Criteria For Intermittent Explosive Disorder Research Articles

Salivary cortisol awakening levels are reduced in human subjects with intermittent explosive disorder compared with controls

BackgroundThe role of the hypothalamic-pituitary-adrenal (HPA) axis in human aggressive behavior is poorly characterized, though some studies report that, unlike depression, circulating or salivary levels of cortisol are low compared with controls. MethodsIn this study, we collected three salivary cortisol levels (two in the morning and one in the evening) on three separate days in 78 adult study participants with (n = 28) and without (n = 52) prominent histories of impulsive aggressive behavior. Plasma C-Reactive Protein (CRP) and Interleukin-6 (IL-6) were also collected in most study participants. Aggressive study participants meet DSM-5 criteria for Intermittent Explosive Disorder (IED) while non-aggressive participants either had a history of a psychiatric disorder or no such history (Controls). ResultsMorning, but not evening, salivary cortisol levels were significantly lower in IED (p < 0.05), compared with control, study participants. In addition, salivary cortisol levels correlated with measures of trait anger (partial r = −0.26, p < 0.05) and aggression (partial r = −0.25, p < 0.05) but not with measures of impulsivity, psychopathy, depression, history of childhood maltreatment, or other tested variables that often differ in individuals with IED. Finally, plasma CRP levels correlated inversely with morning salivary cortisol levels (partial r = −0.28, p < 0.05); plasma IL-6 levels showed a similar, though not statistically significant (rp = −0.20, p = 0.12) relationship with morning salivary cortisol levels. ConclusionThe cortisol awakening response appears to be lower in individuals with IED compared with controls. In all study participants, morning salivary cortisol levels correlated inversely with trait anger, trait aggression, and plasma CRP, a marker of systemic inflammation. This suggests the present of a complex interaction between chronic-low level inflammation, the HPA axis, and IED that warrants further investigation.

A wait-list controlled study of a trauma-focused cognitive behavioral treatment for intermittent explosive disorder in Timor-Leste.

We tested a trauma-focused, cognitive-behavior therapy treatment (TF-CBT-anger) for intermittent explosive disorder (IED) and related dimensions of anger adapted to the local culture in postconflict Timor-Leste. The intention-to-treat sample (n = 78) comprised Timorese nationals (women = 49; men = 29), ages 18 years and older, meeting Diagnostic and Statistical Manual of Mental Disorders (4th ed.) criteria for IED, with equal numbers (n = 39 each) being randomized to the treatment group (TG) and wait-list (WL). Assessments were made at 1 week prior to therapy, immediately at posttreatment, and at 1 month follow-up. Primary measures included an IED diagnosis made according to the East Timor explosive anger measure and the directionality of expression and control of anger assessed by 4 dimensions of the State-Trait Anger Expression Inventory (STAXI-2). Secondary measures included psychological distress assessed using the Kessler scale and an index of posttraumatic stress disorder (PTSD) assessed using the Harvard Trauma Questionnaire. In the TG, there was a decline in IED from 100% to zero at follow-up. In the WL, more than 70% (of the 100% at baseline) showed persisting IED at second and third assessments. The TG alone showed significant (p < .05) improvements on all STAXI-2 scales, the effect sizes for the intervention being uniformly large (>0.80). Psychological distress and PTSD showed substantial reductions in the TG but not the WL group. Although based on a modest-sized sample, our findings provide the first evidence in support of the efficacy of TF-CBT-anger for IED in a culturally diverse, postconflict setting. (PsycINFO Database Record

Development of a screening questionnaire for DSM-5 intermittent explosive disorder (IED-SQ)

