Thursday, July 3, 2008

Intermittent Explosive Disorder and Agression

One of the organic syndromes, considered to be hereditary, that has been linked to pathological aggression is Episodic Dyscontrol Syndrome, now referred to in the DSM-IV (APA, 2000) as Intermittent Explosive Disorder (Valavka, 1995). Results of neurological batteries given to marital aggressors who have been diagnosed with Intermittent Explosive Disorder indicate impairment in the frontal and temporal lobes, which are areas of the brain involving self-regulation. Damage in this region has been associated with increased aggression (Lezak, 1983) and permanent changes in the control and expression of emotional response (Macchi, 1989).
Intermittent Explosive Disorder has been found to occur in individuals with borderline and antisocial personality disorders, ADHD, as well as other organic brain syndromes (Elliot, 1988, 1998). Elliott described the neurological factors contributing to this syndrome as falling into two categories: (a) those that arise early in life and are attributed to hereditary and early prenatal and infant development, and (b) those that develop during adolescence or later (Elliot, 1988, 1998).
Elliott’s original description of this disorder, which included TBI as a possible cause, is different from what is now listed in the DSM-IV (APA, 2000), which specifically states that Intermittent Explosive Disorder is not the result of a head injury. Although it is considered not to be the result of a head injury, the DSM IV (APA, 2000) states,

“A history of neurological conditions (e.g. head injury, episodes of unconscious, 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 used instead (p.610).”
The DSM-IV (APA, 2000) has given the following diagnostic criteria for Intermittent Explosive Disorder:
(a) Several discrete episodes of loss of control of aggressive impulses resulting in serious assaultive acts or destruction of property.
(b) The degree of aggressiveness during episodes is out of proportion to the precipitating stress.
(c) The episodes of loss of control are not better accounted for by antisocial or borderline personality disorders, psychosis, or ADHD, and they are not due to the direct effects of a substance or general medical condition (e.g. a personality change due to head injury).
In his article,” The Neurology of Explosive Rage: The Dyscontrol Syndrome,” Elliot (1977) stated that unprovoked explosive rage, as manifested in either verbal or physical aggression, may be psychogenic or organic in origin. These outbursts of uncontrollable anger associated with this syndrome can vary in severity and form. More severe forms of Intermittent Explosive Disorder according to Miller (1994),

“Can appear as sudden, often unprovoked outbursts, primitive and poorly organized in nature – flailing, spitting, scratching, etc. – and usually directed at the nearest available object or person. The act itself can be quite destructive to furniture, pets, or people who happen to get in the way, but human injury is usually the result of misguided efforts on the part of observers to subdue the patient during an episode. In such cases, the wild thrashing that inflicts the injurious blows probably represents a desperate attempt to escape restraint rather than a directed assault against a particular individual – although sudden, directed but usually unsustained attacks may occur. The outbursts are typically short-lived and may be followed by feelings of regret and remorse when the individual becomes aware what he/she has done (p.92).”
Intermittent Explosive Disorder has been found to be intergenerational, although a number of confounding variables, such as parental conflict or separation, trauma and neglect, are also often present. This overlap makes it difficult to tease out heredity from environmental factors. Intermittent explosive disorder is listed in the DSM-IV (APA, 2000) under the category of Impulse-Control Not Elsewhere Classified, and information available on Intermittent Explosive Disorder is limited.

1 comment:

Mindsite said...

Dr. Byron -

We have posted an online version of the World Health Organization's CIDI diagnostic for IED as well as the full text of the DSM-IV here: http://www.mindsite.com/portal/intermittent_explosive_disorder/diagnostic_criteria

We are a new site, what do you think of our approach? How can we improve?