intermittent explosive disorder

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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.
A person must meet certain specific criteria to be diagnosed with IED:
  • There must be several separate episodes of failure to restrain aggressive impulses that result in serious assaults against others or property destruction.
  • The degree of aggression expressed must be out of proportion to any provocation or other stressor prior to the incidents.
  • 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.

Treatment

Emergency room treatment

A person brought to a hospital emergency room by family members, police, or other emergency personnel after an explosive episode will be evaluated by a psychiatrist to see whether he can safely be released after any necessary medical treatment. If the patient appears to be a danger to himself or others, he may be committed against his will for further treatment. In terms of legal issues, a doctor is required by law to notify the specific individuals as well as the police if the patient threatens to harm particular persons. In most states, the doctor is also required by law to report suspected abuse of children, the elderly, or other vulnerable family members.
The doctor will perform a thorough medical examination to determine whether the explosive outburst was related to substance abuse, withdrawal from drugs, head trauma, delirium, or other physical conditions. If the patient becomes assaultive inside the hospital, he may be placed in restraints or given a tranquilizer (usually either lorazepam [Ativan] or diazepam [Valium]), most often by injection. In addition to the physical examination, the doctor will obtain as detailed a history as possible from the family members or others who accompanied the patient.

Medications

Medications that have been shown to be beneficial in treating IED in nonemergency situations include lithium, carbamazepine (Tegretol), propranolol (Inderal), and such selective serotonin reuptake inhibitors as fluoxetine (Prozac) and sertraline (Zoloft). Adolescents diagnosed with IED have been reported to respond well to clozapine (Clozaril), a drug normally used to treat schizophrenia and other psychotic disorders.

Psychotherapy

Some persons with IED benefit from cognitive therapy in addition to medications, particularly if they are concerned about the impact of their disorder on their education, employment, or interpersonal relationships. Psychoanalytic approaches are not useful in treating IED.

Prognosis

The prognosis of IED depends on several factors that include the individual's socioeconomic status, the stability of his or her family, the values of the surrounding neighborhood, and his or her motivation to change. One reason why the Chicago researchers think that IED is more common than previously thought is that most people who meet the criteria for the disorder do not seek help for the problems in their lives that result from it. The researchers found that although 88% of the 253 individuals with IED that they studied were upset by the results of their explosive outbursts, only 13% had ever asked for treatment in dealing with it.

Prevention

Since the cause(s) of IED are not fully understood as of the early 2000s, preventive strategies should focus on treatment of young children (particularly boys) who may be at risk for IED before they enter adolescence.

Resources

Books

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 4th ed., revised. Washington, D.C.: American Psychiatric Association, 2000.
Beck, Aaron T., MD. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins Publishers, 1999.
Beers, Mark H., MD., and Robert Berkow, MD, editors. "Psychiatric Emergencies." Section 15, Chapter 194. In The Merck Manual of Diagnosis and Therapy. Whitehouse Station, NJ: Merck Research Laboratories, 2004.

Periodicals

Citrome, Leslie L., MD, MPH, and Jan Volavka, MD. "Aggression." eMedicine. February 8, 2002. http://www.emedicine.com/Med/topic3005.htm.
Coccaro, E. F., C. A. Schmidt, J. F. Samuels, and G. Nestadt. "Lifetime and 1-Month Prevalence Rates of Intermittent Explosive Disorder in a Community Sample." Journal of Clinical Psychiatry 65 (June 2004): 820-824.
Grant, J. E., and M. N. Potenza. "Impulse Control Disorders: Clinical Characteristics and Pharmacological Management." Annals of Clinical Psychiatry 16 (January-March 2004): 27-34.
Kant, R., R. Chalansani, K. N. Chengappa, and M. F. Dieringer. "The Off-Label Use of Clozapine in Adolescents with Bipolar Disorder, Intermittent Explosive Disorder, or Posttraumatic Stress Disorder." Journal of Child and Adolescent Psychopharmacology 14 (Spring 2004): 57-63.
McElroy, Susan L. "Recognition and Treatment of DSMIV Intermittent Explosive Disorder." Journal of Clinical Psychiatry (1999): 12-16.

