Intermittent explosive disorder
312.34 Intermittent Explosive Disorder
Diagnostic Features
The essential feature of Intermittent Explosive Disorder is the occurrence of discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property (Criterion A). Examples of serious assaultive acts include striking or otherwise hurting another person or verbally threatening to physically assault another individual. Destruction of property entails purposeful breaking of an object of value; minor or unintentional damage is not of sufficient severity to meet this criterion. The degree of aggressiveness expressed during an episode is grossly out of proportion to any provocation or precipitating psychosocial stressor (Criterion B). A diagnosis of Intermittent Explosive Disorder is made only after other mental disorders that might account for episodes of aggressive behavior have been ruled out (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) (Criterion C). The aggressive episodes are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease) (Criterion C). The individual may describe the aggressive episodes as "spells" or "attacks" in which the explosive behavior is preceded by a sense of tension or arousal and is followed immediately by a sense of relief. Later the individual may feel upset, remorseful, regretful, or embarrassed about the aggressive behavior.
Associated Features and Disorders
Associated descriptive features and mental disorders.
Individuals with Intermittent Explosive Disorder sometimes describe intense impulses to be aggressive prior to their aggressive acts. Explosive episodes may be associated with affective symptoms (irritability or rage, increased energy, racing thoughts) during the aggressive impulses and acts, and rapid onset of depressed mood and fatigue after the acts. Some individuals may also report that their aggressive episodes are often preceded or accompanied by symptoms such as tingling, tremor, palpitations, chest tightness, head pressure, or hearing an echo. Individuals may describe their aggressive impulses as extremely distressing. The disorder may result in job loss, school suspension, divorce, difficulties with interpersonal relationships or other impairment in social or occupational spheres, accidents (e.g., in vehicles), hospitalization (e.g., because of injuries incurred in fights or accidents), financial problems, incarcerations, or other legal problems.
Signs of generalized impulsivity or aggressiveness may be present between explosive episodes. Individuals with Intermittent Explosive Disorder may report problems with chronic anger and frequent "subthreshold" episodes, in which they experience aggressive impulses but either manage to resist acting on them or engage in less destructive aggressive behaviors (e.g., screaming, punching a wall without damaging it).
Individuals with narcissistic, obsessive, paranoid, or schizoid traits may be especially prone to having explosive outbursts of anger when under stress. Preliminary data suggest that Mood Disorders, Anxiety Disorders, Eating Disorders, Substance Use Disorders, and other Impulse-Control Disorders may be associated with Intermittent Explosive Disorder. Childhood histories may show severe temper tantrums, impaired attention, hyperactivity, and other behavioral difficulties, such as stealing and fire setting.
Associated laboratory findings.
There may be nonspecific EEG findings (e.g., slowing) or evidence of abnormalities on neuropsychological testing (e.g., difficulty with letter reversal). Signs of altered serotonin metabolism (e.g., low mean 5-hydroxyindoleacetic acid [5-HIAA] concentrations) have been found in the cerebrospinal fluid of some impulsive and temper-prone individuals, but the specific relationship of these findings to Intermittent Explosive Disorder is unclear.
Associated physical examination findings and general medical conditions.
There may be nonspecific or "soft" findings on neurological examinations (e.g., reflex asymmetries or mirror movements). Developmental difficulties indicative of cerebral dysfunction may be present (e.g., delayed speech or poor coordination). A history of neurological conditions (e.g., migraine headaches, head injury, episodes of unconsciousness, or febrile seizures in childhood) may be present. However, if the clinician judges that the aggressive behavior is a consequence of the direct physiological effects of a diagnosable general medical condition, the appropriate Mental Disorder Due to a General Medical Condition should be diagnosed instead (e.g., Personality Change Due to Head Trauma, Aggressive Type; Dementia of the Alzheimer's Type, Early Onset, Uncomplicated, With Behavioral Disturbance).
Specific Culture and Gender Features
Amok is characterized by an episode of acute, unrestrained violent behavior for which the person claims amnesia. Although traditionally seen in southeastern Asian countries, cases of amok have been reported in Canada and the United States. Unlike Intermittent Explosive Disorder, amok typically occurs as a single episode rather than as a pattern of aggressive behavior and is often associated with prominent dissociative features. Episodic violent behavior is more common in males than in females.