ObjectiveThis study was designed to develop and test a screening approach to identify individuals with DSM-5 Intermittent Explosive Disorder (IED), a disorder of recurrent, problematic, impulsive aggression. MethodsA screening approach to diagnose DSM-5 IED (IED-SQ) was developed by combining items related to life history of aggression and items related to the DSM-5 diagnostic criteria for IED. In study 1, the IED-SQ was studied in 72 adult participants; 33 that met DSM-5 criteria for lifetime IED and 39 that did not. In study 2, the IED-SQ was given to 740 undergraduates at a US university. Measures of aggression and anger expression and anger control were assessed in both studies. ResultsIn study 1, the IED-SQ demonstrated strong concordance with the best estimate diagnoses (Kappa =.80) for lifetime IED by DSM-5 criteria and good test–retest reliability (kappa =0.71). In study 2, the IED-SQ identified 4.3% of the undergraduate sample as meeting DSM-5 criteria for lifetime IED, a rate comparable to that in recent epidemiological studies. Participants identified as meeting DSM-5 criteria for lifetime IED, in both studies, had higher aggression scores, and higher anger expression, and lower anger control scores, compared to participants that did not meet DSM-5 criteria for lifetime IED. ConclusionsThese data suggest that the IED-SQ is a useful screening tool that can quickly identify the presence of IED by DSM-5 criteria in adults.

Prevalence of DSM-IV intermittent explosive disorder in Black adolescents: Findings from the National Survey of American Life, Adolescent Supplement.

Little is known about the epidemiology of Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM–IV) intermittent explosive disorder (IED) in adolescents, and no information is currently available regarding the relationship between race/ethnicity and IED among Black youth in the United States. Using the World Health Organization World Mental Health Composite International Diagnostic Interview (Adolescent Version), we estimated the prevalence, severity, and disability of IED in a national, probability sample of African American and Caribbean Black youth (ages 13–17) from the National Survey of American Life, Adolescent Supplement. Face-to-face surveys of 810 African American and 360 Caribbean Black youth were conducted between 2001 and 2003. We calculated lifetime and 12-month diagnoses of IED using diagnostic algorithms based on DSM–IV and assessed IED disability using a modified Sheehan Disability Scale. Overall findings indicated lifetime and 12-month IED prevalence rates of 9.2% and 7.0%, respectively. Lifetime prevalence rates of IED were 9.0% for African American and 12.4% for Caribbean Black teens. Within the past 12 months, 6.7% of African American and 11.5% of Caribbean Black adolescents met diagnostic criteria for IED. Lifetime and 12-month IED were associated with anxiety disorders. In addition, few teens with lifetime IED received any treatment. Findings are consistent with recent evidence that intermittent explosive disorder may be more common than previously considered, especially among adolescents. Significant acts of aggression and impairment are associated with IED, and low treatment rates indicate that more research on this disorder and intervention options is warranted.

Testing a cycle of family violence model in conflict-affected, low-income countries: A qualitative study from Timor-Leste

The present study examines key aspects of an emerging cycle of violence model as applied to conflict-affected countries. We focus specifically on the roles of intimate partner violence (IPV), consequent experiences of explosive anger amongst women, and associated patterns of harsh parenting. Between 2010 and 2011, we conducted a women-centred and culturally sensitive qualitative inquiry with 77 mothers drawn consecutively from a data-base of all adults residing in two villages in Timor-Leste. We over-sampled women who in the preceding whole of household survey met criteria for Intermittent Explosive Disorder (IED). Our methodology included in-depth qualitative interviews followed by a focus group with a comprehensive array of service providers. We used the NVivo software package to manage and analyse data. Our findings provide support for a link between IPV and experiences of explosive anger amongst Timorese mothers. Furthermore, women commonly reported that experiences of explosive anger were accompanied by harsh parenting directed at their children. Women identified the role of patriarchy in legitimizing and perpetuating IPV. Our findings suggest that empowering women to address IPV and poverty may allow them to overcome or manage feelings of anger in a manner that will reduce risk of associated harsh parenting. A fuller examination of the cycle of violence model will need to take into account wider contributing factors at the macro-level (historical, conflict-related, political), the meso-level (community-wide adherence to patriarchal norms affecting the rights and roles of women), and the micro-level (family interactions and gendered role expectations, individual psychological responses, and parenting). Longitudinal studies in post-conflict settings are needed to examine whether the sequence of male violence against women, mothers experience of explosive anger, and consequent harsh parenting contributes to risk of aggression and mental disorder in offspring, both in childhood and adulthood.

