Intermittent explosive disorder: Taming temper tantrums in the volatile, impulsive adult
More-inclusive diagnostic criteria acknowledge the true prevalence of this aggression disorder, and a new algorithm suggests a two-pronged treatment approach.
All subjects met research criteria for IED. A reanalysis suggests that SSRIs may be most effective in moderately aggressive patients (Table 3),17 whose serotonergic system may be less impaired than that of highly aggressive patients.18
Mood stabilizers. Impulsively aggressive subjects who do not respond to an SSRI may respond to a mood stabilizer.19 An antiaggressive response in IED-like subjects has been reported for lithium,20 carbamazepine,21 and diphenylhydantoin.22
Recently, Hollander et al23 reported greater reduction in overt aggression scores in IED subjects with a DSM cluster B personality disorder who were treated with divalproex, compared with placebo. This study used the same design and outcome measure as our study12 and included subjects who met both DSM-IV and research criteria for IED.
For unknown reasons, divalproex was no more effective than placebo in IED subjects without cluster B personality disorder. More research is needed to uncover predictors of antiaggressive response in IED subjects.
Unipolar vs. bipolar. McElroy9 has suggested using SSRIs (or other antidepressants) as first-line treatment for IED subjects with unipolar affective symptoms and mood stabilizers for those with bipolar affective symptoms. IED subjects without bipolar affective symptoms should be treated first with SSRIs (Algorithm). Preliminary data suggest a role for atypical antipsychotics to treat aggressive behavior in patients with schizophrenia or bipolar disorder, but no empiric data exist.
Beta blockers such as propranolol also may be considered.2 However, beta blockers are more difficult to dose and are associated with more burdensome side effects, compared with SSRIs.
Algorithm Suggested 2-pronged approach for treating intermittent explosive disorder
* With or without an anger management program, which may precede drug interventionThe full effects of antiaggressive treatment with an SSRI (E. Coccaro, unpublished observations) or a mood stabilizer19 may take 3 months to observe12,20,22,23 and tend to disappear soon after treatment is discontinued.
Therefore, an adequate trial of SSRIs or mood stabilizers is no less than 3 months. If improvement is seen, continue drug treatment indefinitely.
Case report continued.
Mr. P was started on an SSRI. His aggressive outbursts decreased in intensity and frequency over 3 months but were not eliminated. After 6 months he dropped out of treatment, but returned 5 weeks later because his aggressive outbursts had resumed their pre-treatment level.
SSRI treatment was restarted, and Mr. P began a 12-week anger management course of relaxation training, cognitive restructuring, and coping skills training. He gained greater control over his aggressive outbursts and continues monthly medication checks and anger management “booster sessions.”
Related resources
- Galovski T, Blanchard EB, Veazey C. Intermittent explosive disorder and other psychiatric comorbidity among court-referred and self-referred aggressive drivers. Behav Res Ther 2002;40:641-51.
- Olvera RL. Intermittent explosive disorder: epidemiology, diagnosis and management. CNS Drugs 2002;16:517-26.
Drug brand names
- Carbamazepine • Tegretol
- Diphenylhydantoin • Dilantin
- Divalproex • Depakote
- Fluoxetine • Prozac
- Lithium • Lithobid
- Propanolol • Inderal
Disclosure
Dr. Coccaro reports that he receives research grants and serves on the speaker’s bureau or as a consultant to Eli Lilly and Co., Abbott Laboratories, GlaxoSmithKline, and Forrest Laboratories.