Organizations

American Academy of Child and Adolescent Psychiatry. 3615 Wisconsin Avenue, NW, Washington, DC 20016-3007. (202) 966-7300. Fax: (202) 966-2891. http://www.aacap.org.
American Psychiatric Association. 1400 K Street, NW, Washington, DC 20005. http://www.psych.org.
National Institute of Mental Health. 6001 Executive Boulevard, Room 8184, MSC 9663, Bethesda, MD 20892-9663. (301) 443-4513. http://www.nimh.nih.gov.

Other

Padgitt, Steven T. "Treating Intermittent Explosive Disorder with Neurofeedback" Behavenet.com. May 7, 2001. http://www.behavenet.com/capsules/disorders/explosivedis.htm.

Key terms

Cognitive therapy — A form of short-term psychotherapy that focuses on changing people's patterns of emotional reaction by correcting distorted patterns of thinking and perception.
Delirium — An acute but temporary disturbance of consciousness marked by confusion, difficulty paying attention, delusions, hallucinations, or restlessness. Delirium may be caused by drug intoxication, high fever related to infection, head trauma, brain tumors, kidney or liver failure, or various metabolic disturbances.
Kleptomania — A mental disorder characterized by impulsive stealing.
Neurotransmitter — Any of a group of chemicals that transmit nerve impulses across the gap (synapse) between two nerve cells.
Pyromania — A mental disorder characterized by setting fires.
Serotonin — A neurotransmitter or brain chemical that is responsible for transporting nerve impulses.

intermittent

 [in″ter-mit´ent]
marked by alternating periods of activity and inactivity.
intermittent claudication a group of symptoms characterized by pain, cramping, and weakness in the calf muscles of one or both lower limbs, brought on by walking and relieved by resting for a few minutes. It is a form of arterial occlusive disease and is caused by atherosclerotic lesions of the limbs, which diminish blood supply to the muscles of the lower leg. Called also angina cruris.

Treatment has traditionally involved vascular reconstructive surgery to bypass the diseased portion of the vessel. Modification of risk factors has also proved beneficial, such as smoking cessation, weight loss, and introduction of a graduated program of walking and exercise.
intermittent explosive disorder a rare impulse control disorder in which a periodic loss of control of aggressive impulses results in serious assault or destruction of property; the outbursts are totally out of proportion to any apparent stress.
intermittent positive pressure breathing (IPPB) a form of respiratory therapy using a ventilator for the treatment of selected patients with atelectasis, those needing occasional assistance breathing, or those requiring some types of aerosol medications. As the name implies, this involves application of pressure only during the inspiratory phase, in order to help the patient breathe more deeply. It is used when other less expensive, less invasive forms of respiratory care have not been effective. Called also intermittent positive pressure ventilation.

Because of their compact size and capability of operating independently of an electrical current, IPPB machines are used widely. Similar treatment can also be delivered with a volume-, pressure-, or time-limited ventilator or manual resuscitation device. The American Association for Respiratory Care has published detailed and comprehensive clinical practice guidelines for the use of intermittent positive pressure breathing, which are available online at http://www.rcjournal.com/online_resources/cpgs/ippbcpg.hotmail.

in·ter·mit·tent ex·plo·sive dis·or·der

1. a disorder that may begin in early childhood, or following head injury at any age, characterized by repeated acts of violent, aggressive behavior in otherwise normal persons that is markedly out of proportion to the event that provokes it.
2. a DSM diagnosis that is established when the specified criteria are met.

intermittent explosive disorder

a mental disturbance beginning in childhood and characterized by discrete episodes of violence and aggressive behavior or destruction of property in otherwise normal individuals. The acts may occur as an overreaction to an ordinarily minor event.
A disorder of impulse control, which is characterised by abrupt ‘detonations’ of negative emotive forces—anger, snarling, snapping and/or violence—in response to seemingly mild external stimuli

in·ter·mit·tent ex·plo·sive dis·or·der

(in'tĕr-mit'ĕnt eks-plō'siv dis-ōr'dĕr)
An uncommon disorder that begins in early childhood, characterized by repeated acts of violent, aggressive behavior in otherwise normal people that is markedly out of proportion to the event that provokes it.

in·ter·mit·tent ex·plo·sive dis·or·der

(in'tĕr-mit'ĕnt eks-plō'siv dis-ōr'dĕr)
Disorder that may begin in early childhood, or following head injury at any age, characterized by repeated acts of violent, aggressive behavior in otherwise normal people.