DSM-5 Intermittent Explosive Disorder Research Articles

Plasma and cerebrospinal fluid inflammatory markers and human aggression.

A growing body of work suggests that individuals with aggressive behavior and/or aggressive tendencies have evidence of chronic, low level, inflammation as manifested by elevated circulating levels of acute phase reactant proteins and pro-inflammatory cytokines. While animal studies report that direct application of pro-inflammatory proteins in brain increase aggressive behavior, there is no data on the relationship of central levels of these proteins and aggression in human subjects. We simultaneously measured levels of both plasma and lumbar cerebrospinal fluid (CSF) C-Reactive Protein (CRP) and IL-6, IL-8, and TNF-α in 77 medically healthy, drug-free, individuals with varying degrees of aggression including 22 individuals with DSM-5 Intermittent Explosive Disorder (IED). Aggression was assessed using the Life History of Aggression (LHA) and the Buss-Perry Aggression Questionnaire (BPAQ). Plasma and CSF levels of CRP, IL-8, and TNF-α, but not IL-6, correlated significantly with each other. Aggressive individuals with IED displayed elevated plasma, but not CSF, levels of proinflammatory markers and this relationship was specific to IED. Similarly, composite aggression scores correlated significantly with plasma, but not CSF, pro-inflammatory markers. Aggressive behavior in humans is correlated with Plasma, but not CSF, proinflammatory markers despite the observation that these two sets of markers are significantly correlated. Since the direct application of proinflammatory proteins in brains of animals increase aggressive behavior, proinflammatory proteins likely influence brain-based behavior in a manner not reflected in lumbar CSF.

Childhood and parental characteristics of adults with DSM-5 intermittent explosive disorder compared with healthy and psychiatric controls

BackgroundIntermittent Explosive Disorder (IED) is a disorder primarily of aggression, defined by recurrent behavioral outbursts out of proportion to provocations or stressors. IED first appears in childhood and adolescence. This study examines the underlying childhood environment of those with IED, particularly familial and school-related factors. MethodsAdult participants from a larger study completed diagnostic assessments and a battery of self-report measures. Group assignment was based on the assessment: 1) IED diagnosis; 2) non-IED psychiatric diagnosis; and 3) no significant psychiatric history. Groups were compared on factors of parental demographics, intrafamilial aggression, lifetime syndromal and personality diagnoses, neurodevelopmental and learning difficulties, childhood peer relationships, and juvenile legal issues. ResultsSignificant patterns emerged specific to IED for not being raised by both parents, greater physical aggression to participant, and greater degree of fighting with peers by age ten. LimitationsThe retrospective, and cross-sectional, nature of the study, which prevent the making of causal inferences, and the basic nature of the questions asked of participants which limit a more nuanced interpretation of the data. A further limitation is bias associated with self-reported responses. ConclusionsResults suggest the prevalence childhood adversaries may be linked with IED; the childhood environment of those with IED likely is substantially more tumultuous than individuals with or without other psychiatric disorders.

A latent class analysis of intermittent explosive disorder symptoms

Intermittent explosive disorder (IED), the sole diagnosis in the DSM-5 for which the cardinal symptom is recurrent affective aggressive outbursts, is a common and substantially impairing disorder. IED is also associated with several cognitive and affective impairments. However, little is known about the heterogeneity of the disorder and how this may correspond to aggression severity and related adverse outcomes. The current study employed a latent class analysis (LCA) among individuals diagnosed with lifetime DSM-5 IED to derive distinct subgroups that differed in the quality and/or frequency of cognitive-affective symptoms. These subgroups were then externally validated on a number of adverse outcomes. Statistical and clinical indicators supported a four-class model. Classes were distinguished mainly by the level of emotion dysregulation participants endorsed, with two moderate emotion dysregulation classes differing on their emotional information processing and impulsive tendencies. The external validation analysis revealed that classes differed in terms of various adverse outcomes (e.g., interpersonal problems, life satisfaction, suicide risk). Overall, the present study suggests distinct cognitiveaffective symptom profiles among those with IED that differ meaningfully with regard to risk for adverse outcomes. These findings provide evidence of the heterogeneity within IED and may suggest a more personalized therapeutic approach to patients with IED.

Prevalence and correlates of DSM-IV and DSM-5 Intermittent Explosive Disorder amongst Myanmar refugees living in Malaysia: a population-based study.

