Intermittent Explosive Disorder - A Wicked Problem

Intermittent Explosive Disorder

Uncontrollable episodes of aggression, where the person loses control and assaults others or destroys property.

Persons with this disorder experience episodes of aggressive or violent behavior that result in assault of a person or animal or the destruction of property. These intense episodes occur spontaneously, not in response to provocation or threat, and individuals often express regret as soon as the episode ends. Usually he or she does not exhibit aggressive tendencies between episodes. This disorder can appear at any age, but is more common in adolescence through the 20s, and is more common in males. This disorder is believed to be rare, and reliable statistics on the frequency of occurrence are not available.

Aggression Definition

Aggressive behavior is reactionary and impulsive behavior that often results in breaking household rules or the law; aggressive behavior is violent and unpredictable. 

Frustration, resentment and anger are often generated by what Buddha called desire or attachment, which is the expectation that life will work out as we wish. Dr. Albert Ellis' Rational Emotive Behavior Therapy (REBT) similarly recognized the frustrating nature of irrational cognitions like "life should be fair." And anger can be and is often used by some (not unlike a drug) to cover up painful feelings, fear, anxiety, vulnerability and shame. Popular recovery counselor John Bradshaw refers to such bellicose individuals as "rageaholics." The best defense is a good offense. Certainly, much anger and resentment also stems from an underlying matrix of neurotic narcissism and grandiose sense of entitlement in adolescents and adults. Narcissistic Personality Disorder, is defined by the DSM-IV-TR as "a pervasive pattern of grandiosity (in fantasy or behavior), need for admiration, and lack of empathy " and commonly includes a sense of entitlement, interpersonal exploitation, and preoccupation with fantasies of unlimited power, fame, brilliance, success,  beauty or ideal love. For the narcissist, it's all about me, my needs, what I want, my ego gratification. Such pathological narcissism and can be seen as a pervasive characterological defense compensating against profound feelings of inferiority, helplessness, sadness, and unlovability stemming from certain fundamental infantile and childhood needs having never been adequately met. When this over-inflated persona is inevitably deflated by stressful life events like divorce, rejection, abandonment, failure, aging and loss, narcissistic rage is triggered, along with other long-buried emotions. The burning desire for revenge, retaliation, and the compulsive need to vengefully repay the hurt, slight or insult no matter what it takes or costs is the central characteristic of narcissistic rage. These fiery, often overpowering emotional reactions can sometimes get so intense as to precipitate a major depressive, manic or even psychotic episode ("madness"), causing clinically significant temporary impairment of perception, rationality, judgment and impulse control. In such extremely debilitating, disorienting and dangerous states of mind, almost anything can happen. And often does.

Who is to blame for this problem? Well, in part, we all are. To the extent our society condemns and denigrates the affect of anger as negative, worthless or evil, ignoring and denying its positive potentialities, we are partially responsible for the subsequent carnage. To the extent mental health professionals continue to avoid confronting anger head on in our patients, choosing instead to try to drug, behaviorally modify or cognitively restructure the demon of anger away, we clinicians too are compounding the problem. Whatever our own complicity in this evil on the part of society, psychology and psychiatry, clearly the primary responsibility for violent behavior falls on the perpetrators shoulders. No matter what his or her childhood circumstances or subsequent traumatic experiences, adults are responsible for how they deal with their own history and their negative feelings about that history. Not addressing an anger disorder by denying its existence or refusing professional assistance is no excuse for the consequences of not doing so.

What can be done to contain the rage epidemic? When it comes to dealing effectively with anger disorders, so-called "anger management" classes are no substitute for intensive psychotherapy. In psychotherapy, the single most powerful, healing and difficult intervention the clinician can offer is to listen to the angry patient, and to acknowledge and accept his or her rage. Anger and rage have to first be validated, expressed, tolerated and understood before the underlying affects or distorted cognitions can be constructively addressed. The dilemma is that most mental health professionals tend to dread, denigrate and demonize anger, dismissing it as an inappropriate, destructive, negative and neurotic emotion. But anger is an appropriate, natural, normal and healthy response to frustration, injury, insult, and anything that threatens one's survival or psychological integrity. We need to be able to get angry at life's obstacles, challenges and assaults. Anger can bestow necessary strength, courage and tenacity in the face of adversity. When we are socialized to view getting angry as negative, evil, immoral or unspiritual, as so many of us have been, we automatically repress our anger--as we repress other impulses or passions of which we are ashamed. This is exactly what Jung describes as the shadow and Rollo May described as the daimonic: those aspects of human experience we find unacceptable, reject, banish and quarantine to unconsciousness. Anger is commonly experienced (if it is consciously experienced at all) as a shameful, frightening, negative emotion which must be hidden from others, and often, even from ourselves. The last thing therapists should do when working with angry patients is to further shame, criticize or punish them for feeling angry.

