Intermittent Explosive Disorder DSM-5 312.34 (F63.81)
DSM-5 Category: Disruptive, Impulse-Control, and Conduct Disorders
Introduction
The DSM-5 defines intermittent explosive disorder as “recurrent behavioral outbursts representing a failure to control aggressive impulses.” (American Psychiatric Association, 2013). Intermittent explosive disorder, which can be diagnosed in children as young as six, is characterized by a wide variety of aggressive outbursts. Intermittent explosive disorder is extremely common, as more than half of youth and young adults have experienced at least one angry outburst. Still, certain populations, such as those who have served in combat, those who have experienced trauma and morbidly obese adults are at increased risk. Intermittent explosive disorder is important to address because a pattern of aggressive behavior can lead to a host of relational and occupational problems. Although many patients resist intervention, cognitive behavioral therapy is an effective treatment for managing anger and learning positive coping skills. Intermittent explosive disorder is considered to be in remission when only one or two symptoms of the disorder persist.
Symptoms of Intermittent Explosive Disorder
According to the DSM_5, intermittent explosive disorder is characterized by impulsive and aggressive outbursts. These outbursts can be in the form of verbal tirades or physical aggression. These outbursts are impulsive, not premeditated and extremely difficult to predict. Additionally, the outbursts happen without trigger or are not proportionate to the preceding trigger or stressor. To qualify for diagnosis, outbursts must occur about twice a week for at least three months (American Psychiatric Association, 2013).
Prevalence of Intermittent Explosive Disorder
In the United States, more than 60% of adolescents have reported at least one angry outburst that resulted in violence, threat of violence, or destruction of property. Of these young people around 8% meet the DSM-5 criteria for intermittent explosive disorder (McLaughlin, et al., 2012). Although the disorder can persist throughout the lifespan, symptoms are most likely to begin in individuals younger than 40. The DSM-5 explains that individuals with a high school education or less are more likely to be diagnosed than more educated adults (American Psychiatric Association, 2013). Little is known about the prevalence of intermittent explosive disorder outside the United States, although it is predicated that individuals from war-torn areas are at increased risk. Many experts believe that because intermittent explosive disorder is understudied, it is also under-diagnosed (McLaughlin, et al, 2012).
Studies have found that intermittent explosive disorder is particularly prevalent among the military population. Engaging in combat requires some level of aggression or hostility to be effective. Combat training places heavy emphasis on aggression, while traits such as fear or compassion can lead or distraction or even death. These traits are necessary in combat, but are maladaptive in the civilian world (Morland, et al., 2012). The prevalence of intermittent explosive disorder is also high among the morbidly obese population. In a study of 100 bariatric surgery candidates, 27% met criteria for an impulse control disorder. 10% of the patients studied met criteria for intermittent explosive disorder (Schmidt, et al., 2012).
Social Consequences of Intermittent Explosive Disorder
The DSM-5 explains that because of the violent and intimidating nature of intermittent explosive disorder, the patient is likely to experience significant impairment in many areas (American Psychiatric Association, 2013). Common behavioral manifestations of intermittent explosive disorder include road rage, domestic violence, child abuse, and property damage. Violent and aggressive behavior creates a sense of distrust among family members and friends. (Morland, et al., 2013). Relationships are likely to suffer. If the outbursts occur at work, the patient may be faced with employment. Additionally, public and private outbursts, particularly those that cause injury or property damage may result in arrest or other legal trouble (American Psychiatric Association, 2013).
Causes and Course of Intermittent Explosive Disorder
Onset of intermittent explosive disorder usually begins around age 12 (McLaughlin, et al., 2012), but can be diagnosed in children as young as six (American Psychiatric Association, 2013). At least 80% of patients diagnosed with experience an explosive episode at least once per year throughout the lifespan (McLaughlin, et al., 2012). Although no direct cause of intermittent explosive disorder has been identified, several studies have linked the disorder to childhood trauma. In addition to being high among those in military service, high rates of intermittent explosive disorder is also found among individuals who has survived abuse, assault, and human rights violations. Refugees and emergency service workers are also at higher risk (Nickerson, et al., 2012). Although alcohol use is not a cause of intermittent explosive disorder, intoxication significantly increases aggressive behavior (Coccaro, 2012).
Comorbidity
Intermittent explosive disorder is most often diagnosed with depressive disorders, substance use disorders and post traumatic stress syndrome. Personality disorders, such as borderline personality disorder and antisocial disorder may also be comorbid with intermittent explosive disorder (American Psychiatric Association, 2013).
Treatment of Intermittent Explosive Disorder
Remission is the treatment goal for intermittent explosive disorder. Remission is achieved when only one or two symptoms persist (Coccaro, 2012). It is often difficult for people diagnosed with intermittent explosive disorder to seek help. Most patients are treated as result of court order or a loved one presenting an ultimatum. Patients usually have poor insight and a tendency to externalize blame. Many see aggressive behavior as a positive thing, supporting their strength as a person. Patients also tend to see the therapist as an enemy. Consequently, therapeutic relationships may be difficult to establish and maintain. Because of this, intermittent explosive disorder is typically treated with medications such as antidepressants or mood stabilizers. Still, when the patient is cooperative, psychotherapy is extremely helpful. The most effective psychotherapy intervention for intermittent explosive disorder is cognitive behavioral therapy that focuses on the direct treatment of anger. This approach is helpful because it addresses the affective, cognitive, and behavioral components of violent outbursts. Patients learn anger management skills, deal with underlying concerns, learn to manage stress, and build positive coping skills (Morland, et al., 2012).
Prognosis
In general, aggressive outbursts tend to decrease as patients age. The average duration of intermittent explosive disorder is between 12 and 20 years. One study of 463 patients found that the average patient experienced 56 aggressive outbursts through the duration of the disorder (Cocarro, 2014).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Coccaro, E.F. (2012) Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. American Journal of Psychiatry. 169:577-588.
McLaughlin, K.A., Green, J. Hwang, I.,Sampson, N.A.,Zaslavsky, A.M & Kessler, R.C. (2012) Intermittent explosive disorder in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry. 69(11): 1131-9
Morland. L.A., Love, A.R, Mackintosh, M.A., Greene, C.J. & Rosen, C.S. (2012). Treating Anger and Aggression in Military Populations: Research Updates and Clinical Implications. Clinical Psychology: Science and Practice, 19 (3): 305-322
Nickerson, A., Aderla, I.M., Hofmann, S.G., & Bryant, R.A. (2012) The relationship between childhood exposure to trauma and intermittent explosive disorder. Psychiatry Research, 197 1-2: 128-134
Schmidt, F., Korber, Stephanie, Zwann, M. & Muller, A. (2012). Impulse control disorders in obese patients. European Eating Disorder Review, 20(3): 144-147
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