Intermittent explosive disorder

Intermittent explosive disorder is a pattern of behavioral outbursts in adults 18 years and older characterized by an inability to control aggressive impulses. The aggression can be verbal or physical and targeted toward other persons, animals, property, or even themselves. It was originally termed monomanie instinctive, referring to how these impulsive acts seem almost instinctive.

Anything can trigger the inappropriate aggression reaction to the situation. An example may be a person punching his fist through a pane of glass after not being able to locate his favorite video game. He may destroy his room, break furniture, or damage costly properly. As the rage continues, he may attack anyone who intervenes and often causes injury. The explosive anger may occur during a competitive sport, such as lashing out at opposing baseball fans when his team loses. The behavior needs to show a repetitive pattern and interference with normal functioning, such as a person being unable to stay employed because they scream and curse at their boss when given any negative feedback (Tamam et al., 2011).

The pattern goes from being upset to being remorseful. The first stage is tension and arousal based on some environmental stimuli, such as someone driving too slowly in the passing lane on the expressway. This is followed by explosive behavior and aggression. A response to the slow driver may be hitting the gas and dangerously passing the person on the shoulder of the road. Immediately thereafter the person experiences a sense of relief and release, taking satisfaction by looking at the offender in the rearview mirror and delivering a negative hand signal. Delayed consequences include feelings of remorse, regret, and embarrassment over the aggressive behavior. After the event, reality may set in. “Wow, I just risked my life to pass an 80-year-old man to get to a party that will go on for hours. I have to stop doing this.”

This disorder can impede on a person’s functioning by leading to problems with interpersonal relationships and occupational difficulties and can lead to criminal problems as well. Additionally, significant problems with physical health, such as hypertension and diabetes, have been linked to this disease (McCloskey et al., 2010). Being in a heightened state of stress and agitation for a prolonged period of time may be the correlation.

Conduct disorder

Conduct disorder is a persistent pattern of behavior in which the rights of others are violated and societal norms or rules are disregarded. The behavior is usually abnormally aggressive and can frequently lead to destruction of property or physical injury. Persons with this disorder initiate physical fights and bully others, and they may steal or use a weapon to intimidate or hurt others. Coercion into activity against the will of others, including sexual activity, is characteristic of this disorder. These behaviors are enduring patterns and continue over a period of 6 months and beyond.

It is one of the most frequently diagnosed disorders of childhood and adolescence. The people affected by this disorder may have a normal intelligence, but they tend to skip class or disrupt school so much that they fall behind and may be expelled or drop out. Complications associated with conduct disorder include academic failure, school suspensions and dropouts, juvenile delinquency, drug and alcohol abuse and dependency, and juvenile court involvement (Harvard Medical School, 2011). People with conduct disorder crave excitement and do not worry as much about consequences as others do.

Though the literature tends to focus on children and adolescents with conduct disorder, it is quite a problem in adults as well. In adults, conduct disorder has similar characteristics of aggression, destruction of property, stealing, deceitfulness, and criminal behavior. Adults, like younger persons, have family problems based on self-interest and lack of engagement. Rule breaking takes such forms as parole violation, disregard for general laws such as speed limits, and employment problems such as frequent lateness or absence with unacceptable or unbelievable excuses.

There are two subtypes of conduct disorder—child-onset and adolescent-onset—both of which can occur in mild, moderate, or severe forms. Predisposing factors are ADHD, oppositional child behaviors, parental rejection, inconsistent parenting with harsh discipline, early institutional living, chaotic home life, large family size, absent or alcoholic father, antisocial and drug-dependent family members, and association with delinquent peers.

Childhood-onset conduct disorder occurs prior to age 10 years and is found mainly in males who are physically aggressive, have poor peer relationships, show little concern for others, and lack feelings of guilt or remorse. These children frequently misperceive others’ intentions as hostile and believe their aggressive responses are justified. Violent children also often display antisocial reasoning, such as “he deserved it,” when rationalizing aggressive behaviors (Farrell et al., 2008). Children with childhood-onset conduct disorder attempt to project a strong image, but they actually have a low self-esteem. Limited frustration tolerance, irritability, and temper outbursts are hallmarks of this disorder. Individuals with childhood-onset conduct disorder are more likely to have problems that persist through adolescence, and without intensive treatment they may later develop antisocial personality disorder as adults.

In adolescent-onset conduct disorder, no symptoms are present prior to age 10. Affected adolescents tend to act out misconduct with their peer group (e.g., early onset of sexual behavior, substance abuse, risk-taking behaviors). Males are more likely to fight, steal, vandalize, and have school discipline problems whereas girls tend to lie, be truant, run away, abuse substances, and engage in prostitution. The male-to-female ratio is not as high as for the childhood-onset type, indicating more girls become aggressive during this period of development.

