Intermittent explosive disorder Definition and clinical features

Intermittent explosive disorder is defined in DSM-IV as several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property (criterion A). Also, the degree of aggression expressed during an episode is grossly out of proportion to any precipitating psychosocial stressors (criterion B) and the explosive episodes are not better accounted for by another mental disorder or due to the direct physiological effects of a substance or a general medical condition (criterion C). ICD-10 lists intermittent explosive disorder under 'Other habit and impulse disorders', but does not provide specific guidelines for its diagnosis.

Some authorities continue to doubt the validity of intermittent explosive disorder as an independent diagnostic entity, seeing loss of control of aggressive impulses

(also called explosive rage, rage outbursts, or episodic dyscontrol) instead as a non-specific symptom that occurs in a wide range of psychiatric and medical disorders/2 By contrast, other authorities argue that intermittent explosive disorder is in fact a distinct mental disorder that is an important cause of violent behaviour, that the DSM criteria for intermittent explosive disorder are too narrow, and that clinically significant milder forms of intermittent explosive disorder exist that should be nosologically recognized.(5)

Although there are few systematic studies of the phenomenology of intermittent explosive disorder, there are numerous clinical reports of people with rage outbursts which are described as explosive, uncontrollable, unpremeditated, and brief, provoked by minor stimuli, and associated with various psychological and physical symptoms, especially changes in mood, awareness, and sympathetic arousal.(5) For example, of 27 subjects with DSM-IV intermittent explosive disorder,(6) all reported aggressive impulses or violent urges prior to their aggressive acts which were variously described as the 'need to attack', the 'need to defend oneself', the 'need to strike out', an 'adrenalin rush', 'seeing red', or the 'urge to kill someone'. Most subjects described tension with the impulses and relief that was sometimes pleasurable with the acts. Most subjects also reported that affective symptoms accompanied their aggressive episodes. The most common affective symptoms associated with the impulses and acts were manic-like, and included irritability/rage, increased energy, and racing thoughts. After performance of the acts, the most frequent affective symptoms were depressed mood and fatigue. Approximately one-half of subjects stated that their episodes were associated with some degree of loss of or change in awareness, and one-third reported that their episodes were often preceded or accompanied by physical symptoms (e.g. tingling, tremor, palpitations, chest tightness, or head pressure).

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