We investigate the prevalence and risk factor profiles of Intermittent Explosive Disorder (IED) and comparison between two diagnostic measures for IED in a large population-based study of three ethnic groups of refugees (Chin, Kachin and Rohingya) from Myanmar resettled in Malaysia. Trained field personnel interviewed in total 2058 refugees, applying a clustered, probabilistic, proportional-to-size sampling framework and using the DSM-IV and DSM-5 criteria to diagnose IED. We used descriptive and bivariate analyses to explore associations of IED (using DSM IV or DMS 5) with ethnic group membership, sociodemographic characteristics and exposure to premigration traumatic events (TEs) and postmigration living difficulties (PMLDs). We also examined associations of IED with other common mental disorders (CMDs) (depression, anxiety and posttraumatic stress disorder) and with domains of functional impairment. Finally, we compared whether IED measured using DSM IV or DSM 5 generated the same or different prevalence. For the whole sample (n = 2058), the 12-month prevalence of DSM-IV IED was 5.9% (n = 122) and for DSM-5, 3.4% (n = 71). Across the three ethnic groups, 12-month DSM-5 IED prevalence was 2.1% (Chin), 2.9% (Rohingya) and 8.0% (Kachin), whereas DSM-IV defined IED prevalence was 3.2% (Chin), 7% (Rohingya) and 9.2% (Kachin). Being single, and exposure to greater premigration TEs and PMLDs were each associated with IED. Over 80% of persons with IED recorded one or more comorbid CMDs. Persons with IED also showed greater levels of functional impairment compared with those without IED. The pooled IED prevalence was higher than global norms but there was substantial variation in prevalence across the three study groups.

Disordered Aggression and Violence in the United States.

To determine the prevalence and correlates of DSM-5 intermittent explosive disorder and related aggressive disorders in the United States. Community survey data (collected between 2001-2004) from the National Comorbidity Survey-Replication (NCS-R) and Adolescent Supplement (NCS-AS) involving 10,148 adolescents and 9,282 adults, respectively, were reanalyzed with recurrent aggressive behavior defined as 3 serious aggressive outbursts in any given year. In addition to prevalence, assessments of aggression severity, property damage, injury to others, intimate partner assault, utilization of guns and weapons to threaten, and treatment utilization for recurrent aggressive behavior were also assessed. About 17% of adolescents and 8% of adults report a pattern of recurrent aggressive outbursts within at least 1 year. Such individuals are much more aggressive and impulsive than nonaggressive controls and are more likely to engage in intimate partner assault, carry and use guns and other weapons to threaten others, and be arrested by law enforcement. Few aggressive individuals speak with health care providers about this behavior, and fewer receive treatment for aggression. Recurrent aggressive behavior is common in both adolescents and adults, with clinically significant consequences to those with this pattern and to others in their environment (ie, using guns and other weapons to threaten others). While this type of behavior can be reduced though pharmacologic/psychosocial treatment intervention, the vast majority of aggressive individuals do not engage in treatment for their aggressive behavior. Screening individuals for such behavior in one's practice may do much toward identifying this problem and bringing such individuals into treatment.

Social desirability, deceptive reporting, and awareness of problematic aggression in intermittent explosive disorder compared with non-aggressive healthy and psychiatric controls

Individuals with DSM-5 Intermittent Explosive Disorder (IED) are often suspected of minimizing the nature of their recurrent, problematic, impulsive aggressive behavior due to the social undesirability of these behaviors. Our first study involved 400 study participants categorized as Healthy Controls (HC), Psychiatric Controls (PC) and as having IED and included the Crowne-Marlowe Social Desirability Scale (SDS), the Lie Scale from the Eysenck Personality Questionnaire-Revised (EPQ-R Lie), and the Readiness to Change (Anger) Questionnaire (RTC). IED study participants had lower SDS and lower EPQ-R Lie scores, while having higher RTC scores, compared with both HC and PC study participants. Thus, when studied in a clinical research setting, IED study participants do not provide socially desirable answers to questions and do not engaging in deceptive reporting; likely because they have recognized their need/interest in reducing their own impulsive aggressive behavior. The second study, part of a family study of 70 probands and their first-degree relatives revealed a very high positive (96.3%), but substantially lower negative (55.8%), predictive power for IED based on informant report. This suggests that, while interview of close informants can confirm the diagnosis of IED, informant interviews cannot rule out IED when such informants provide a negative report.