Intermittent Explosive Disorder and aversive parental care

Parental bonding has been shown to have lasting impacts on the psychological development of children. Despite a growing body of research examining trauma as it relates to Intermittent Explosive Disorder (IED), no prior research has examined the relationship between parental bonding and IED. Six hundred fifty eight subjects were studied and categorized into one of three groups: Normal Control (no history of current or lifetime Axis I or Axis II disorder), Psychiatric Control (current and/or lifetime Axis I and/or Axis II disorders without IED), and IED (met current and/or lifetime criteria for IED). Self-reported parental care was assessed using the Parental Bonding Inventory (PBI). PBI Care scores were lowest among IED subjects, which were lower than among Psychiatric Control subjects, which were lower than among Normal Control subjects. PBI Control scores were highest among IED and Psychiatric Control subjects, which were higher than among Normal Control subjects. The diagnostic group differences in PBI Care/PBI Control scores were not impacted by the number of Axis I/II diagnoses. The findings in this study expand the link between childhood trauma exposure, violent behavior, and IED. This is the first report of an association of IED with an aversive childhood parenting environment.

Validity of the new A1 and A2 criteria for DSM-5 intermittent explosive disorder

A disorder of impulsive aggression has been in the Diagnostic and Statistical Manual for Mental Disorders (DSM) since the first edition. In DSM-III, this disorder was codified as Intermittent Explosive Disorder (IED) and was thought to be rare. However, DSM criteria for IED were poorly operationalized and empiric research in IED was limited until the past decade when research criteria were developed. Subsequently, renewed interest in disorders of impulsive aggression led to a recent series of community based studies that have now documented IED to be as common as many other psychiatric disorders. Recent research indicates that the core of IED (A criteria) can be captured with new criteria that identify high frequency/low intensity aggressive outbursts (A1) and low frequency/hi intensity outbursts (A2). This paper presents new data regarding the phenomenology, comorbidity/life course of IED as a function of A1 and A2 criteria. Together with reanalysis of previously published data regarding family history, biomarkers, and treatment response in individuals with recurrent, problematic, impulsive aggression, these data provide empirical support for both A1 and A2 criteria for DSM-5 IED.

Intermittent Explosive Disorder in the National Comorbidity Survey Replication Adolescent Supplement

Epidemiologic studies of adults show that DSM-IV intermittent explosive disorder (IED) is a highly prevalent and seriously impairing disorder. Although retrospective reports in these studies suggest that IED typically begins in childhood, no previous epidemiologic research has directly examined the prevalence or correlates of IED among youth. To present epidemiologic data on the prevalence and correlates of IED among US adolescents in the National Comorbidity Survey Replication Adolescent Supplement. United States survey of adolescent (age, 13-17 years) DSM-IV anxiety, mood, behavior, and substance disorders. Dual-frame household-school samples. A total of 6483 adolescents (interviews) and parents (questionnaires). The DSM-IV disorders were assessed with the World Health Organization Composite International Diagnostic Interview (CIDI). Nearly two-thirds of adolescents (63.3%) reported lifetime anger attacks that involved destroying property, threatening violence, or engaging in violence. Of these, 7.8% met DSM-IV/CIDI criteria for lifetime IED. Intermittent explosive disorder had an early age at onset (mean age, 12.0 years) and was highly persistent, as indicated by 80.1% of lifetime cases (6.2% of all respondents) meeting 12-month criteria for IED. Injuries related to IED requiring medical attention reportedly occurred 52.5 times per 100 lifetime cases. In addition, IED was significantly comorbid with a wide range of DSMIV/CIDI mood, anxiety, and substance disorders, with 63.9% of lifetime cases meeting criteria for another such disorder. Although more than one-third (37.8%) of adolescents with 12-month IED received treatment for emotional problems in the year before the interview, only 6.5% of respondents with 12-month IED were treated specifically for anger. Intermittent explosive disorder is a highly prevalent, persistent, and seriously impairing adolescent mental disorder that is both understudied and undertreated. Research is needed to uncover risk and protective factors for the disorder, develop strategies for screening and early detection, and identify effective treatments.

