Green, & Robie, 2004). This would suggest that CBT would be of limited efficacy in treating IED. Batterers and individuals diagnosed with IED are similar in that they both engage in repeated acts of aggression. However, only a small portion of individuals diagnosed with IED have a history of domestic violence. Furthermore, for many batterers, aggression is used as a means to gain power and control (Jasinski, 2005; Leone, Johnson, Cohan, & Lloyd, 2004). In contrast, for individuals diagnosed with IED, revenge for a perceived slight or injustice is the motivation for aggression. Patients with IED represent a patient population that is overlapping but still distinct from those used in anger management and domestic violence treatment studies. (McClosky, Deffenbacher, Noblett & Gollan, 2008, p. 877)
Intermittent Explosive Disorder is a debilitating condition which may cause significant distress in the individual and lead to extensive problems in the areas of work, interpersonal relationships, and the legal system. Research on this topic appears highly limited, and the true etiology of the disorder remains unknown. Further investigations into the efficacy of various psychopharmacological and psychotherapeutic interventions are needed to determine more consistent, reliable lines of treatment.
I am not, at this time, bothering to provide an appropriately formatted list of references at the bottom here, partly because I hate writing References pages, and partly because some of these articles are likely only accessible to those of you who can access EBSCOhost. I tried to provide proper parenthetical citation, but I really do suck at citing things and typically resort to asking professors, friends, or websites for help. If, however, anyone is bothered by the lack of a Reference list, let me know in the comments, and I will provide one.
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