Primary care clinicians are becoming increasingly comfortable with diagnoses such as ADHD, OCD, and even depression but what about Intermittent explosive disorder (IED, not to be confused with improvised explosive device)? IED refers to individuals who experience recurrent episodes of aggression that is disproportionate to the precipitating trigger and that the person finds unable to
control. The diagnostic criteria are vague, even for the DSM, any many child psychiatrists (including most of us here) tend to avoid the diagnosis due to its lack of research evidence or approved treatments, and the fact that it seems most everyone meets criteria for at least something that is better defined
A recent study on IED, however, was published in the prestigious Archives of General Psychiatry that comes from the National Comorbidity Survey Replication Adolescent Supplement: one of the most comprehensive and rigorous epidemiologic studies to date for adolescent psychiatric disorders. Over 6000 adolescents were interviewed to examine the rate of IED and subjects were excluded from the analysis if they had a history of bipolar disorder, ADHD, oppositional defiant disorder, or conduct disorder. Both more broadly and more narrowly defined IED were investigated.
Results revealed that the rate of lifetime anger episodes was extremely high with 63.3% of subjects reporting at least one episode of an anger “attack” that included acts such as destroying property, verbal threats, or actual physical violence or aggression. The estimated lifetime prevalence of more narrowly defined IED was 5.3% while an additional 2.5% met criteria for broadly defined IED. Comorbidity with other disorders was high, and only 6.5% of IED adolescents were receiving treatment specifically for anger.
Interestingly, anger is one of the core negative human emotions that is not well captured by a specific diagnostic category. Rather, irritability and aggression is found across of number of diagnoses. Unfortunately, the decision to exclude from this study adolescents with conditions such as bipolar disorder and ODD make this paper less useful towards resolving some of the diagnostic controversy between these diagnoses. At the same time, these data suggest that explosive anger can exist fairly commonly even in the absence of these other disorders.
Is this a “real” disorder or just another way to pathologize normal behavior? In the conclusions, the authors advocated that more research is strongly needed to understand explosive anger in order to develop effective treatment strategies and to resolve its relations with other mental disorders. What exactly is that ubiquitous “Anger Management” treatment that reporters and judges seem so fond of discussing, you might ask? That one will have to wait for another posting.
Reference
McLaughlin KA, Green JG, Hwang I, et al. Intermittent explosive disorder in the National Comorbidity Survey Replication Adolescent Supplement. Archives of General Psychiatry: Online First, July 2012.
Tags: anger attack, child psychiatry, Intermittent Explosive Disorder
The real problem with IED in my mind is that children and adolescents are supposed to have occasional outbursts and learning to control them is a developmental process. We would not say that a typically-developing 2 year old has dysgraphia or dyslexia, for example.
Furthermore, I’ve yet to see the evidence that IED is discrete from other entities such as oppositional defiant disorder, depression, PTSD, or bipolar disorder, at least in childhood.