IED Quite Common, but Treatments Elusive

Back to table of contents Previous article Next article Clinical & Research NewsFull AccessIED Quite Common, but Treatments ElusiveJoan Arehart-TreichelJoan Arehart-TreichelSearch for more papers by this authorPublished Online:17 Aug 2012https://doi.org/10.1176/pn.47.16.psychnews_47_16_12-aAbstractRonald Kessler, Ph.D., a professor of health care policy at Harvard Medical School, isn’t easily astonished by mental illness. He headed up the National Comorbidity Survey Replication (Psychiatric News, July 15, 2005). But the outcome of his most recent national mental disorder prevalence study—of intermittent explosive disorder (IED) among adolescents—came, he told Psychiatric News, “as a complete surprise.”Ronald Kessler, Ph.D.“I was surprised by the large proportion of adolescents in the United States who meet criteria for IED,” he admitted. “It is one of the most common of all DSM-IV disorders among adolescents. …”In essence, Kessler and his team found in their national sample of some 6,500 adolescents in which they used a modified version of the Composite International Diagnostic Interview, that 8 percent met DSM-IV criteria for lifetime IED. The disorder is characterized by recurrent episodes of aggression involving violence or destruction of property out of proportion to a provocation or precipitating stressors and is not explained by another mental disorder or by substance abuse.Still other provocative findings emerged from the study, which was published online in the July Archives of General Psychiatry.IED had an early age of onset, on average at age 12, and was highly persistent, as indicated by 80 percent of lifetime cases meeting 12-month criteria for IED.Moreover, every other time a youngster with lifetime IED experienced an outburst of anger, he or she injured someone enough that that person needed medical attention.While more than one-third of adolescents with current IED received treatment for emotional problems in the year before the diagnostic interview, only 7 percent were treated specifically for anger.And whereas boys were more likely than girls to engage in anger outbursts, the prevalence of IED did not differ between boys and girls. Kessler said he cannot explain this apparent contradiction. But “speculatively,” he said, “it’s likely that there are a lot of reasons why people have anger attacks. Some of them involve other mental disorders, like conduct disorder, bipolar disorder, and substance use disorder. Others occur for reasons unrelated to mental disorders. And then there are the minority of anger attacks that are due to IED.”The study results have clinical implications, Kessler believes. “I would like clinicians to know that an awful lot of adolescents have anger attacks who are not being treated,” he said. “And if effective treatments exist, there should be efforts to get a higher proportion of these youth into treatment.”Yet when Psychiatric News asked Emil Coccaro, M.D., chair of psychiatry at the University of Chicago and an expert on IED treatments, whether there are any evidence-based treatments for IED in adolescents, he replied: “Yes, but there’s not that much data in this regard, partly because child and adolescent psychiatrists don’t use IED as a diagnosis that often, given that there are other disruptive behavior disorders that they can give as a diagnosis.”David Fassler, M.D., a child and adolescent psychiatrist who is a clinical professor of psychiatry at the University of Vermont and APA’s treasurer, noted that “There is no specific or ‘approved’ treatment for IED. In general, treatment would be individualized to the person.… Psychotherapy will generally be the key, often augmented by medication.”For example, Fassler said, cognitive-behavioral therapy can help youth with the disorder identify situations or behaviors that may trigger an aggressive response and teach them how to manage their anger and control inappropriate responses with relaxation exercises. Medications that may help include antidepressants, anticonvulsants, antianxiety agents, and mood regulators, he said.The study was funded by the National Institutes of Health, the Substance Abuse and Mental Health Services Administration, the Robert Wood Johnson Foundation, and the John W. Alden Trust. “Intermittent Explosive Disorder in the National Comorbidity Survey Replication Adolescent Supplement” is posted at http://archpsyc.jamanetwork.com/article.aspx?articleid=1206777. ISSUES NewArchived

Table of Contents

AbstractEarly Stimulant Use for ADHD Lowers Risk of Academic DeclineFDA Study Finds Spike in ADHD Medication Use in ChildrenVariables Found in How Parents Medicate ADHD ChildStudy Proposes New Criteria for Intermittent Explosive Disorder in DSM‐5Donepezil Not Effective for Fragile X SyndromeAge Differences Found in Mania Symptom SeverityLink Between Gene Variant and Antipsychotic‐Induced Weight GainMethylphenidate‐Induced Orofacial and Extremity DyskinesiaEffectiveness of Antipsychotics for Anorexia NervosaCelecoxib Added to Risperidone Effective for AutismGuanfacine ER and Excessive Weight GainLabeling Update: StratteraApprovalsShortages