DSM-5 intermittent explosive disorder: Relationship with Disruptive Mood Dysregulation Disorder

ObjectiveThis study was designed to estimate how many adults with DSM-5 Intermittent Explosive Disorder (IED) would also meet diagnostic criteria for Disruptive Mood Dysregulation Disorder (DMDD). This was done by examining how many individuals with IED would meet the DMDD criterion of being persistently angry in between impulsive aggressive outbursts. MethodsThe first one-hundred study participants diagnosed with DSM-5 IED in our clinical research program were included in this study. Two questions were added to the IED module from the Structured Clinical Interview for DSM-5 Disorders (SCID) inquiring about the duration of anger in between impulsive aggressive outbursts in IED study participants. Data regarding aggression, impulsivity, anger expression, and related dysphoric variables were also collected. ResultsThe proportion of time spent as angry in between impulsive aggressive outbursts was <50% of the time (~35%) for the vast majority (92%) of study participants with DSM-5 IED. Despite this, persistently-angry (i.e., angry >50% time in between outbursts) IED study participants displayed no differences from not-persistently-angry IED study participants in dysphoric and aggression/impulsivity related variables. ConclusionsThese data indicate that inter-outburst anger in those with IED is relatively brief and that such individuals do not generally display the kind of persistent anger that is a diagnostic feature of DMDD.

Intermittent Explosive Disorder and Substance Use Disorder: Analysis of the National Comorbidity Survey Replication Sample.

A relationship between aggression and substance use has been debated for many years. While substance use increases the risk of aggressive behavior, no studies have reported on the relationship between impulsive aggression and substance use/disorder, specifically. We analyzed data from the community-based National Comorbidity Survey Replication (N = 9,282 subjects) in order to examine the relationship between current DSM-5 intermittent explosive disorder (IED), a disorder of impulsive aggression, and current substance use disorders (SUDs), overall, and with regard to alcohol, tobacco, and cannabis use disorders and nondisordered use. Occurrence of current SUD was elevated in current IED versus non-IED adult subjects, and onset of IED preceded that of SUD in 92.5% of comorbid IED + SUD cases. This relationship was not due to the presence, or absence, of current depressive or anxiety disorders. Examination of the severity of IED and of SUD revealed that the presence of IED increases SUD severity but that the presence of SUD does not increase IED severity. Subjects with IED are at increased risk of developing SUD, compared with those without IED. This suggests that history of recurrent, problematic, impulsive aggression is a risk factor for the later development of SUD rather than the reverse. If so, effective treatment of impulsive aggression, before the onset of substance misuse, may prevent, or delay, the development of SUD in young people.

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.

Social emotional information processing in adults: Development and psychometrics of a computerized video assessment in healthy controls and aggressive individuals

A computerized version of an assessment of Social-Emotional Information Processing (SEIP) using audio-video film stimuli instead of written narrative vignettes was developed for use in adult participants. This task allows for an assessment of encoding or relevant/irrelevant social-emotional information, attribution bias, and endorsement of appropriate, physically aggressive, and relationally aggressive responses to aversive social-emotional stimuli. The psychometric properties of this Video-SEIP (V-SEIP) assessment were examined in 75 healthy controls (HC) and in 75 individuals with DSM-5 Intermittent Explosive Disorder (IED) and were also compared with the original questionnaire (SEIP-Q) version of the task (HC=26; IED=26). Internal consistency, inter-rater reliability, and test-retest properties of the V-SEIP were good to excellent. In addition, IED participants displayed reduced encoding of relevant information from the film clips, elevated hostile attribution bias, elevated negative emotional response, and elevated endorsement of physically aggressive and relationally aggressive responses to the ambiguous social-emotional stimuli presented in the V-SEIP. These data indicate that the V-SEIP represents a valid and comprehensive alternative to the paper-and-pencil assessment of social-emotional information processing biases in adults.

Social cognition in Intermittent Explosive Disorder and aggression

Social-emotional information processing (SEIP) was assessed in individuals with current DSM-5 Intermittent Explosive Disorder (IED: n = 100) and in healthy (n = 100) and psychiatric (n = 100) controls using a recently developed and validated self-rated questionnaire. SEIP vignettes depicted both direct aggressive and relationally aggressive scenarios of a socially ambiguous nature and were followed by questions assessing subjects' reactions and judgments about the vignettes. IED subjects differed from both healthy and psychiatric controls in all SEIP components. While hostile attribution was highly related to history of aggression, it was also directly correlated with negative emotional response. Further analysis revealed that this component, as well as response valuation and response efficiency, rather than hostile attribution, best explained history of aggressive behavior. A reformulated SEIP model, including self-reported history of childhood trauma, found that negative emotional response and response efficiency were the critical correlates for history of aggressive behavior. Psychosocial interventions of aggressive behavior in IED subjects may do well to include elements that work to reduce the emotional response to social threat and that work to restructure social cognition so that the tendency towards overt, or relationally, aggressive responding is reduced.

