Under-diagnosed rage disorder more prevalent than previously thought

Intermittent Explosive Disorder could be behind cases of road rage and spousal abuse; Early detection key to treatment

BOSTON--A seldom-studied mental illness called Intermittent Explosive Disorder, characterized by recurrent episodes of angry and potentially violent outbursts--seen in cases of road rage or spousal abuse--has been found to be much more common than previously thought. Depending upon how broadly it is defined, this disorder affects as many as 7.3 percent of adults, or 16 million Americans, in their lifetimes. In a year, Intermittent Explosive Disorder affects nearly 4 percent of Americans, or 8.6 million adults, reports Ronald Kessler, PhD, professor of health care policy at Harvard Medical School (HMS), and colleagues. The study also found that Intermittent Explosive Disorder may predispose people to other mental illnesses and substance abuse. These results are reported in the June 2006 issue of Archives of General Psychiatry.

Intermittent Explosive Disorder attacks are out of proportion to the social stressors triggering them and are not due to another mental disorder or the effects of drugs or alcohol, according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). People with this disorder overreact to situations with uncontrollable rage, feel a sense of relief during the angry outburst, and then feel remorseful about their actions.

"Intermittent Explosive Disorder is not a clinical term well-known in society, but 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 is based on data from the National Comorbidity Survey Replication (NCS-R), a nationally representative face-to-face household survey of 9,282 American adults, conducted from 2001 to 2003. The NCS-R is carried out in conjunction with the World Health Organization World Mental Health Survey Initiative.

"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 Emil Coccaro, MD, the Ellen C. Manning professor and chair of the Department 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."

Among people with this disorder, 81.8 percent 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 Kessler. This raises the possibility that Intermittent Explosive Disorder may be a risk factor for other mental disorders.

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 life where, according to the study, 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/or physical harm (or threat of physical harm) to others.

A narrow definition of Intermittent Explosive Disorder includes three or more of these attacks in one year. In the study, people with narrow Intermittent Explosive Disorder had a more persistent and severe illness, particularly if they attacked both people and property, causing 3.5 times more property damage than other violent Intermittent Explosive Disorder subgroups.

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.

Although most study respondents with the disorder had seen a professional for emotional problems at some time in their lives, only 11.7 percent had been treated for their anger in the 12 months prior to the study interview.

Shame or embarrassment about these violent reactions may prevent people from discussing this disorder with their doctors, says coauthor Maurizio Fava, MD, professor of psychiatry at HMS and Massachusetts General Hospital (MGH). "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.

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 thath often lead to explosive episodes."

A form of cognitive-behavioral therapy involving cognitive restructuring, coping skills training, and relaxation training--a combination known as CRCST--has proven to be effective in treating Intermittent Explosive Disorder, says Coccaro, who is also director of the University of Chicago's Clinical Neuroscience and Psychopharmacology Research Unit. Interventions like CRCST are also helpful because they work to teach people to identify triggers that set off attacks of rage, says Fava, who is also the associate chief of psychiatry for clinical research at MGH and director of the MGH Depression Clinical and Research Program. These programs can teach people to identify triggers that set off attacks of rage.

"The study clearly shows that we have a problem of low early outreach in addition to a problem of under-evaluated treatment technology for this serious condition," says Kessler. "Outreach and treatment intervention studies need to be taken out of the laboratory and into a real-life setting, such as schools. This will help determine the true impact of Intermittent Explosive Disorder on later development and the potential value of early intervention programs in preventing these adverse effects."

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This work was funded by the National Institute of Mental Health, the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the John W. Alden Trust.

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Last reviewed: By John M. Grohol, Psy.D. on 21 Feb 2009
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