Intermittent Explosive Disorder as a Disorder of Impulsive Aggression for DSM-5

A disorder of impulsive aggression has been included in DSM since the first edition. In DSM-III, this disorder was codified as intermittent explosive disorder, and it was thought to be rare. However, the diagnostic criteria for the disorder were poorly operationalized, and empirical research was limited until research criteria were developed a decade ago. Subsequently, renewed interest in disorders of impulsive aggression led to a recent series of community-based studies that have documented intermittent explosive disorder to be as common as many other psychiatric disorders. Other recent research indicates that compared with DSM-IV criteria for intermittent explosive disorder, research criteria for the disorder better identify individuals with elevated levels of aggression, impulsivity, familial risk of aggression, and abnormalities in neurobiological markers of aggression. In addition, other data strongly suggest important delimitation from other disorders previously thought to obscure the diagnostic uniqueness of intermittent explosive disorder. Overall, these data suggest that the diagnostic validity for the integrated research criteria is substantial and is now sufficient for recognition and inclusion in DSM-5.

Intermittent explosive disorder: development of integrated research criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

This study was designed to develop a revised diagnostic criteria set for intermittent explosive disorder (IED) for consideration for inclusion in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition ( DSM-V). This revised criteria set was developed by integrating previous research criteria with elements from the current DSM-IV set of diagnostic criteria. Evidence supporting the reliability and validity of IED-IR (“IED Integrated Criteria”) in a new and well-characterized group of subjects with personality disorder is presented. Clinical, phenomenologic, and diagnostic data from 201 individuals with personality disorder were reviewed. All IED diagnoses were assigned using a best-estimate process (eg, kappa for IED-IR >0.85). In addition, subjects meeting IED-IR criteria had higher scores on dimensional measures of aggression and had lower global functioning scores than non–IED-IR subjects, even when related variables were controlled. The IED-IR criteria were more sensitive than the DSM-IV criteria only in identifying subjects with significant impulsive-aggressive behavior by a factor of 16. We conclude that the IED-IR criteria can be reliably applied and have sufficient validity to warrant consideration as DSM-V criteria for IED.

Aggression, Suicidality, and Intermittent Explosive Disorder: Serotonergic Correlates in Personality Disorder and Healthy Control Subjects

Central serotonergic (5-HT) activity has long been implicated in the regulation of impulsive aggressive behavior. This study was performed to use a highly selective agent for 5-HT (d-Fenfluramine, d-FEN) in a large group of human subjects to further explore this relationship dimensionally and categorically. One hundred and fifty healthy subjects (100 with personality disorder, PD and 50 healthy volunteer controls, HV) underwent d-FEN challenge studies. Residual peak delta prolactin (DeltaPRL[d-FEN]-R; ie, after the removal of potentially confounding variables) was used as the primary 5-HT response variable. Composite measures of aggression and impulsivity were used as dimensional measures, and history of suicidal/self-injurious behavior as well as the presence of intermittent explosive disorder (IED) were used as categorical variables. DeltaPRL[d-FEN]-R responses correlated inversely with composite aggression, but not composite impulsivity, in all subjects and in males and females examined separately. The correlation with composite aggression was strongest in male PD subjects. DeltaPRL[d-FEN]-R values were reduced in PD subjects with a history of suicidal behavior but not, self-injurious behavior. DeltaPRL[d-FEN]-R values were also reduced in patients meeting Research Criteria for IED. Physiologic responses to 5-HT stimulation are reduced as a function of aggression (but not generalized impulsivity) in human subjects. The same is true for personality disordered subjects with a history of suicidal, but not self-injurious, behavior and for subjects with a diagnosis of IED by research criteria. These data have particular relevance to the notion of impulsive aggression and the biological validity of IED.

Inverse relationship between numbers of 5-HT transporter binding sites and life history of aggression and intermittent explosive disorder

The objective of this study was to determine if platelet 5-HT transporter (5-HTT) sites vary as a function of aggression, and/or impulsiveness, and differ as a function of Intermittent Explosive Disorder (IED). Accordingly, the number of platelet 5-HTT sites was assessed in 100 personality disordered (PD) individuals with varying degrees of aggressiveness. The number of platelet 5-HTT sites was assessed by examining the Bmax of H 3-Paroxetine Binding to the blood platelet. Life history of aggression was assessed by Life History of Aggression. Impulsivity was assessed by the Barratt Impulsiveness Scale. Diagnoses of IED were made by both DSM-IV and Research Criteria. Examination of the data revealed that Bmax, but not Kd, values of Platelet H 3-Paroxetine Binding correlated inversely with the LHA Aggression score ( r = −.42 n = 87, p < .001) but not with the BIS-11 Impulsivity score ( r = .03, n = 77, p = .777). PD subjects meeting Research Criteria for IED demonstrated a significant reduction in Bmax values for Platelet H 3-Paroxetine Binding. These results were similar after accounting for the effect of lifetime history of depressive mood disorder on Bmax values for Platelet H 3-Paroxetine Binding. These data indicate a significant inverse relationship between platelet 5-HTT and aggression, though not impulsivity, as a dimensional variable in personality disordered individuals. Results from the examination of IED as a categorical aggression variable suggest that Research, rather than DSM-IV, criteria better identify individuals with reduced numbers of platelet 5-HTT sites.

A Double-Blind, Randomized, Placebo-Controlled Trial of Fluoxetine in Patients With Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is a disorder of impulsive aggression that affects as many as 7.3% of the U.S. population during some period of life. Since central serotonergic (5-HT) system dysfunction is related to impulsive aggressive behavior, pharmacologic enhancement of 5-HT activity should reduce impulsive aggressive behavior in individuals with IED. A double-blind, randomized, placebo-controlled trial of the selective 5-HT uptake inhibitor fluoxetine was conducted in 100 individuals with IED (research diagnostic criteria) and current histories of impulsive aggressive behavior. The primary efficacy measure was the aggression score from the Overt Aggression Scale-Modified (OAS-M) for Outpatient Use. Secondary efficacy measures included the irritability score from the OAS-M and the Clinical Global Impressions-Improvement scale (CGI-I) score. The study took place between July 1990 and July 1999. Fluoxetine treatment resulted in a sustained reduction in OAS-M aggression, and OAS-M irritability scores, apparent as early as week 2 (p < .01 for aggression and p < .001 for irritability at endpoint). Fluoxetine was also superior to placebo in the proportion of responders on the CGI-I (p < .001). Closer examination of the data revealed that full or partial remission of impulsive aggressive behaviors, as reflected by the A criteria for IED, occurred in 46% of fluoxetine-treated subjects. Fluoxetine did not exert an antidepressant or antianxiety effect, and its effects on impulsive aggression were not influenced by presence of current symptoms of depression or anxiety. Fluoxetine treatment has a clear antiaggressive effect in impulsive aggressive individuals with IED. However, while fluoxetine's antiaggressive effects appear robust, they lead to full or partial remission of IED in less than 50% of subjects treated with fluoxetine.

Aripiprazole in Children and Adolescents with Tourette Disorder with and without Explosive Outbursts

We conducted a retrospective, observational study of aripiprazole for the treatment of tics and/or co-morbid explosive outbursts in 37 children and adolescents with Tourette disorder (TD). Thirty seven children and adolescents with TD, with and without explosive outbursts, and refractory to previous treatment were treated at one of two university affiliated specialty clinics. All diagnoses were made using Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR) criteria. Tic severity was rated using the Clinical Global Impressions Scale for tics (CGI-Tics) and frequency of explosive outbursts was assessed using the CGI-Rage; both measures were obtained at pretreatment baseline and at posttreatment follow up. High rates of psychiatric co-morbidity were observed in these subjects: 31 of 37 (84%) subjects met criteria for obsessive-compulsive disorder (OCD), and 31 of 37 (84%) met criteria for attention-deficit/hyperactivity disorder (ADHD). Twenty nine of 37 (78%) subjects met criteria for intermittent explosive disorder (IED) minus criterion C; the remaining 8 subjects had TD only. Eight subjects (22%) discontinued treatment before 12 weeks due to inability to tolerate the drug. At follow up, tics reduced at a mean daily dose of 12.3 (7.50) mg in 29 of 29 (100%) subjects who completed the study, and explosive outbursts improved in 24/25 subjects (96%) who completed the study. Aripiprazole was tolerated reasonably well, although 8/37 (22%) subjects discontinued treatment; most common side effects included weight gain, akathisia, and sedation. Aripiprazole should be investigated further as a treatment option for TD with and without co-morbid explosive outbursts.

