coccaro hiaa ied operationalized comorbid fluvoxamine dsm anxiolytics 10.4088 gondii nondestructive toxoplasma gabapentin psychogenic outbursts comorbidity fluoxetine csf bromet aggressiveness prevalences tamam gollan premeditated 9169 concordantly 8448 impulsive assaultive jcp
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Intermittent explosive disorder - wikipedia Intermittent explosive disorder <Th_colspan="2"> Intermittent explosive disorder <Th_colspan="2"> Classification and external resources Specialty Psychiatry ICD - 10 F63. 8 ICD - 9 - CM 312.34 <Td_colspan="2"> ( edit on Wikidata ) Intermittent explosive disorder ( sometimes abbreviated as IED ) is a behavioral disorder characterized by explosive outbursts of anger and violence , often to the point of rage , that are disproportionate to the situation at hand ( e.g. , impulsive screaming triggered by relatively inconsequential events ) . Impulsive aggression is not premeditated , and is defined by a disproportionate reaction to any provocation , real or perceived . Some individuals have reported affective changes prior to an outburst ( e.g. , tension , mood changes , energy changes , etc . ) . The disorder is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders ( DSM - 5 ) under the `` Disruptive , Impulse - Control , and Conduct Disorders '' category . The disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders , particularly bipolar disorder . Individuals diagnosed with IED report their outbursts as being brief ( lasting less than an hour ) , with a variety of bodily symptoms ( sweating , stuttering , chest tightness , twitching , palpitations ) reported by a third of one sample . Aggressive acts are frequently reported accompanied by a sensation of relief and in some cases pleasure , but often followed by later remorse . Contents 1 Diagnosis 1.1 DSM - 5 diagnosis 1.2 DSM - IV diagnosis 1.3 Differential diagnosis 2 Treatment 3 Pathophysiology 4 Epidemiology 5 History 6 See also 7 References 8 External links Diagnosis ( edit ) DSM - 5 diagnosis ( edit ) The current DSM - 5 criteria for Intermittent Explosive Disorder include : Recurrent outbursts that demonstrate an inability to control impulses , including either of the following : Verbal aggression ( tantrums , verbal arguments or fights ) or physical aggression that occurs twice in a week - long period for at least three months and does not lead to destruction of property or physical injury ( Criterion A1 ) Three outbursts that involve injury or destruction within a year - long period ( Criterion A2 ) Aggressive behavior is grossly disproportionate to the magnitude of the psychosocial stressors ( Criterion B) The outbursts are not premeditated and serve no premeditated purpose ( Criterion C ) The outbursts cause distress or impairment of functioning , or lead to financial or legal consequences ( Criterion D ) The individual must be at least six years old ( Criterion E ) The recurrent outbursts can not be explained by another mental disorder and are not the result of another medical disorder or substance use ( Criterion F ) It is important to note that DSM - 5 now includes two separate criteria for types of aggressive outbursts ( A1 and A2 ) which have empirical support : Criterion A1 : Episodes of verbal and / or non damaging , nondestructive , or non injurious physical assault that occur , on average , twice weekly for three months . These could include temper tantrums , tirades , verbal arguments / fights , or assault without damage . This criterion includes high frequency / low intensity outbursts . Criterion A2 : More severe destructive / assaultive episodes which are more infrequent and occur , on average , three times within a twelve - month period . These could be destroying an object without regard to value , assaulting an animal or individual . This criterion includes high - intensity / low - frequency outbursts . DSM - IV diagnosis ( edit ) The past DSM - IV criteria for IED were similar to the current criteria , however verbal aggression was not considered as part of the diagnostic criteria . The DSM - IV diagnosis was characterized by the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property . Additionally , the degree of aggressiveness expressed during an episode should be grossly disproportionate to provocation or precipitating psychosocial stressor , and , as previously stated , diagnosis is made when certain other mental disorders have been ruled out , e.g. , a head injury , Alzheimer 's disease , etc. , or due to substance abuse or medication . Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM - IV . The DSM - IV - TR was very specific in its definition of Intermittent Explosive Disorder which was defined , essentially , by exclusion of other conditions . The diagnosis required : several episodes of impulsive behavior that result in serious damage to either persons or property , wherein the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation , and the episodic violence can not be better accounted for by another mental or physical medical condition . Differential diagnosis ( edit ) Many psychiatric disorders and some substance use disorders are associated with increased aggression and are frequently comorbid with IED , often making differential diagnosis difficult . Individuals with IED are , on average , four times more likely to develop depressive or anxiety disorders , and three times more likely to develop substance use disorders . Bipolar disorder has been linked to increased agitation and aggressive behavior in some individuals , but for these individuals aggressiveness is limited to manic and / or depressive episodes , whereas individuals with IED experience aggressive behavior even during periods with a neutral or positive mood . In one clinical study , the two disorders co-occurred 60 % of the time . Patients report manic - like symptoms occurring just before outbursts and continuing throughout . According to a study , the average onset age of IED was around five years earlier than the onset age of bipolar disorder , indicating a possible correlation between the two . Similarly , alcohol and other substance use disorders may exhibit increased aggressiveness , but unless this aggression is experienced outside of periods of acute intoxication and withdrawal , no diagnosis of IED is given . For chronic disorders , such as PTSD , it is important to assess whether the level of aggression met IED criteria prior to the development of another disorder . In antisocial personality disorder , interpersonal aggression is usually instrumental in nature ( i.e. , motivated by tangible rewards ) , whereas IED is more of an impulsive , unpremeditated reaction to situational stress . Treatment ( edit ) Treatment is attempted through both cognitive behavioral therapy and psychotropic medication regimens , though the pharmaceutical options have shown limited success . Therapy aids in helping the patient recognize the impulses in hopes of achieving a level of awareness and control of the outbursts , along with treating the emotional stress that accompanies these episodes . Multiple drug regimens are frequently indicated for IED patients . Cognitive Relaxation and Coping Skills Therapy ( CRCST ) has shown preliminary success in both group and individual settings compared to waitlist control groups . This therapy consists of 12 sessions , the first three focusing on relaxation training , then cognitive restructuring , then exposure therapy . The final sessions focus on resisting aggressive impulses and other preventative measures . Tricyclic antidepressants and selective serotonin reuptake inhibitors ( SSRIs ) such as fluoxetine , fluvoxamine , and sertraline appear to alleviate some pathopsychological symptoms . GABAergic mood stabilizers and anticonvulsive drugs such as gabapentin , lithium , carbamazepine , and divalproex seem to aid in controlling the incidence of outbursts . Anxiolytics help alleviate tension and may help reduce explosive outbursts by increasing the provocative stimulus tolerance threshold , and are especially indicated in patients with comorbid obsessive - compulsive or other anxiety disorders . However , certain anxiolytics are known to increase anger and irritability in some individuals , especially benzodiazepines . Pathophysiology ( edit ) Impulsive behavior , and especially impulsive violence predisposition has been correlated to a low brain serotonin turnover rate , indicated by a low concentration of 5 - hydroxyindoleacetic acid ( 5 - HIAA ) in the cerebrospinal fluid ( CSF ) . This substrate appears to act on the suprachiasmatic nucleus in the hypothalamus , which is the target for serotonergic output from the dorsal and median raphe nuclei playing a role in maintaining the circadian rhythm and regulation of blood sugar . A tendency towards low 5 - HIAA may be hereditary . A putative hereditary component to low CSF 5 - HIAA and concordantly possibly to impulsive violence has been proposed . Other traits that correlate with IED are low vagal tone and increased insulin secretion . A suggested explanation for IED is a polymorphism of the gene for tryptophan hydroxylase , which produces a serotonin precursor ; this genotype is found more commonly in