Bad behavior when furious is another matter, and must be firmly confronted. Evil deeds and destructiveness toward self or others cannot be condoned. These are neurotic forms of acting out, and function as a defense mechanism against fully experiencing that which underlies the anger or toward whom the anger is truly directed. Still, it is through first acknowledging, confronting, articulating and accepting the anger that the patient can become more conscious of what truly lies behind it, what drives and triggers it. Anger is not something that can be avoided or circumvented during the psychotherapy process. Anger is the alchemical key to the healing process, the exclusion, suppression or minimization of which impedes rather than promotes therapeutic progress. Without a courageous willingness to deal directly with the daimonic passions of anger or rage in treatment rather than trying merely to manage or defuse them cognitively, behaviorally or pharmacologically, psychotherapists cannot facilitate the deep emotional healing such patients seek. Instead, we unwittingly contribute to the growing epidemic of anger, rage, hostility, bitterness and destructive behavior.

Description

Aggression can a problem for children with both normal development and those with psychosocial disturbances. Aggression constitutes intended harm to another individual, even if the attempt to harm fails (such as a bullet fired from a gun that misses its human target). There is no single theory about the causes of aggressive behavior in humans. Some believe aggression is innate or instinctive. Social theorists suggest the breakdown in commonly shared values, changes in traditional family patterns of child-rearing, and social isolation lead to increasing aggression in children, adolescents, and adults. Aggression in children correlates with family unemployment, strife, criminality, and psychiatric disorders.

Differences exist between levels of aggression in boys and girls in the same families. Boys are almost always more aggressive than girls. Larger children are more aggressive than smaller ones. Active and intrusive children are also more aggressive than passive or reserved ones.

Aggressive behavior may be intentional or unintentional. Many hyperactive, clumsy children are accidentally aggressive, but their intentions are compassionate. Careful medical evaluation and diagnostic assessments distinguish between intentional behaviors and the unintentional behaviors of emotionally disturbed children.

Children in all age groups learn that aggressive behavior is a powerful way to communicate their wishes or deal with their likes and dislikes.

Infancy

Infants are aggressive when they are hungry, uncomfortable, fearful, angry, or in pain. Parents can tell what babies need by the loudness and pitch of crying and the flailing of arms and legs. Crying is an infant's defense, the way to communicate feelings and needs.

Toddlers

Children between two and four years of age show aggressive outbursts such as temper tantrums and hurting others or damaging toys and furniture because they are frustrated. Usually the aggression in this age group is expressed toward parents as a way to get their compliance with the child's wishes. Verbal aggression increases as vocabulary increases.

Preschool

Children between four and five years of age can be aggressive toward their siblings and peers. Because of greater social interaction, children need to learn the differences between real and imaginary insults, as well as the difference between standing up for their rights and attacking in anger.

School-age and adolescence

Aggressive boys between three to six years of age are likely to carry their behavior style into adolescence. In extreme cases, they may show aggression by purse snatching, muggings, or robbery, or in less overt ways by persistent truancy, lying, and vandalism. Girls younger than six years of age who have aggressive styles toward their peers do not tend to continue being aggressive when they are older, and their earlier aggression does not correlate with adult competitiveness.

Common problems

Frustration is a response to conditions that keep children from achieving goals important to self-esteem. Frustration and aggression are closely associated. If children learn that being aggressive when frustrated is tolerated or gives them special treatment, the behavior is reinforced and may be repeated. Aggression may be a way for children to face obstacles or solve problems. It is important not to attribute malice to children who are responding to anxiety, feelings of incompetence, or a sense of low self-esteem.

Through the media, including film, the U.S. culture reinforces violence and aggressive behavior in children. Police brutality, crime-based television programs, and governmental reliance on military aggression to solve political and economic differences all create a climate in which violence is presented to children as a legitimate solution to problems.

Violent behavior in children and adolescents

CULTURAL VIOLENCE Violence includes a wide range of behaviors: explosive temper tantrums, physical aggression, fighting, and threats or attempts to hurt others (including homicidal thoughts). Violent behaviors also include the use of weapons, cruelty toward animals, setting fires, and other intentional forms of destruction of property.