Development of a social emotional information processing assessment for adults (SEIP-Q).

An expanded self-report, vignette-based, questionnaire was developed to assess five components in a social emotional information processing model (SEIP: attribution, emotional response, response valuation, outcome expectancy, response efficacy, and response enactment), first in a population-based sample (n = 250) and, second in healthy control participants (n = 50) and in those with DSM-5 Intermittent Explosive Disorder (IED: n = 50). SEIP-Q vignettes depict, separately, both overtly aggressive and relationally aggressive as well as socially ambivalent scenarios. This expanded SEIP-Q assessment demonstrated good internal reliability, as well as convergent and discriminant validity, for all five SEIP components. IED participants differed from healthy controls in all SEIP-Q components. This expanded SEIP-Q assessment is thus proposed as a reliable and valid method for studying the various stages of SEIP in adult human subjects. Aggr. Behav. 43:47-59, 2017. © 2016 Wiley Periodicals, Inc.

Toxoplasma gondii infection: relationship with aggression in psychiatric subjects.

Toxoplasma gondii (T. gondii), a protozoan parasite that persists in host tissues, including brain, has been associated with several psychiatric disorders and with suicidal behavior. We sought to test the hypothesis that latent T. gondii infection, as manifest by circulating immunoglobulin G (IgG) antibodies to T. gondii, is associated with both categorical and dimensional measures of aggression. IgG antibodies to T. gondii were collected between 1991 and 2008 from 358 adult subjects with DSM-5 intermittent explosive disorder (IED), non-IED psychiatric disorders (psychiatric controls), or no evidence of any psychiatric diagnosis (healthy controls). Assessments of aggression, anger, and impulsivity, as well as state/trait anger, depression, and anxiety were completed. T. gondii seropositive status (IgG > 12 IU) was the primary outcome measure for this study. T. gondii seropositive status (IgG > 12 IU) was associated with higher aggression (P = .022) and impulsivity (P = .05) scores. When both aggression and impulsivity scores were controlled for, however, only aggression scores were higher in seropositive subjects (P = .011). In addition, T. gondii seropositive status and marginal mean ± SE aggression scores increased from healthy controls (9.1% and -0.66 ± 0.05) to psychiatric controls (16.7% and -0.27 ± 0.05) to subjects with IED (21.8% and 1.15 ± 0.06; P ≤ .05). These findings were not accounted for by the presence of other syndromal/personality disorders or by states or traits related to depressed or anxious moods. These data are consistent with previous studies suggesting a relationship between T. gondii and self-directed aggression (ie, suicidal behavior) and further add to the biological complexity of impulsive aggression both from a categorical and a dimensional perspective.

Frontolimbic Morphometric Abnormalities in Intermittent Explosive Disorder and Aggression

BackgroundConverging evidence from neuroimaging studies suggests that impulsive aggression, the core behavior in the DSM-5 diagnosis intermittent explosive disorder (IED), is regulated by frontolimbic brain structures, particularly orbitofrontal cortex, ventral medial prefrontal cortex, anterior cingulate cortex, amygdala, insula, and uncus. Despite this evidence, no brain volumetric studies of IED have been reported as yet. This study was conducted to test the hypothesis that gray matter volume in frontolimbic brain structures of subjects with IED is lower than in healthy subjects and subjects with other psychiatric conditions. MethodsHigh-resolution magnetic resonance imaging scans using a three-dimensional magnetization-prepared rapid acquisition gradient-echo sequence were performed in 168 subjects (n = 53 healthy control subjects, n = 58 psychiatric controls, n = 57 subjects with IED). Imaging data were analyzed by voxel-based morphometry methods employing Statistical Parametric Mapping (SPM8) software. ResultsGray matter volume was found to be significantly lower in subjects with IED compared with healthy control subjects and psychiatric controls in orbitofrontal cortex, ventral medial prefrontal cortex, anterior cingulate cortex, amygdala, insula, and uncus. These differences were not due to various confounding factors or to comorbidity with other disorders previously reported to have reduced gray matter volume. Gray matter volume in these areas was significantly and inversely correlated with measures of aggression. ConclusionsReductions in the gray matter volume of frontolimbic structures may be a neuronal characteristic of impulsively aggressive individuals with DSM-5 IED. These data suggest an anatomic correlate accounting for functional deficits in social-emotional information processing in these individuals.

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.

