The Angry People – Intermittent Explosive Disorder:


Wayne Fenton, MD was not just a regular psychiatrist. He was
an associate director for clinical affairs at the National Institute of Mental
Health. He was a co-author of 50 scientific papers, chapters and a textbook on
schizophrenia. He served as a Consultant to the Department of Justice, Civil
Rights Division. He was involved with the World Psychiatric Association.


If even Dr. Wayne Fenton, a world-class psychiatrist, could
not predict this angry and deadly violent outburst from a “typical” bipolar or
schizophrenic patient, how we, lay people, could recognize and predict it in
people around us? How we, who live closely with this type of persons could
predict what next will provoke the anger? How other people would believe us if
we tell them that this handsome man is a violent husband or this cute lady is a
witch’s mother?


Not many people know about The
Anger Disorder with a confusing and politically correct name: Intermittent
Explosive Disorder [IED]. IED is more prevalent than panic disorder and
warrants our full attention. Depending on how it is defined, IED affects
between 5.4% and 7.3% of adults (11.5 to 16 million angry Americans!) in their
lifetimes based on the study of 9,282 US adults aged 18 years and older.


IED affects not only the person
who has it, but all people around the person with the disorder – the people
whom the lamp gets thrown at or who are verbally abused, – noted a professor
from Harvard Medical School, Dr. Ronald Kessler.

Explaining why IED has gone
relatively unnoticed in the psychiatric community, Dr. Kessler pointed out that
people who are angry have not traditionally sought help in the same way as
people who are depressed or anxious. Most of these persons received treatment
for emotional problems but not for their anger.


“So what it is telling us is that
a lot of these people are sitting in mental health professionals’ offices, but
the clinicians don’t ask and the patients don’t volunteer that they have this
problem,” Dr. Kessler said. “They are there talking about their alcoholism,
depression, or anxiety, but not about their anger.”


Mental health professionals don’t
ask about anger, because they don’t know what to do once they find out about
it, Dr. Kessler believes. Another factor relates to different definitions of
Disorder versus Normal variation. American classification of psychiatric
Disorders – DSM-IV has the following criteria for IED:

  • Several discrete episodes of
    failure to resist aggressive impulses that result in serious assaultive
    acts or destruction of property.
  • The degree of aggressiveness
    expressed during the episodes is grossly out of proportion to any
    precipitating psychosocial stressors.
  • The aggressive episodes are not
    better accounted for by another medical disorder.


In another type of diagnostic
Interview, the aggressive episodes criterion was defined by requiring the
respondent to report at least 1 of 3 types of anger attacks: suddenly losing
control and breaking or smashing something worth more than a few dollars;
hitting or trying to hurt someone; or threatening to hit or hurt someone. The
“several episodes” criterion was delineated by using narrow versus broad
definitions: 3 or more attacks during one’s lifetime (the broad definition) or
3 attacks in the same year (the narrow definition).

Dr. Emil Coccaro from Chicago
recommends that the narrow definition of IED be included in upcoming DSM-V,
since it is “really more compatible with a pathologic condition that you
treat. If somebody has 3 big attacks in the course of their life and they are
50 years old, what are you going to treat?”


IED is not just another name for
bad behavior. It is a real disorder with a biologic basis. There are brain
networks that are altered in IED. Specifically, the frontal lobes don’t inhibit
the lower centers of the brain, which are actually hyperactive in response to
threat by anger outbursts.


Angry people, especially if they
are violent, are easy to diagnose. The only tricky aspects are judging whether
someone has mostly impulsive aggression as opposed to premeditative aggression,
determining to what degree the impulsivity and aggression are impairing
function, and ensuring that the patient does not have bipolar illness or
another mental disorder that would better account for the behavior.


Biochemical basis of anger lies
in deviation of the balance between dopamine and serotonin metabolic networks.
By the way, serotonin is a major neurotransmitter of sleep. That is why anger
and aggression increased after sleep deprivation and during night times.


Both medications and
psychotherapy have been used to treat IED, according to Dr. E. Coccaro. “We think
any of the SSRIs will work because they increase serotonin, and by doing that,
they increase the threshold at which somebody is going to explode, given
whatever provocation they have,” he said. “Other drugs that will work are some
of the mood stabilizers for persons with some personality disorders.”


Research in treatment of angry
people is under way. In the meantime, be aware and stay away from them, if you
can. If not, ask for help. Do not procrastinate until it too late.

Ref: Psychiatric Times, January, 2007 – Vol. XXIV, No. 1