Intermittent Explosive Disorder
Definition
The DSM-IV-TR (2002) lists Intermittent Explosive Disorder (IED), which is “discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.” IED individuals are apt to explode “with little or no provocation”.
Description
A person with an IED diagnosis behaves disproportionately violently and aggressively in situations where such actions are considered extreme; his behavior is inconsistent with the degree or severity of the stressor or situation. The episodes or assaultive attacks include, but are not limited to: striking someone or battery, throwing something or most any action to inflict harm to someone. This attack may come in another form, verbal assault or actively threatening to harm the individual. The severe intentional destruction of any property as a result of the urge is a criterion for the disorder, accidental or minor damage is not considered a key component here (DSM-IV-TR, 2002). This disorder is separated because it can not be classified by any other disorder or linked by any other specific cause. This disorder should only be diagnosed when all other disorders have been omitted as the cause of the aggressive behavior and all other possible contributing factors have been eliminated, e.g.: drug abuse, medical substances, head trauma or disease, etc. Also the acts of aggression associated with IED are separated from purposeful or premeditated behavior to harm someone by the omission of any specific gain, the lack of motivation for such behaviors, and the ultimate inability to maintain control of them (DSM-IV-TR, 2002). The environmental factors or stressors that trigger the attacks are distinguishably different per individual, one person may be set off by regular activity by a person and another may be set off by stresses in their daily life or nothing at all. The Gale encyclopedia (2001) provides that regularly IED performances begin to show in adolescence and gradually worsen as the individual progresses into adulthood. It is also noted that more men than women are given the IED diagnosis, but women are more apt to report it coinciding with cycles of premenstrual syndrome (PMS) (Gale Encyclopedia, 2001 & McElroy, 1999).
Causes and Symptoms
An actual direct cause of IED is still undetermined and more research needs to be conducted to better define the mechanisms involved. However, psychologists have found some associated factors, e.g., Head trauma or other disorders. A causational link between IED and prenatal dysfunction and exposure to aggressive behavior as a child has been noted by Dr. Coccaro (2002). Gale encyclopedia (2001) also suggests that IED may have a genetic basis. Dr. Coccaro (2002) also provides evidence that the disorder has a genetic foundation.
These episodes of violence are commonly preceded by heightened senses (inability to focus on anything but the “provoking” event, staring, single auditory focuses), arousal, extreme aggravation, and tension. The aggressive behavior provides relief from these sensations, but is usually followed by embarrassment and greater upset because, of inability to control their anger, remorse for harming the person or destroying their property, depression and many other negative feelings (DSM-IV-TR, 2002). Though many experience such regretful feelings, it has not aided in preventing episodes in the future (McElroy, 1999). McElroy (1998) and associates completed a study of twenty-three IED subjects and of these many expressed minor psychosocial stressors precipitated the episodes and some occurred without any specified stressor. Many of these same subjects reported episodes in which they had attempted murder, committed aggravated assault, actual homicide, or violent suicide (Gale, 2001 & McElroy, SL., Soutullo CA., Beckman DA., et. Al., 1998). All of McElroy’s patients claimed that episodes averaged approximately twenty-two minutes in length and monthly occurrences range between nine and fourteen episodes. Other bodily sensations reportedly associated with the episodes are: head pressure, possible loss of awareness, numbness, heart rate fluctuations, and differential hearing. Many IED patients maintain that the attacks also include changes in energy levels (highs and lows), mood changes (depression, irritability and anxiety), and a sense of “flight of thoughts”; all of which are symptoms that point towards a specific type of manic episode (McElroy, 1999).
Diagnosis
The DSM-IV claims this disorder to be rare but, is it really? Though the DSM-IV lists IED as rare, perhaps it is more common than not and is a valid explanation for many violent behaviors (McElroy, 1999). Differential diagnosis may be partly contributed to by the change in the definition or focus through the years by the DSM itself. The changing definition and definition focus has hindered past test results on IED as well. For example Coccaro (2002) states some problems in the current revision of the DSM-IV-TR, are that the “type of aggression” is not defined, the frequency of behavior is not specified, and distress is not required. Presumably differences of interpretation of the definition and vagueness both play a role in the frequency of diagnoses and the consideration of prior diagnoses (Olvera, 2002).
Some mental health professionals do not believe that IED is a separate entity and that it is just an underlying factor for another disorder, disease, or a common pathway for numerous disorders; e.g. Alzheimer’s disease, borderline personality disorder, bi-polar, etc. (Gale, 2001, McElroy, 1999). Other problems arise about the idea and definition of an “irresistible impulse” and the debilitating inability to maintain control of one’s self (McElroy, 1999). A problem with recognizing the disorder as more common is that it would allow for many more people to escape responsibility for their actions, by claiming an IED diagnosis (McElroy, 1999). That statement leads us to another problem within itself, accepting the disorder and trying to treat the individual in the early stages would be very difficult for a society that has a largely punitive agenda. People that act violently would have to be viewed as suffering from a disorder and treated, not just sent to prison or jailed without the offer for treatment of their disorder.
On the other hand, indifferent to how it is defined, if one were to accept that IED is more common and tried to properly treat these individuals, it could aid in reducing future episodes and prevent other violent crimes. Though not all violent offenders would show favorable results, many individuals would benefit from learning to properly handle such stressors and with the aid of medication prevent future attacks (Gale, 2001). With a proper (and/ or early) diagnosis and given the appropriate therapy and effective medications the prognosis for IED is good (Gale, 2001). If such tactics were employed, the possible benefits that a reduction in violent behaviors would have on violent crime rates might be helpful.
