Intermittent Explosive Disorder
What is Intermittent Explosive Disorder?
Intermittent Explosive Disorder is the inability to control violent impulses but it is critical to distinguish this from bouts of bad temper and/or bad behaviour by excluding innumerable other possible causes. Indeed, many researchers and clinicians are reluctant to accept this disorder as a separate entity, given that anger and aggression are extremely common in a wide range of psychiatric conditions.
Official Criteria
The DSM IV-TR is very specific in its definition of Intermittent Explosive Disorder which is defined, essentially, by exclusion of other conditions. The diagnosis requires:
- 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.
Prevalence
Loose application of the term suggests that the disorder is more prevalent than it may be. In the majority of cases where impulsive outbursts of aggression take place, there is also another diagnosis under the DSM-IVTR to which it may be attributed. In fact, under the official criteria, the episode of aggression must be attributed to the other disorder present in the first instance.
Strictly defined, Intermittent Explosive Disorder is quite rare. In fact, in reviewing over 800 possible cases in the preparation of DSM IV, only 17 likely cases were identified (Bradford, et al. 1994).
Manifestation
Individuals with this disorder experience aggressive impulses which they act upon reflexivity and without thought or concern for the situation and find this lack of control distressing. Physiological symptoms such as tingling, buildup of pressure inside the head or chest, or palpitations may accompany the episode. Some individuals report sudden exhaustion or deflated mood after the episode passes.
Individuals usually have a history of problems with relationships, job loss, criminal behaviour, alcohol abuse and injuries resulting from fights and accidents.
Co-morbidity
Chronic aggression is often present in patients with Cluster B Personality Disorders (ie. borderline, antisocial, narcissistic, histrionic). In clinical practice it is often difficult to distinguish Intermittent Explosive Disorder from antisocial or borderline personality characteristics, substance abuse and deliberate violence for some specific end.
Chronic aggression is typical of many patients with Cluster B Personality Disorders and several studies show an overlap with Intermittent Explosive Disorder
Treatment
Early studies suggested that the violent outbursts may be due to minor neurological abnormalities and hence a full neurological and neuropsychological assessment is often suggested. However, discrete organic pathology is usually not identifiable. In recent years, interest has focused on serotonergic and adrenergic neurotransmitter abnormalities in violence-prone individuals.
Treatment of Intermittent Explosive Disorder has traditionally involved psychodynamic behavioural and social therapies have been used but recently serotonergic medications (such as Prozac) have been used as well. The vulnerability of individuals with this disorder to substance abuse needs to be borne in mind when prescribing and monitoring the medications.
Further Reading
Felthous, A. R., Bryant, S.G., Wingerter, C.B., & Barratt, E. (1991). The diagnosis of intermittent explosive disorder in violent men. Bulletin of the American Academy of Psychiatry and Law, 19, 71-79.
Hollander & D. Stein (Eds.) Impulsivity and aggression. (pp.109-136). New York: Wiley.
Monopolis, S. & Lion, J. (1983). Problems in the diagnosis of intermittent explosive disorder. American Journal of Psychiatry, 140, 1200-1202.
Studies Referred to in Text
Bradford, J., Geller, J., Lesieur, H., Rosenthal, R. & Wise, M. (1994). In T.A. Widiger, A.J. Widiger, A.J. Frances, H.A. Pincus, M.B. First, R. Ross & W. Davis (Eds). DSM-IV Sourcebook. Washingston, DC: American Psychiatric Association Press.
Brown, G.L., Goodwin, F.K., Ballenger, J.C., Goyer, P.F., & Major, L.F. (1989). Aggression in humans: Correlates with CSF amine metabolites. Psychiatry Research, 1, 131-139.
Pattison, M. & Kahan, J. (1983). The deliberate self-harm syndrome. American Journal of Psychiatry, 140, 867-872.
Virkkunen, M. (1976). Self-mutilation in antisocial personality (disorder). Acta Psychiatric Scandinavica, 54, 347-352.
Virkkunen, M.,Dejong, J., Bartko, J. & Linnoila, M. (1989). Psychobiological concomitants of history of suicide attempts among violent offenders and impulsive firesetters. Archives of General Psychiatry, 46, 604-606.
Other Resources:
Therapy for Sexual Impulsivity: The Paraphilias and Paraphilia-Related Disorders. Martin Kafka, MD, Psychiatric Times (on-line)
© Stephen Hucker, MB,BS, FRCP(C), FRCPsych 2003,2004,2005
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