individuals with impulsive behavior . IED may also be associated with lesions in the prefrontal cortex , with damage to these areas , including the amygdala , increasing the incidence of impulsive and aggressive behavior and the inability to predict the outcomes of an individual 's own actions . Lesions in these areas are also associated with improper blood sugar control , leading to decreased brain function in these areas , which are associated with planning and decision making . A national sample in the United States estimated that 16 million Americans may fit the criteria for IED . Epidemiology ( edit ) Two epidemiological studies of community samples approximated the lifetime prevalence of IED to be 4 -- 6 % , depending on the criteria set used . A Ukrainian study found comparable rates of lifetime IED ( 4.2 % ) , suggesting that a lifetime prevalence of IED of 4 -- 6 % is not limited to American samples . One - month and one - year point prevalences of IED in these studies were reported as 2.0 % and 2.7 % , respectively . Extrapolating to the national level , 16.2 million Americans would have IED during their lifetimes and as many as 10.5 million in any year and 6 million in any month . Among a clinical population , a 2005 study found the lifetime prevalence of IED to be 6.3 % . Prevalence appears to be higher in men than in women . Of US subjects with IED , 67.8 % had engaged in direct interpersonal aggression , 20.9 % in threatened interpersonal aggression , and 11.4 % in aggression against objects . Subjects reported engaging in 27.8 high - severity aggressive acts during their worst year , with 2 -- 3 outbursts requiring medical attention . Across the lifespan , the mean value of property damage due to aggressive outbursts was $1603 . A study in the March 2016 Journal of Clinical Psychiatry suggests a relationship between infection with the parasite Toxoplasma gondii and psychiatric aggression such as IED . History ( edit ) In the first edition of the American Psychiatric Association 's Diagnostic and Statistical Manual ( DSM - I ) , a disorder of impulsive aggression was referred to as a passive - aggressive personality type ( aggressive type ) . This construct was characterized by a `` persistent reaction to frustration are `` generally excitable , aggressive , and over-responsive to environmental pressures '' with `` gross outbursts of rage or of verbal or physical aggressiveness different from their usual behavior '' . In the third edition ( DSM - III ) , this was for the first time codified as intermittent explosive disorder and assigned clinical disorder status under Axis I . However , some researchers saw the criteria as poorly operationalized . About 80 % of individuals who would now be diagnosed with the disorder would have been excluded . In the DSM - IV , the criteria were improved but still lacked objective criteria for the intensity , frequency , and nature of aggressive acts to meet criteria for IED . This led some researchers to adopt an alternate criteria set with which to conduct research , known as the IED - IR ( Integrated Research ) . The severity and frequency of aggressive behavior required for the diagnosis was clearly operationalized , the aggressive acts were required to be impulsive in nature , subjective distress was required to precede the explosive outbursts , and the criteria allowed for comorbid diagnoses with borderline personality disorder and antisocial personality disorder . These research criteria became the basis for the DSM - 5 diagnosis . In the current version of the DSM ( DSM - 5 ) , the disorder appears under the `` Disruptive , Impulse - Control , and Conduct Disorders '' category . In the DSM - IV , physical aggression was required to meet criteria for the disorder , but these criteria were modified in the DSM - 5 to include verbal aggression and nondestructive / noninjurious physical aggression . The listing was also updated to specify frequency criteria . Further , aggressive outbursts are now required to be impulsive in nature , and must cause marked distress , impairment , or negative consequences for the individual . Individuals must be at least six years old to receive the diagnosis . The text also clarified the disorder 's relationship to other disorders such as ADHD and disruptive mood dysregulation disorder . See also ( edit ) Episodic dyscontrol syndrome Passive -- aggressive personality disorder References ( edit ) ^ Jump up to : McElroy SL ( 1999 ) . `` Recognition and treatment of DSM - IV intermittent explosive disorder '' . J Clin Psychiatry . 