Prevalence
Reliable information is lacking, but Intermittent Explosive Disorder is apparently rare.
Course
Limited data are available on the age at onset of Intermittent Explosive Disorder, but it appears to be from childhood to the early 20s. Mode of onset may be abrupt and without a prodromal period. The course of Intermittent Explosive Disorder is variable, with the disorder having a chronic course in some individuals and a more episodic course in other individuals.
Familial Pattern
Mood Disorders, Substance Use Disorders, Intermittent Explosive Disorder, and other Impulse-Control Disorders may be more common among the first-degree relatives of individuals with Intermittent Explosive Disorder than among the general population.
Differential Diagnosis
Aggressive behavior can occur in the context of many other mental disorders. A diagnosis of Intermittent Explosive Disorder should be considered only after all other disorders that are associated with aggressive impulses or behavior have been ruled out. If the aggressive behavior occurs exclusively during the course of a delirium, a diagnosis of Intermittent Explosive Disorder is not given. Similarly, when the behavior develops as part of a dementia, a diagnosis of Intermittent Explosive Disorder is not made and the appropriate diagnosis is dementia with the specifier With Behavioral Disturbance. Intermittent Explosive Disorder should be distinguished from Personality Change Due to a General Medical Condition, Aggressive Type, which is diagnosed when the pattern of aggressive episodes is judged to be due to the direct physiological effects of a diagnosable general medical condition (e.g., an individual who has suffered brain injury from an automobile accident and subsequently manifests a change in personality characterized by aggressive outbursts). In rare cases, episodic violence may occur in individuals with epilepsy, especially of frontal and temporal origin (partial complex epilepsy).
A careful history and a thorough neurological evaluation are helpful in making the determination. Note that nonspecific abnormalities on neurological examination (e.g., "soft signs") and nonspecific EEG changes are compatible with a diagnosis of Intermittent Explosive Disorder and only preempt the diagnosis if they are indicative of a diagnosable general medical condition.
Aggressive outbursts may also occur in association with Substance Intoxication or Substance Withdrawal, particularly associated with alcohol, phencyclidine, cocaine and other stimulants, barbiturates, and inhalants. The clinician should inquire carefully about the nature and extent of substance use, and a blood or urine drug screen may be informative.
Intermittent Explosive Disorder should be distinguished from the aggressive or erratic behavior that can occur in Oppositional Defiant Disorder, Conduct Disorder, Antisocial Personality Disorder, Borderline Personality Disorder, a Manic Episode, and Schizophrenia. If the aggressive behavior is better accounted for as a diagnostic or associated feature of another mental disorder, a separate diagnosis of Intermittent Explosive Disorder is not given. However, impulsive aggression in individuals with Antisocial Personality Disorder and Borderline Personality Disorder can have specific clinical relevance, in which case both diagnoses may be made. For example, if an individual with an established diagnosis of Borderline Personality Disorder develops discrete episodes of failure to resist aggressive impulses resulting in serious physical or verbal assaultive acts or destruction of property, an additional diagnosis of Intermittent Explosive Disorder may be warranted.
"Anger attacks"-sudden spells of anger associated with autonomic arousal (tachycardia, sweating, flushing) and feelings of being out of control-have been described in individuals with Major Depressive Disorder and Panic Disorder. If these attacks occur only in the setting of a Major Depressive Episode or a Panic Attack, they should not count toward a diagnosis of Intermittent Explosive Disorder. However, if these anger attacks also occur at times other than during Major Depressive Episodes or Panic Attacks, and meet the Intermittent Explosive Disorder criterion for serious assaultive acts, then both diagnoses may be given.
Aggressive behavior may, of course, occur when no mental disorder is present. Purposeful behavior is distinguished from Intermittent Explosive Disorder by the presence of motivation and gain in the aggressive act. In forensic settings, individuals may malinger Intermittent Explosive Disorder to avoid responsibility for their behavior. Anger as a normal reaction to specific life events or environmental situations also needs to be distinguished from the anger that may occur as part of an aggressive episode in Intermittent Explosive Disorder, which occurs with little or no provocation.
Diagnostic criteria for 312.34 Intermittent Explosive Disorder
- Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.
- The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.
- The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease).