Intermittent explosive disorder
IED is defined by recurrent, significant outbursts of aggression, often leading to assaultive acts against people or property, which are disproportionate to outside stressors and are not better explained by another psychiatric diagnosis. Research suggests IED is common, with 6.3% of a community sample meeting criteria for lifetime IED.21
IED symptoms tend to start in adolescence and appear to be chronic.21,22 People with IED regard their behavior as distressing and problematic.22 Outbursts generally are short-lived (usually <30 minutes) and frequent (multiple times a month22). Legal and occupational difficulties are common.22
Pharmacotherapy. Data on drug treatment for IED comes for a small set of double-blind studies (Table). Although pharmacotherapies have been studied for treating aggression, impulsivity, and violent behavior, only 5 controlled studies are specific to IED.
A double-blind, randomized, placebo-controlled trial of fluoxetine in 100 participants with IED found that fluoxetine produced a sustained reduction in aggression and irritability as early as the second week of treatment. Full or partial remission of impulsive aggressive behaviors occurred in 46% of fluoxetine-treated subjects. These findings have been supported by studies assessing other samples of aggressive patients, but not specifically IED.23,24 Another treatment study found that oxcarbazepine produced significant improvements in IED symptom severity, specifically on impulsive aggression.25
In a randomized, double-blind, placebo-controlled study, 96 participants with Cluster B personality disorders, 116 with IED, and 34 with posttraumatic stress disorder were assigned to divalproex sodium or placebo for 12 weeks. Using an intent-to-treat analysis, divalproex had no significant influence on aggression in patients with IED.26 Similarly, a study assessing levetiracetam for IED did not show any improvements to measures of impulsive aggression.27
Psychological treatments. The only available study on psychological treatments for IED found that patients receiving active cognitive-behavioral therapy (CBT) or group therapy showed significant improvements compared with waitlist controls. These improvements spanned several target symptoms of IED.28
Conclusions. Although there is a paucity of treatment studies for IED, fluoxetine may be an effective treatment based on available studies, and oxcarbazepine has shown some preliminary efficacy. CBT also has shown some initial efficacy in reducing symptom severity in IED.
The essential feature of CD is a repetitive and persistent pattern of behavior in which the basic rights of others or social norms are violated.3 These behaviors can entail:
• aggressive conduct that causes or threatens harm to others or to animals
• nonaggressive behavior resulting in property damage
• deceitfulness or theft
• serious violation of rules.
Prevalence among the general population is 2% to 10%. The disorder is more common among boys than girls.3
Pharmacotherapy. No medication is FDA-approved to treat CD. Fifteen controlled studies have examined medications in patients with CD (Table), although a number of these included a high rate of comorbid ADHD.
To date, 7 studies have shown efficacy with lithium for patients with CD.29-35 A number of trials assessing lithium also included a treatment condition with haloperidol, which showed significant improvement.29,30,33,34 Both lithium and haloperidol were associated with select deficits on cognitive tests, suggesting that there may be risks associated with these medications.
Preliminary double-blind results have indicated that methylphenidate, risperidone, quetiapine, molindone, thioridazine, and carbamazepine might be effective options for treating CD.36-43 The evidence for these medications is limited and additional studies are needed to replicate initial findings.
Three studies of divalproex sodium have shown some efficacy in randomized studies comparing high and low dosages of the drug.40-42 Because these studies did not include a placebo, additional studies are necessary to corroborate these findings.
Psychological treatments. Several forms of behavioral, family-based, and school-based therapies have been found effective in randomized trials. Specifically, behavioral therapy and parental skills training have shown consistent benefits for patients and their families. As with ODD, parental training programs for CD focus on parents’ skill acquisition to help manage outbursts and aggressive behavior. These treatments often follow a similar course to those used for other externalizing and disruptive disorders.44-46
Conclusions. Based on evidence, psychotherapy and some pharmacotherapies (eg, lithium) could be considered first-line treatment options for CD. Psychotherapy programs have shown efficacy in reducing aggression in high-risk groups.44 Lithium or antipsychotics could be useful for patients who do not respond sufficiently to psychotherapy. The risk of cognitive deficits with lithium and antipsychotics should be weighed against potential benefits of these medications.33,34
Kleptomania is characterized by repetitive, poorly controlled stealing of items that are not needed for personal use. Kleptomania often begins in late adolescence or early adulthood.47 The course of the illness generally is chronic, with waxing and waning symptoms. Women are twice as likely as men to suffer from kleptomania.48 People with kleptomania frequently hoard, discard, or return stolen items.47