60 Suppl 15 : 12 -- 6 . PMID 10418808 . ^ Jump up to : McElroy SL , Soutullo CA , Beckman DA , Taylor P , Keck PE ( April 1998 ) . `` DSM - IV intermittent explosive disorder : a report of 27 cases '' . J Clin Psychiatry . 59 ( 4 ) : 203 -- 10 ; quiz 211 . doi : 10.4088 / JCP. v59n0411 . PMID 9590677 . Jump up ^ Tamam , L. , Eroğlu , M. , Paltacı , Ö. ( 2011 ) . `` Intermittent explosive disorder '' . Current Approaches in Psychiatry , 3 ( 3 ) : 387 -- 425 . Jump up ^ American Psychiatric Association . ( 2013 ) . Diagnostic and statistical manual of mental disorders ( 5th ed . ) . Arlington , VA : American Psychiatric Publishing . Jump up ^ Coccaro , EF , Lee , R , & McCloskey , MF ( 2014 ) . Validity of the new A1 and A2 criteria for DSM - 5 intermittent explosive disorder . Comprehensive Psychology , 55 ( 2 ) . doi : 10.1016 / j. comppsych. 2013.09. 007 . ^ Jump up to : Coccaro , E.F. ( 2012 ) . Intermittent explosive disorder as a disorder of impulsive aggression for DSM - 5 . `` American Journal of Psychiatry , '' 169 . 577 - 588 . Jump up ^ Coccaro , EF ( 2000 ) . Intermittent explosive disorder . Current Psychiatry Reports , 2 : 67 - 71 . ^ Jump up to : Aboujaoude , E. , & Koran , L.M. ( 2010 ) . Impulsive control disorders . Cambridge University Press : Cambridge . ^ Jump up to : McCloskey , M.S. , Noblett , K.L. , Deffenbacher , J.L , Gollan , J.K. , Coccaro , E.F. ( 2008 ) Cognitive - Behavioral Therapy for Intermittent Explosive Disorder : A Pilot Randomized Clinical Trial . 76 ( 5 ) , 876 - 886 . Jump up ^ Goodman , W.K. , Ward , H. , Kablinger , A. , & Murphy , T. ( 1997 ) . Fluvoxamine in the Treatment of Obsessive - Compulsive Disorder and Related Conditions . J Clin Psychiatry , 58 ( suppl 5 ) , 32 - 49 . ^ Jump up to : Boyd , Mary Ann ( 2008 ) . Psychiatric nursing : contemporary practice . Philadelphia : Wolters Kluwer Health / Lippincott Williams & Wilkins . pp. 820 -- 1 . ISBN 0 - 7817 - 9169 - 3 . Jump up ^ Bozikas , V. , Bascilla , F. , Yulis , P. , & Savvidou , I. ( 2001 ) . Gabapentin for Behavioral Dyscontrol with Mental Retardation . Am J Psychiatry , 158 ( 6 ) , 965 . Jump up ^ Coccaro EF , et al . `` A Double - Blind , Randomized , Placebo - Controlled Trial of Fluoxetine in Patients With Intermittent Explosive Disorder , '' Journal of Clinical Psychiatry ( April 21 , 2009 ) : Vol. 70 , No. 5 , pp. 653 -- 62 . Jump up ^ `` Archived copy '' ( PDF ) . Archived ( PDF ) from the original on 2016 - 07 - 17 . Retrieved 2016 - 10 - 13 . Jump up ^ Virkkunen M , Goldman D , Nielsen DA , Linnoila M ( July 1995 ) . `` Low brain serotonin turnover rate ( low CSF 5 - HIAA ) and impulsive violence '' . J Psychiatry Neurosci. 20 ( 4 ) : 271 -- 5 . PMC 1188701 . PMID 7544158 . Jump up ^ Best M , Williams JM , Coccaro EF ( June 2002 ) . `` Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggressive disorder '' . Proc. Natl. Acad. Sci. U.S.A. 99 ( 12 ) : 8448 -- 53 . doi : 10.1073 / pnas. 112604099 . PMC 123087 . PMID 12034876 . ^ Jump up to : Kessler RC , Coccaro EF , Fava M , Jaeger S , Jin R , Walters E ( June 2006 ) . `` The prevalence and correlates of DSM - IV intermittent explosive disorder in the National Comorbidity Survey Replication '' . Arch. Gen. Psychiatry . 63 ( 6 ) : 669 -- 78 . doi : 10.1001 / archpsyc. 63.6. 669 . PMC 1924721 . PMID 16754840 . Archived from the original on 2011 - 10 - 10 . ^ Jump up to : Coccaro EF , Schmidt CA , Samuels JF et al. Lifetime and one - month prevalence rates of intermittent explosive disorder in a community sample . J Clin Psychiatry 65 : 820 -- 824 , 2004 . Jump up ^ Bromet EJ , Gluzman SF , Paniotto VI et al. Epidemiology of psychiatric and alcohol disorders in Ukraine : Findings from the Ukraine World Mental Health survey . Soc Psychiatry Psychiatr Epidemiol 40 : 681 -- 690 , 2005 . Jump up ^ Coccaro EF , Posternak MA , Zimmerman M ( October 2005 ) . `` Prevalence and features of intermittent explosive disorder in a clinical setting '' . J Clin Psychiatry . 66 ( 10 ) : 1221 -- 7 . doi : 10.4088 / JCP. v66n1003 . PMID 16259534 . Archived from the original on 2012 - 07 - 01 . Jump up ^ Coccaro EF , Lee R , Groer MW , Can A , Coussons - Read M , Postolache TT ( March 2016 ) . `` Toxoplasma gondii Infection : Relationship With Aggression in Psychiatric Subjects '' Archived 2016 - 03 - 24 at the Wayback Machine ... J Clin Psychiatry 77 ( 3 ) : 334 -- 341 . Jump up ^ Felthous et al. , 1991 Jump up ^ Coccaro et al. , 1998 Jump up ^ Highlights of Changes from DSM - IV - TR to DSM - 5 by American Psychiatric Publishing . Retrieved from http://www.ldaofky.org/changes-from-dsm-iv-tr--to-dsm-5[1].pdf on July 13 , 2013 . 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