NewDSMChapter to Focus on Disorders of Self-Control

Back to table of contents Previous article Next article Professional NewsFull AccessNew DSM Chapter to Focus on Disorders of Self-ControlMark MoranMark MoranSearch for more papers by this authorPublished Online:5 Apr 2013https://doi.org/10.1176/appi.pn.2013.4a20AbstractThe chapter on disruptive disorders brings together diagnoses previously classified as disorders of childhood and adolescence with other disorders of self-control not limited by age.Refinements to oppositional defiant disorder (ODD), conduct disorder, and intermittent explosive disorder mark the prominent changes clinicians will see in a new chapter in DSM-5 on “Disruptive, Impulse-Control, and Conduct Disorders.”The chapter brings together disorders marked by problems with emotional and behavioral self-control that were previously included in the chapter in DSM-IV titled “Disorders Usually First Diagnosed in Infancy, Childhood, or Adolescence” (ODD, conduct disorder, and intermittent explosive disorder) and other disorders of self-control not confined to childhood, such as pyromania and kleptomania.Because of significant overlap with antisocial personality disorder, the latter appears in the disruptive disorders chapter as well as in the chapter on personality disorders. (Attention-deficit/hyperactivity disorder, whose symptoms also overlap with many of the disorders in this chapter, appears in the chapter on neurodevelopmental disorders; see Psychiatric News, January 18.)“All of these disorders have previously been identified as ‘externalizing’ as compared to ‘internalizing’ disorders,” explained Darrel Regier, M.D., M.P.H., APA director of research and vice chair of the DSM-5 Task Force. “Since we eliminated a section that included only disorders of childhood and adolescence in order to distribute these to disorder sections that would cover the entire lifespan, putting ODD and conduct disorder together with antisocial personality disorder, intermittent explosive disorder, pyromania, and kleptomania was appropriate.”Four refinements mark changes to criteria for oppositional defiant disorder. Symptoms are now grouped into three types: angry/irritable mood, argumentative/defiant behavior, and vindictiveness, reflecting that the disorder includes both emotional and behavioral symptoms. The exclusion criterion for conduct disorder has been removed. “You can have both conduct disorder and ODD,” Francisco Castellanos, M.D., a member of the Work Group on Disruptive Disorders, told Psychiatric News. “It’s not as simple as you graduate from one to the other.” Additionally, the criteria will indicate that symptoms must be present more than once a week to distinguish the diagnosis from symptoms common to normally developing children and adolescents. And a severity rating has been added to the criteria to reflect research showing that the degree of pervasiveness of symptoms across settings is an important indicator of severity. Castellanos explained that the work group considered whether children who showed only symptoms of ODD toward one particular member of the family, for instance, would still meet the criteria. “Turns out the predictive validity is the same,” he said. “But what does seem to matter is the severity of prognosis. If a child displays only this behavior toward mother, it turns out that is better prognostically than if the child displays the behavior pervasively. So it seems that the number of different settings in which the symptoms appear is a very reasonable indicator of severity.” The primary change in DSM-5 intermittent explosive disorder is the type of aggressive outbursts that should be considered: physical aggression was required in DSM-IV, whereas verbal aggression and nondestructive/noninjurious physical aggression also meet criteria in DSM-5. DSM-5 also provides more specific criteria defining frequency needed to meet criteria and specifies that the aggressive outbursts are impulsive and/or anger and must cause marked distress, cause impairment in occupational or interpersonal functioning, or be associated with negative financial or legal consequences. Because of the paucity of research on this disorder in young children and the potential difficulty of distinguishing these outbursts from normal temper tantrums in young children, a minimum age of 6 years (or equivalent developmental level) is now required.Work group chair David Shaffer, M.D., said changes to the criteria are based largely on the work of Emil Coccaro, M.D., chair of the Department of Psychiatry at the University of Chicago, and are designed to make the criteria considerably more specific than are DSM-IV criteria. He also said the changes are expected to decrease prevalence of the diagnosis. Criteria for conduct disorder are largely unchanged from DSM-IV, but a descriptive specifier has been added for children who are deficient in “pro social behaviors.” Castellanos said the designation replaces the phrase “callous and unemotional”—a term used by research psychologists that has been deemed stigmatizing. The new specifier is based on research showing that individuals with conduct disorder who are deficient in pro social behaviors may show a more severe form of the disorder and a different treatment response. “There is a compelling literature that this subtype of conduct disorder exists and is predictive of long-term outcome, and that identification of such children can help to target treatment,” Castellanos told Psychiatric News. ■A fact sheet and audio clips on conduct disorder can be accessed at http://www.psychiatry.org/dsm5. ISSUES NewArchived