PREDISPOSITION TO VIOLENCE Some children are supersensitive, easily offended, and quick to anger. Many children are tense and unusually active, even as infants. They are often more difficult to soothe and settle as babies. Beginning in the preschool years, they are violent toward other children, adults, and even animals. They often lash out suddenly, sometimes for no obvious reason. When they hurt someone in their anger, they tend not to be sorry and may tend not to take responsibility for their actions. Instead, they blame others for their own actions. Parent should give this behavior serious attention and take measures to correct it.

Children may go through a brief period of aggressive behavior if they are worried, tired, or stressed. If the behavior continues for more than a few weeks, parents should talk to the pediatrician. If it becomes a daily pattern for more than three to six months, it could be a serious problem.

Factors that increase risk of violent behavior

Parents and teachers should be careful not to play down aggressive behaviors in children. In fact, certain factors put some children at risk for developing violent behaviors as adults. These factors include the following:

• being the victim of physical and sexual abuse
• exposure to violence in the home and community
• exposure to violence in media (TV, movies)
• use of drugs and alcohol
• presence of firearms in home
• combination of stressful family socioeconomic factors (poverty, severe deprivation, marital breakup, single parenting, unemployment, loss of support from extended family)
• brain injury

Parents can teach children nonviolence by controlling their own tempers. If parents express anger in quiet, assertive ways, children may follow their parent's example. Children need to understand when they have done something wrong so they can learn to take responsibility for their actions and learn ways to make amends. Responsible parenting does not to tolerate violence or use it in any way.

Violence prevention strategies

Efforts should be directed at dramatically decreasing the exposure of children and adolescents to violence in the home, community, and through the media. Clearly, violence leads to violence. Parents can use the following strategies to reduce or prevent violent behavior:

• prevent child abuse in the home
• provide sex education and parenting programs for adolescents
• provide early intervention programs for violent youngsters
• monitor children's TV programs, videos, and movies

The most important step that parents can take with aggressive children is to set firm, consistent limits and be sure that everyone caring for the children acts in accord with the parents' rules and expectations.

Parents should know the importance of helping children find ways to deal with anger without resorting to violence. Children can learn to say no to their peers, and they can learn how to settle differences with words instead of physical aggression. When children control their violent impulses, they should be praised.

Parental concerns

All children have feelings of anger and aggression. Children need to learn positive ways to express these feelings and to negotiate for what they want while maintaining respect for others. Parents can help their children develop judgment, self discipline, and the other tools children need to express feelings in more acceptable ways and to live with others in a safe way.

Understanding the aggressive child

When children lose their sense of connection to others, they may feel tense, frightened, or isolated. These are the times when they may unintentionally lash out at other children, even children to whom they are close. Parents should be careful not to let children think aggression is acceptable.

When children are overcome with feelings of isolation or despair, they may run for the nearest safe person and begin to cry. They immediately release the terrible feelings, trusting that they are safe from danger and criticism. Effective parents listen and allow the child to vent without becoming alarmed.

Disciplining aggressive behavior

Parents can control the aggressive child in various ways. They should intervene quickly but calmly to interrupt the aggression and prevent the their child from hurting another child. Younger children may need a time-out to calm down and before rejoining a group. Simple rules about appropriate behavior are easier for a child to understand than lengthy explanations. Parents can affirm feelings while stressing that all feelings cannot be acted upon.

Parents can reach older children with eye contact, a stern voice, and physical contact. Older children can be told that they need to learn a better way to handle conflicts. Parents can suggest that, for instance, the child ask an adult to intervene before lashing out at a classmate. Any disciplinary measures should be explained as a simple consequence to the child's aggression.

When parents arrive after conflict occurs, it may be useful to listen to the child's explanation. Having a parent listen can encourage the child to develop trust in the parent.

Parents should not expect the aggressive child to be reasonable when he or she is upset. The child may need time to calm down. Sometimes the child may feel trapped and may need adult support. Parents should encourage the aggressive child to come to them when they are upset, hopefully before violence occurs.

KEY TERMS

Anxiety—Worry or tension in response to real or imagined stress, danger, or dreaded situations. Physical reactions, such as fast pulse, sweating, trembling, fatigue, and weakness, may accompany anxiety.
Consequences—Events that occur immediately after the target behavior.
Misbehavior—Behavior outside the norms of acceptance within the group.
Time-out—A discipline strategy that entails briefly isolating a disruptive child in order to interrupt and avoid reinforcement of negative behavior.

