An 18-year-old adult male dropped out of school due to lack of progress and behavioral difficulties. He was referred to the Mental Health Service after a history of progressive deterioration in his impulsive actions for over a year and a half. His behavior has been described as episodic and intense, beginning with demands and progressing to hostility toward his family. At other times, he became verbally abusive. His impulsive aggressiveness caused relationship problems because his violent outbursts featured insulting claims directed at his sisters; this happened multiple times, even when no apparent issues were present. At several instances, the patient grew so irritated that he threw objects around the house, including kitchen plates, books, food cans, and refrigerator contents, damaging television screens and expensive goods he could get his hands on. His family reported that he had become increasingly isolated in his room, refusing to leave during the day, and only leaving at night after everyone had gone to bed. He routinely smashed items and opened all food cans and dropped them on the floor when he entered the kitchen. Attempts to manage his behavior occasionally required his father to use force to restrain him, as he could injure himself and others during these instances. His father continued to sleep during the day and woke up at night to ensure safety from his actions. When he had these rage outbursts, he would leave his house and damage vehicles, including those of the family and neighbors, using stones. His mood has been volatile, impatient, and easily aroused, and he is frequently skeptical of all family members, resulting in a serious problem in the relationship. With increasing social isolation, he refused to leave his room and neglected self-care, yelling angrily if prompted. He also displayed sexually unrestrained behavior toward female family members, generating distress and avoidance. He stayed awake all night and slept during the day. He removed his brothers' belongings and broke them while keeping his own safe and preventing others from accessing them. These attacks, as described earlier, were episodic in nature and unprovoked; they occurred around two to three times on a weekly basis, and in between the episodes, he was generally manageable with no concerns from his family. However, his appetite, concentration, energy level, and interest were not generally affected between episodes; hence, he did not meet the criteria for major depression.
He was previously seen by a child and adolescent psychiatrist, who diagnosed his behavioral problems as social avoidance with anxiety and mild intellectual disability. According to his family, he had neither manic nor depressive symptoms nor any hallucinations or obsessive thoughts. According to his parents, their child's mental abilities were also evaluated (they provided us with his previous report evaluation), and he achieved a total intelligence quotient (IQ) score of 57 to 60 on the Wechsler Intelligence Scale for Children-III (WISC-III).