Levetiracetam in Patients With Impulsive Aggression

There are few controlled studies evaluating drug treatment for impulsive aggression. The objective of this study was to evaluate levetiracetam in patients with impulsive aggression, and whether diagnosis or other baseline characteristics predict response. Outpatients with clinically significant impulsive aggression (meeting Coccaro et al. revised criteria for intermittent explosive disorder), without other psychiatric symptomatology clearly requiring treatment, were randomly assigned to levetiracetam or placebo, double-blind, for 10 weeks, at a variable dose with a maximum dose of 3000 mg/day. The primary efficacy measure was change in the total aggression score from the revised Overt Aggression Scale-Modified. The study was conducted from September 2005 to July 2006. Of 40 patients (20 in each treatment group), 34 completed at least 4 weeks of treatment with double-blind medication. There was no overall statistical evidence of levetiracetam benefit, and no subgroup more responsive to levetiracetam could be identified. Levetiracetam was not as efficacious as oxcarbazepine was in a prior similar study. Additional studies of medications for impulsive aggression seem warranted.

Platelet serotonin content correlates inversely with life history of aggression in personality-disordered subjects

The objective of this study was to test the hypothesis that platelet serotonin (5-hydroxytryptamine, 5-HT) content is correlated with measures of aggression in healthy human subjects. Platelet 5-HT content (ng/mg protein) was measured in personality-disordered (PD) and normal control (NC) subjects. Aggression was assessed with the Life History of Aggression (LHA), the Buss–Durkee Hostility Inventory (BDHI), and the Motor Aggression and Research Criteria for Intermittent Explosive Disorder (IED-IR); impulsivity was assessed with the Eysenck Personality Questionnaire II (EPQII) and the Barratt Impulsiveness Scale (BIS-11). LHA Aggression, but not impulsivity, scores showed significant inverse correlations with platelet 5-HT content in all subjects or in PD subjects alone. The findings in PD subjects remained significant after co-varying for race. PD subjects with IED-IR had lower platelet 5-HT content compared with PD subjects who did not have IED-IR, although this finding only approached significance after controlling for race. This study demonstrates an association between reduced platelet 5-HT content and aggression in PD subjects. Similar to other studies of platelet 5-HT markers, these data suggest that platelet 5-HT content may also reflect central 5-HT alterations and may be used as a biological marker in appropriate patient samples.

Clinical phenomenology of episodic rage in children with Tourette syndrome

Objective: Episodic rage of unknown etiology causes significant morbidity in children with Tourette's syndrome (TS). Using modified Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria for intermittent explosive disorder (IED), we developed a screen and symptom questionnaire to explore rage attack phenomenology and to preliminarily investigate whether symptom clusters can identify clinical subgroups of TS children with rage attacks. Methods: 48 children with TS between ages 7 and 17 years consecutively presenting with rage attacks completed the Rage Attacks Screen and Questionnaire. Data was subjected to factor analysis. Cluster analytic procedures were used to identify clinical subgroups. Results: Final cluster solution revealed four homogeneous subgroups of TS children with rage who were differentiated by predominant clinical characteristics: specific urge resolution, environmentally secure reactivity, nonspecific urge resolution or labile nonresolving. Conclusion: Episodic rage in TS has stereotypic features, but diverse and complex etiologies. Identifying particular symptom clusters may facilitate improved treatment strategies.

Intermittent explosive disorder and other psychiatric co-morbidity among court-referred and self-referred aggressive drivers

We assessed possible Axis I and Axis II disorders in two groups of aggressive drivers ( n=20, court-referred; n=10, self-referred) and 30 non-aggressive driver controls, using the SCID and SCID-II. Aggressive drivers were more likely than controls to be positive for any Axis I and Axis II disorders. They were also more likely to meet the criteria for Intermittent Explosive Disorder (IED), current or past alcohol or substance abuse or dependence and Antisocial PD and Borderline PD. The self-referred aggressive drivers were more likely than court-referred aggressive drivers to meet the criteria for a current or past Anxiety Disorder. Re-analysis of aggressive driver data on the basis of presence or absence of IED revealed differences only in Axis II disorders: those with IED were more likely to meet the criteria for any Axis II disorder and Antisocial PD.