BOOKS

Davis, Jean Q. Anger, Aggression, and Adolescents. New York: Pantheon Books, 2004.
Delfos, Martine F. Anxiety, ADHD, Depression, and Aggression in Childhood: Guidelines for Diagnostics and Treatment. Herndon, VA: Jessica Kingsley Publishers, 2003.
Valkenburg, Pattie M. Children's Responses to the Screen: A Media Psychological Approach. Mahwah, NJ: Lawrence Erlbaum Associates, 2004.

ORGANIZATIONS

Parents Leadership Institute. PO Box 1279, Palo Alto, CA 94302. Web site: .

WEB SITES

"Understanding Violent Behavior in Children and Adolescents." American Academy of Child and Adolescent Psychiatry, March 2001. Available online at (accessed December 12, 2004).

Impulse Control Disorders

A psychological disorder characterized by the repeated inability to refrain from performing a particular action that is harmful either to oneself or others.

Impulse control disorders are thought to have both neurological and environmental causes and are known to be exacerbated by stress. Some mental health professionals regard several of these disorders, such as compulsive gambling or shopping, as addictions. In impulse control disorder, the impulse action is typically preceded by feelings of tension and excitement and followed by a sense of relief and gratification, often—but not always—accompanied by guilt or remorse. Researchers have discovered a link between the control of impulses and the neurotransmitter serotonin, a chemical agent secreted by nerve cells in the brain. Selective serotonin reuptake inhibitors (SSRIs), medications such as Prozac that are used to treat depression and other disorders, have been effective in the treatment of impulse control disorders. The American Psychiatric Associationpyromanía, trichotillomania (compulsive hair-pulling), intermittent explosive disorder, kleptomania, pathological gambling, and other impulse-control disorders not otherwise specified. The first three of these disorders are known to affect children and/or adolescents. describes several impulse control disorders:

Pyromania involves the repeated setting of fires for no specific reason (such as sabotage or revenge). Rather, the pyromaniac is someone who tends to have a fascination with fire itself, often expressed as an interest in firefighters and their procedures and equipment. It is not uncommon for a pyromaniac to set a fire, report it himself, and then watch as firefighters put it out, even offering to assist them. Pyromania can occur in a child as young as age three, although it is rare at any age and even rarer in childhood. While children and adolescents account for over 40% of those arrested for arson in the United States, only a small percent of fires set by young people indicate the presence of pyromania. Juvenile fire-setting is usually attributed to more generalized conditions characterized by a broad range of impulsive and/or antisocial behavior, such as conduct or adjustment disorders attention deficit/hyperactivity disorder (ADHD).

Of those persons diagnosed with pyromania, the vast majority—some 90%—are male. Pyromaniacs have feelings of sadness and loneliness that eventually give way to rage, for which setting fires serves as an outlet. Some researchers have linked pyromania to victims of child abuse. Persons affected by this disorder often suffer from other behavioral problems and also tend to have learning disabilities and attention disorders. Often, children who set fires also have a history of cruelty to animals. Some common biological characteristics have been discovered in pyromaniacs, including abnormalities in the levels of the neurotransmitters norepinephrine and serotonin, which may be related to problems with impulse control, and low blood sugar levels.

Pyromania has responded to behavioral treatment designed to increase a person's awareness of the emotions that lead up to a fire-setting episode and provide alternate ways of dealing with them. Often this type of therapy is followed by a more psychodynamically oriented approach that deals with the deeper underlying problems that arouse the negative emotions associated with the disorder. Family therapy has been particularly successful with children, as have community-based intervention programs, some of which have the youngsters spend some time with firefighters who can serve as positive role models and help build their self-esteem. Selective serotonin reuptake inhibitors (SSRIs) are also used to treat pyromania. Childhood pyromania responds well to treatment and is eradicated in about 95% of children who demonstrate signs of the disorder.

Trichotillomania is the name given to compulsive hair-pulling not caused by any other condition, such as schizophrenia. In children, it occurs equally among males and females; in adults, it is much more common in females. Statistics on the incidence of trichotillomania are scant, for most people affected by it do not seek professional help. However, a well-documented survey taken on a college campus found between 1-2% of students affected by this disorder, with the incidence in females as high as 3.4%, more than twice that in males. Another study found trichotillomania to be about one-fifth as prevalent as nail-biting, a habit practiced by 20% of Americans, which would place the incidence of trichotillomania at 4% of the population. The primary ages of onset are between 5-8 years of age and 13. Many young children exhibit harmless hair-pulling (often in conjunction with thumb-sucking) that stops by the age of six. However, some continue to revert to this habit in times of stress, a tendency that can eventually lead to trichotillomania. In some individuals the condition is episodic, while in others it continues steadily for long periods of time.

