Intermittent explosive disorder

Intermittent explosive disorder
Classification and external resources
ICD-9	312.34

Intermittent explosive disorder (abbreviated IED) is a behavioral disorder characterized by extreme expressions of anger, often to the point of violence, that are disproportionate to the situation at hand. It is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders as an impulse control disorder. IED belongs to the larger family of Axis I impulse control disorders listed in the DSM-IV-TR, along with kleptomania, pyromania, pathological gambling, and others.^[1] Impulsive aggression is unpremeditated, and is defined by a disproportionate reaction to any provocation, real or perceived. Some individuals have reported affective changes prior to an outburst (e.g., tension, mood changes, energy changes, etc.).^[2]

A 2006 study suggests that the disorder is considerably more prevalent than previously thought. In a study of almost 10,000 individuals 18 years or older, lifetime episodes were reported at 7.3%, while 12-month occurrences were reported at 3.9%. This suggests a mean lifetime occurrence of 43 instances, with an average of $1359 in property damage.^[3]

A 2005 study conducted in the U.S. State of Rhode Island found the prevalence to be 6.3% (SE, +/- 0.7%) for lifetime DSM-IV IED in a study of 1300 patients under psychiatric evaluation.^[4] Prevalence is higher in men than in women.^[5] The disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder.^[6] Individuals diagnosed with IED report their outbursts were brief (lasting less than an hour), with a variety of bodily symptoms (sweating, chest tightness, twitching, palpitations) reported by a third of one sample. The violent acts were frequently reported accompanied by a sensation of relief, and in some cases, pleasure, but accompanied by remorse after the fact.

Diagnosis

The DSM-IV criteria for IED include: the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property, the degree of aggressiveness expressed during an episode is grossly disproportionate to provocation or precipitating psychosocial stressor, and, as previously stated, diagnosis is made when other mental disorders that may cause violent outbursts (e.g., antisocial personality disorder, borderline personality disorder, attention deficit/hyperactivity disorder, etc.) have been ruled out.^[6] Furthermore, the acts of aggression must not be due to a general medical condition, e.g., a head injury, Alzheimer’s disease, etc., or due to substance abuse or medication.^[6] Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM-IV. 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:

1. several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
2. the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
3. the episodic violence cannot be better accounted for by another mental or physical medical condition.

Treatment

Treatment is achieved through both cognitive behavioral therapy and psychotropic medication regimens, though the pharmaceutical options have shown limited success^[7]. Therapy aids in helping the patient recognize the impulses in hopes of achieving a level of awareness and control of the outbursts, along with treating the emotional stress that accompanies these episodes. Multiple drug regimens are frequently indicated for IED patients. Cognitive Relaxation and Coping Skills Therapy (CRCST) has shown preliminary success in both group and individual settings compared to waitlist control groups^[8]. This therapy focuses consists of 12 sessions, the first three focus relaxation training, then cognitive restructuring, then exposure therapy. The final sessions focus on resisting aggressive impulses and other preventative measures.^[9]

Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) such as fluoxetine, fluvoxamine, and sertraline appear to alleviate some pathopsychological symptoms; the reasons for such will be explained further in the subsequent section.^[2][10] GABAergic mood stabilizers and anticonvulsive drugs such as gabapentin, lithium, carbamazepine, and divalproex seem to aid in controlling the incidence of outbursts.^[2][5][11] Anxiolytics help alleviate tension and may help reduce explosive outbursts by increasing the provocative stimulus tolerance threshold, and are especially indicated in patients with comorbid obsessive-compulsive or other anxiety disorders.^[5]

Impulsive behavior, and especially impulsive violence predisposition has been correlated to a low brain serotonin turnover rate, indicated by a low concentration of 5-Hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF). This substrate appears to act on the suprachiasmatic nucleus in the hypothalamus, which is the target for serotonergic output from the dorsal and median raphe nuclei playing a role in maintaining the circadian rhythm and regulation of blood sugar. A tendency towards low 5-HIAA may be hereditary. A putative hereditary component to low CSF 5-HIAA and concordantly possibly to impulsive violence has been proposed. Other traits that correlate with IED are low vagal tone and increased insulin secretion. A suggested explanation for IED is a polymorphism of the gene for tryptophan hydroxylase, which produces a serotonin precursor; this genotype is found more commonly in individuals with impulsive behavior.^[12]