Treatment and Prognosis
Evidence in reducing aggression and the causes of impulsive or explosive behaviors has provided a persuasive alternative to the cause and course of treatment of some violent offenders. For example neurobiological studies of aggression suggest numerous neurotransmitters are involved, but one of the most consistent results implies a malfunction in central serotonin system functioning. In particular low CSF levels of 5- hydroxyindoleacetic acid (5-HIAA), a key serotonin metabolite, are reported to play a significant role in controlling violent/aggressive behaviors in patients. (Linnoila M, Virkkunen, George T, Higley D, 1993, McElroy, 1999, Olvera, 2002, Gale, 2001, Skodol,1999).
Anatomical evidence suggests that irregularity especially in the prefrontal cortex and amygdale are associated with impulsive aggression. (Davidson RJ., Putnam KM., Larson JL., 2000, Olvera, 2002, Best M., Williams M., Coccaro, E, 2002). Best (2002) and associates report that from three different tests administered each measuring different skills, showed significant differences in patients with IED and persons without. These subjects with IED show a deficiency, resembling patients that suffer from some type of prefrontal cortex injury or dysfunction on cognitive tests. Of these differences the study of twenty-seven patients showed: IED persons had difficulty in decision making that avoided high punishment activities and their ability to deal with daily situations involving problem solving skills is inclined to violence or inappropriate behavior that has negative results. IED persons also show impairment in properly recognizing facial expressions pertaining to anger and disgust; they are prone to identify negative emotions in impartial situations: thus persons with IED are easy to provoke into confrontational situations. The olfactory test was the most crucial piece in relating the prefrontal cortex correlation in the disorder, because it utilizes the same portion of the brain that seems to be affected in IED persons (Best, M., Williams, M., Coccaro, E. 2002).
Olvera (2002) states that studies of various medications have provided several alternatives, mainly reducing violence in persons suffering from various forms of impulse control disorders. Mood stabilizers such as lithium, valproate semi-sodium, and carbamazepine have shown to reduce aggression. Phenytoin on a steady schedule has also proven effective and has provided several improvements in other areas of mood status. Selective serotonin reuptake inhibitors, b-Blockers, and atypical antipsychotic drugs have proven useful as well in reducing aggressive behaviors. A2-Agonists and Antipsychotic drugs have also been tried but, are limited by the damaging effects associated with use of these drugs (Olvera, 2002, McElroy, 1999, Coccaro, 2002). Therapy has also provided an outlet for treatment in individuals diagnosed with IED. McElroy documented that patients with IED attending “insight-oriented psychotherapy” or behavior therapy reported these types of therapy as being helpful in controlling aggressive behaviors however, those patients in group, family, or couple therapy did not (McElroy SL., Soutullo CA., Beckman DA., et. Al., 1998).
Though there is suggestive evidence of potential treatment capabilities, there is no known treatment to completely cure IED (Skodol, 1999).
Prevention
There is no founded detectable cause, thus no way to provide preventive treatment, until the diagnosis has been given.
Intermittent explosive disorder (IED) could be a disorder that causes more crime than we realize. If this notion were applied the questions then would be; how many crimes can be attributed to IED and what treatment options are there for violent offenders for violent crime prevention purposes? Steps should be taken to further investigate a disorder with such potentially harmful features and for the better of society overall. There is no harm in trying to treat violent persons, but there is perpetual harm in allowing behaviors to go unattended and untreated.
References:
American Psychiatric Association. (2002). Diagnostic and Statistical Manual of Mental Disorders (4th ed.). Washington, D.C.: Author.
Best, M., Williams, M., Coccaro, E. (2002). Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggression disorder. Proceedings of the National Academy of Sciences, 99 (12), 8445-8453. (As cited in Crime Times, 2002).
Best, M., Williams, M., Coccaro, E. (2002). Linking brain dysfunction to disordered /criminal/psychopathic behavior. Crime Times, 8, 1&6. www.Crime-Times.org.
Coccaro, Emil. (2002). The biology and treatment of IED; violence and its prevention. University of Chicago. www.psychiatry.uchicago.edu/grounds/
Davidson RJ, Putnam KM, Larson JL. (2002). Dysfunction in the neural circuitry of emotional regulation-a possible prelude to violence. Science, 289, 591-594.
Linnoila M.; Virkkunen, George T; Higley, D. (1993). Impulse control disorders. International Clinical Psychopharmacology, 8, 53-56.
Longe, Jacqueline L. (Ed.). (2001). The Gale Encyclopedia of Medicine (2nd. ed.). Farmington Hills, MI. Gale Group, 2001.
McElroy, Susan L. (1999). Recognition and treatment of DSM-IV intermittent explosive disorder. Journal of Clinical Psychiatry (Monograph Series), 60, 12-16.
McElroy SL, Soutullo CA, Beckman DA, et. Al. (1998). DSM-IV intermittent explosive disorder: a report of 27 cases. Journal of Clinical Psychiatry, 59, 203-210.
Olvera, Rene L. (2002). Intermittent explosive disorder: Epidemiology, diagnosis and management. (University of TX Health Science Center) CNS Drugs, 16, 517-526.
Skodol, Andrew E. (Ed.). (1999). Violence: Psychology and violent crime. (Review of Psychiatry Series 17). American Psychiatric Press. Washington, DC.