There is a subset of people with conduct disorder who are also referred to as being callous and unemotional. Callousness is characterized by a lack of empathy, such as disregarding and being unconcerned about the feelings of others, having a lack of remorse or guilt except when facing punishment, and being unconcerned about meeting school and family obligations; unemotional traits include a shallow, unexpressive, and superficial affect (Stellwagen & Kerig, 2010). Callousness may be a predictor of future antisocial personality disorder in adults (Burke et al., 2010).

Two problems are related to impulse control disorders and are worthy of mention in this chapter. They are pyromania and kleptomania. Pyromania is described as repeated deliberate fire setting. The person experiences tension or becomes excited before setting a fire and shows a fascination with or unusual interest in fire and its contexts such as matches. The person also experiences pleasure or relief when setting a fire, witnessing a fire, or participating in the aftermath of a fire. The fire setting is done solely to satisfy this relief pleasure and not for other reasons, such as to conceal a crime. Like many mental illnesses, this disorder can stem from a form of maladaptive coping a person learned early in life in relation to having unmet needs and poorer social skills (Lyons et al., 2010).

Kleptomania is a repeated failure to resist urges to steal objects not needed for personal use or monetary value. For example, a person may take books even though they cannot read or baby outfits they consider cute even though they have no children and have plenty of money to buy them. The person experiences a buildup of tension before taking the object, and this is followed by relief or pleasure following the theft. Some research has explored whether this disorder is more closely linked to others of addictive behavior, such as substance abuse disorder, since the person is acting to satisfy a compulsion (Talih, 2011).

See Table 21-1 for a summary of the characteristics of impulse control disorders.

Gender differences

In regard to oppositional defiant disorder, the disorder is more prevalent in males than females prior to puberty, but the rates equal out after puberty. Symptoms are similar in both sexes, but again males tend to have more confrontational behaviors and also more persistent symptoms.

In general, violent behavior is more common in males than in females. This explains why both intermittent explosive disorder and conduct disorder are more common in males. Males also tend to display more confrontational and aggressive behaviors, such as fighting, while females with conduct disorder tend to show less confrontational behaviors, such as lying.

Genetic

Oppositional defiant disorder tends to occur at a young age and may be related to genetics. Many individuals diagnosed with this disorder have a family history of other mental illness. It may be that genetics produces a vulnerability or predisposition to developing oppositional defiant disorder; likewise, intermittent explosive disorder genetics appears to run in families (Coccaro, 2010). Conduct disorders are more common in children and adolescents whose parents were similarly afflicted (Mental Health America, 2012).

Neurobiological

Research demonstrates that gray matter is less dense in the left prefrontal cortex in young patients with oppositional defiant disorder (Fahim et al., 2012). This area is associated with impulse control and self-regulation. The young patients also had an increase in gray matter in the left temporal area. This area is associated with impulsivity, aggression, and antisocial personality. In boys, the structural abnormalities in brains are more pronounced—gray matter density in the orbitofrontal cortex and white matter density in the superior frontal area are reduced.

People with intermittent explosive disorder may have differences in serotonin regulation in the brain. Also, higher levels of the hormone testosterone have been associated with intermittent explosive disorder.

Adolescents with conduct disorder have been found to have significantly reduced gray matter bilaterally in the anterior insulate cortex and the left amygdala (Sterzer et al., 2007). The insulate cortex is believed to be involved in emotion and empathy, and the amygdala also helps to process emotional reactions. Researchers believe that this reduction may be related to aggressive behavior and have found a positive correlation between this deficit and empathy scores. That is, the less gray matter in these regions of the brain, the less likely adolescents are to feel remorse for their actions or victims. Fairchild and colleagues (2011) found that regardless of age of onset gray matter reductions crucial in brain regions for processing emotional stimuli contribute to this disorder.

Psychological factors

Children with conduct disorders tend to utilize more immature styles of coping and problem solving. People with conduct disorders may be compensating and covering for low self-esteem, which is common with this disorder. They may respond impulsively to situations that remind them either consciously or unconsciously of trauma that they experienced in their childhoods. People who are brought up in chaotic and negligent conditions develop poor emotional responses that are more primitive and id-based, and less ego- and superego-driven. A history of not having their own needs met results in an individual who has a less well-developed sense of empathy.

Intermittent explosive outbursts may be a way of protecting the ego by creating interpersonal distance from others. Vulnerable feelings are compensated for by displays of aggression.