IED may also be associated with lesions in the prefrontal cortex, with damage to these areas, including the amygdala, increasing the incidence of impulsive and aggressive behavior and the inability to predict the outcomes of an individual's own actions. Lesions in these areas are also associated with improper blood sugar control, leading to decreased brain function in these areas, which are associated with planning and decision making.^[13] A national sample in the United States estimated that 16 million Americans may fit the criteria for IED.^[3]

References

1. ^ Diagnostic and statistical manual of mental disorders: DSM-IV. Washington, DC: American Psychiatric Association. 2000. pp. 663–7. ISBN 0-89042-025-4. 
2. ^ ^{a b c} McElroy SL (1999). "Recognition and treatment of DSM-IV intermittent explosive disorder". J Clin Psychiatry 60 Suppl 15: 12–6. PMID 10418808. 
3. ^ ^{a b} Kessler RC, Coccaro EF, Fava M, Jaeger S, Jin R, Walters E (June 2006). "The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication". Arch. Gen. Psychiatry 63 (6): 669–78. doi:10.1001/archpsyc.63.6.669. PMC 1924721. PMID 16754840. http://archpsyc.ama-assn.org/cgi/content/full/63/6/669. 
4. ^ Coccaro EF, Posternak MA, Zimmerman M (October 2005). "Prevalence and features of intermittent explosive disorder in a clinical setting". J Clin Psychiatry 66 (10): 1221–7. doi:10.4088/JCP.v66n1003. PMID 16259534. http://article.psychiatrist.com/?ContentType=START&ID=10001473. 
5. ^ ^{a b c} Boyd, Mary Ann (2008). Psychiatric nursing: contemporary practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. pp. 820–1. ISBN 0-7817-9169-3. 
6. ^ ^{a b c} McElroy SL, Soutullo CA, Beckman DA, Taylor P, Keck PE (April 1998). "DSM-IV intermittent explosive disorder: a report of 27 cases". J Clin Psychiatry 59 (4): 203–10; quiz 211. doi:10.4088/JCP.v59n0411. PMID 9590677. 
7. ^ McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L, Gollan, J.K., Coccaro, E.F. (2008) Cognitive-Behavioral Therapy for Intermittent Explosive Disorder: A Pilot Randomized Clinical Trial. 76(5), 876-886.
8. ^ McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L, Gollan, J.K., Coccaro, E.F. (2008) Cognitive-Behavioral Therapy for Intermittent Explosive Disorder: A Pilot Randomized Clinical Trial. 76(5), 876-886.
9. ^ McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L, Gollan, J.K., Coccaro, E.F. (2008) Cognitive-Behavioral Therapy for Intermittent Explosive Disorder: A Pilot Randomized Clinical Trial. 76(5), 876-886.
10. ^ Goodman, W. K., Ward, H., Kablinger, A., & Murphy, T. (1997). Fluvoxamine in the Treatment of Obsessive-Compulsive Disorder and Related Conditions. J Clin Psychiatry, 58(suppl 5), 32-49.
11. ^ Bozikas, V., Bascilla, F., Yulis, P., & Savvidou, I. (2001). Gabapentin for Behavioral Dyscontrol with Mental Retardation. Am J Psychiatry, 158(6), 965.
12. ^ Virkkunen M, Goldman D, Nielsen DA, Linnoila M (July 1995). "Low brain serotonin turnover rate (low CSF 5-HIAA) and impulsive violence". J Psychiatry Neurosci 20 (4): 271–5. PMC 1188701. PMID 7544158. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=1188701. 
13. ^ Best M, Williams JM, Coccaro EF (June 2002). "Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggressive disorder". Proc. Natl. Acad. Sci. U.S.A. 99 (12): 8448–53. doi:10.1073/pnas.112604099. PMC 123087. PMID 12034876. http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pmcentrez&artid=123087. 

External links

• University of Minnesota Impulse Control Disorders Clinic