In trichotillomania, hair is most often pulled from the scalp, resulting in bald patches, but it can also be pulled from the eyebrows, eyelashes, beard, torso, armpits, or pubic area. The hair may be pulled in short repeated episodes or for hours at a time. Hair-pulling is often accompanied by other actions, including chewing on or swallowing the pulled hair, called tricophagia. Trichotillomania has been associated with depression, anxiety, and obsessive-compulsive disorder (OCD), but it is still recognized as a disorder distinct from these conditions. It has been linked neurologically to distinctive patterns of glucose metabolization and is thought to have a genetic component. Effective drug treatments include selective SSRIs (particularly Prozac), lithium, and SSRIs in combination with the drug pimozide (Orap), which affect the brain chemical dopamine. Psychotherapy has proven more effective in children with the condition than in adolescents or adults. In some cases, hypnosis is used to break the habit and explore any underlying emotional problem that may be at its root.

Intermittent explosive disorder was only recently recognized as an impulse-control disorder. It is characterized by violent and aggressive outbursts of temper that are significantly disproportionate to the events that trigger them. These outbursts often result in property damage and/or personal injury. Occurring mostly in teenagers and young adults, it is four times as common in men as in women and appears to have a genetic component, as evidenced by multigenerational family histories of violence. The outbursts of temper that characterize intermittent explosive disorder, like the symptoms of other impulse control disorders, are often followed by feelings of relief and eventual remorse. Treatment consists of both therapy and medication. Antipsychotic drugs, anticonvulsants, betablockers, lithium, and benzodiazepines have all shown to alleviate the symptoms of this disorder.

A condition not listed by the American Psychiatric Association that some experts consider an impulse-control disorder is repetitive self-mutilation, in which people intentionally harm themselves by cutting, burning, or scratching their bodies. Other forms of repetitive self-mutilation include sticking oneself with needles, punching or slapping the face, and swallowing harmful substances. Self-mutilation tends to occur in persons who have suffered traumas early in life, such as sexual abuse or the death of a parent, and often has its onset at times of unusual stress. In many cases, the triggering event is a perceived rejection by a parent or romantic interest. Characteristics commonly seen in persons with this disorder include perfectionism, dissatisfaction with one's physical appearance, and difficulty controlling and expressing emotions. It is often seen in conjunction with schizophrenia, post-traumatic stress syndrome, and various personality disorders. Usual onset is late childhood or early adolescence; it is more frequent in females than in males.

Those who consider self-mutilation an impulse control disorder do so because, like the other conditions that fall into this category, it is a habitual, harmful activity. Victims often claim that it is accompanied by feelings of excitement, and that it reduces or relieves negative feelings such as tension, anger, anxiety, depression, and loneliness. They also describe it as addictive. Self-mutilating behavior may occur in episodes, with periods of remission, or may be continuous over a number of years. Repetitive self-mutilation often worsens over time, resulting in increasingly serious forms of injury that may culminate in suicide. Treatment includes both psychotherapy and medication. The SSRI Clomipramine (Anafranil), often used to treat obsessive-compulsive disorder, has also been found effective in treating repetitive self-mutilation. Behavioral therapy can teach persons with this disorder certain techniques they can use to block the impulse to harm themselves, such as spending more time in public places (because self-mutilating behavior is almost always practiced secretly), using music to alter the mental state that leads to self-mutilation, and wearing protective garments to prevent or lessen injury. In-depth psychodynamic therapy can help persons with the disorder express the feelings that lead them to harm themselves.

Books

Gaynor, Jessica, and Chris Hatcher. The Psychology of Child Firesetting: Detection and Intervention. New York: Bruner/Mazel, 1987.

Koziol, Leonard F., Chris E. Stout, and Douglas H. Ruben, eds. Handbook of Childhood Impulse Disorders and ADHD: Theory and Practice. Springfield, IL: C.C. Thomas, 1993.

Rider, Anthony Olen. The Firesetter: A Psychological Profile. Washington, D.C.: Federal Bureau of Investigation, U.S. Department of Justice, 1984.

Stein, D. J., ed. Impulsivity and Aggression. Chichester, NY: Wiley, 1995.