Intermittent explosive disorder
Definition:
Intermittent explosive disorder (IED) is a mental disturbance that is characterized by specific episodes of violent and aggressive behavior that may involve harm to others or destruction of property. IED is discussed in the Diagnostic and Statistical Manual of Mental Disorders fourth edition (DSM-IV) under the heading of "Impulse-Control Disorders Not Elsewhere Classified." As such, it is grouped together with kleptomania, pyromania, and pathological gambling.
1) There must be several separate episodes of failure to restrain aggressive impulses that result in serious assaults against others or property destruction.
2) The degree of aggression expressed must be out of proportion to any provocation or other stressor prior to the incidents.
3) The behavior cannot be accounted for by another mental disorder, substance abuse, medication side effects, or such general medical conditions as epilepsy or head injuries.
The reader should note that DSM-IV's classification of IED is not universally accepted. Many psychiatrists do not place intermittent explosive disorder into a separate clinical category but consider it a symptom of other psychiatric and mental disorders. In many cases individuals diagnosed with IED do in fact have a dual psychiatric diagnosis. IED is frequently associated with mood and anxiety disorders, substance abuse and eating disorders, and narcissistic, paranoid, and antisocial personality disorders.
Description:
People diagnosed with IED sometimes describe strong impulses to act aggressively prior to the specific incidents reported to the doctor and/or the police. They may experience racing thoughts or a heightened energy level during the aggressive episode, with fatigue and depression developing shortly afterward. Some report various physical sensations, including tightness in the chest, tingling sensations, tremor, hearing echoes, or a feeling of pressure inside the head.
Many people diagnosed with IED appear to have general problems with anger or other impulsive behaviors between explosive episodes. Some are able to control aggressive impulses without acting on them while others act out in less destructive ways, such as screaming at someone rather than attacking them physically.
Although the editors of DSM-IV stated in 2000 that IED "is apparently rare," a group of researchers in Chicago reported in 2004 that it is more common than previously thought. They estimate that 1.4 million persons in the United States currently meet the criteria for IED, with a total of 10 million meeting the lifetime criteria for the disorder.
With regard to sex and age group, 80% of individuals diagnosed with IED in the United States are adolescent and adult males. Women do experience IED, however, and have reported it as part of premenstrual syndrome (PMS).
Causes and symptoms
Causes:
As with other impulse-control disorders, the cause of IED has not been determined. As of 2004, researchers disagree as to whether it is learned behavior, the result of biochemical or neurological abnormalities, or a combination of factors. Some scientists have reported abnormally low levels of serotonin, a neurotransmitter that affects mood, in the cerebrospinal fluid of some anger-prone persons, but the relationship of this finding to IED is not clear. Similarly, some individuals diagnosed with IED have a medical history that includes migraine headaches, seizures, attention-deficit hyperactivity disorder, or developmental problems of various types, but it is not clear that these cause IED, as most persons with migraines, learning problems, or other neurological disorders do not develop IED.
Some psychiatrists who take a cognitive approach to mental disorders believe that IED results from rigid beliefs and a tendency to misinterpret other people's behavior in accordance with these beliefs. According to Dr. Aaron Beck, a pioneer in the application of cognitive therapy to violence-prone individuals, most people diagnosed with IED believe that other people are basically hostile and untrustworthy, that physical force is the only way to obtain respect from others, and that life in general is a battlefield. Beck also identifies certain characteristic errors in thinking that go along with these beliefs:
Personalizing. The person interprets others' behavior as directed specifically against him.
Selective perception. The person notices only those features of situations or interactions that fit his negative view of the world rather than taking in all available information.
Misinterpreting the motives of others. The person tends to see neutral or even friendly behavior as either malicious or manipulative.
Denial. The person blames others for provoking his violence while denying or minimizing his own role in the fight or other outburst.
Symptoms:
The symptoms of IED are described by the DSM-IV criteria for diagnosing the disorder.
Diagnosis:
The diagnosis of IED is basically a diagnosis of exclusion, which means that the doctor will eliminate such other possibilities as neurological disorders, mood or substance abuse disorders, anxiety syndromes, and personality disorders before deciding that the patient meets the DSM-IV criteria for IED. In addition to taking a history and performing a physical examination to rule out general medical conditions, the doctor may administer one or more psychiatric inventories or screeners to determine whether the person meets the criteria for other mental disorders.
In some cases the doctor may order imaging studies or refer the person to a neurologist to rule out brain tumors, traumatic injuries of the nervous system, epilepsy, or similar physical conditions.
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