When was the last time you really threw a fit? Totally blew your cool, steam coming out of your ears? Maybe it was just a tantrum, a "my bad" moment of anger. But could it have been something more?

According to a study reported in the June 2006 issue of Archives of General Psychiatry, a mental illness dubbed Intermittent Explosive Disorder will afflict 16 million Americans at some point in their lifetimes.

Although it can be difficult to know just where normal anger and impatience end and pathology begins, Intermittent Explosive Disorder is characterized by recurrent episodes of rage, out of proportion to the stress that trigger them. It can be seen in the violent over-reaction that results in lethal road rage or in the physical abuse of a spouse or child.

"In the general population, aggressiveness or 'blowing up' is considered bad behavior; people think, 'This person just needs an attitude adjustment.' But Intermittent Explosive Disorder goes beyond that, having strong genetic and biomedical underpinnings," says coauthor Dr. Emil Coccaro, professor of Psychiatry at the University of Chicago Pritzker School of Medicine. "If people think these explosive outbursts are just bad behavior, they are not thinking of this problem as a serious biomedical problem that can be treated."

Episodes of Intermittent Explosive Disorder rage may not be directly due to another mental disorder or the effects of drugs or alcohol, according to the Diagnostic and Statistical Manual of Mental Disorders. But they may certainly be intimately related.

Among people with this disorder, according to this study, 81.8% also were diagnosed with depression, anxiety, and alcohol or drug abuse disorders, although the age of onset of Intermittent Explosive Disorder was usually much earlier than that of these other disorders.

"This suggests that people with this disorder may be more susceptible to other disorders because of increased stressful life experiences as a result of their disorder, such as financial difficulties or divorce," says Ronald Kessler, professor of health care policy at Harvard Medical School and senior author of the study.

Intermittent Explosive Disorder may be a risk factor for other mental disorders and it may be a lot more common than previously thought. "The weight of these numbers should help patients and physicians come to recognize the pervasiveness of this disorder and develop appropriate treatment strategies," says Kessler, senior author of the study. The study was based on data from the National Comorbidity Survey Replication, a nationally representative face-to-face household survey of 9,282 American adults, conducted from 2001 to 2003.

To be diagnosed with broadly-defined Intermittent Explosive Disorder, a person must have had three major episodes of impulsive aggressiveness at any time in his or her life where the person was significantly more angry than most people would have been in the same situation. These outbursts are sudden and include damage to property and either real or threatened physical harm to others. A narrow definition of Intermittent Explosive Disorder includes three or more of these attacks in one year.

The study shows that for both broad and narrowly-defined Intermittent Explosive Disorder, the first episode of rage occurred in early adolescence, around age 13 for males and age 19 for females. "Given its age of onset, identifying Intermittent Explosive Disorder early, determining its causes, and providing treatment might prevent some of the associated secondary disorders, such as anxiety or alcohol abuse," says Kessler.

What It Means
Telling your doctor that you punched a hole in the wall, tried to run another driver off the road or just totally lost it over a slight isn't easy. And consequently the shame or embarrassment about these violent reactions can understandably prevent people from discussing the problem with their doctors, says coauthor Dr. Maurizio Fava, professor of psychiatry at Harvard Medical School and Massachusetts General Hospital. "Clinicians may also be at fault for concentrating on secondary symptoms, such as anxiety or depression, and not asking about outbursts of anger," he says. But greater awareness of intermittent explosive disorder can help both patients and doctors recognize the need to address the disorder and the havoc it can wreck.

Effective treatment for Intermittent Explosive Disorder includes both behavioral and pharmacological interventions (selective serotonin reuptake inhibitors [SSRIs] and mood stabilizers), says Coccaro. "Ideally, people should be treated with both medicine and cognitive-behavioral therapy. Medicines increase the threshold at which people will explode, and cognitive-behavior therapy teaches people how to handle feelings of frustration or threat that often lead to explosive episodes," he says. Therapy can help teach people to identify triggers that set off attacks of rage.

One thing for sure is that intervention needs to targeted earlier. "If the average onset in males is before age 14, my question is why are we missing it?" asks Jennifer Hartstein, psychologist and assistant professor of Psychiatry and Behavioral Sciences at Montefiore Medical Center in New York City. "Trained people need to be more aware of the diagnosis. ADHD [attention deficit hyperactivity disorder] becomes our go-to diagnosis when kids are inattentive, acting out and having huge temper outbursts. But could some of these problems be better explained with a diagnosis of IED? It is an early warning sign and we are missing it. And if it isn't recognized, these children can't be being taught the coping skills that could help."

The good news is that there are treatment options. But awareness needs to come first. "It appears to come out of nowhere," says Hartstein. "But if someone were to slow it down as though they were watching a movie in slow motion, there are probably times they would notice the buildup of anger. Those are the points at which certain thoughts are taking over and those are the points at which we could potentially help. It is a challenging diagnosis. And it's not just the biological person, but also his or her interactions with their environment. It all argues for an increased awareness and increased presence of school-based mental health clinics."

Intermittent Explosive Disorder may sound exotic now, but chances are we will all hear a lot more about it in the future.

From the Archive:
02/13/2006 Happiness Isn't Normal
11/03/2003 Medicating Young Minds