Intermittent Explosive Disorder Research Articles

Irritability as a criterion in diagnosis of child and adolescent bipolar disorder: thorny road ahead.

Byline: M. Reddy Diagnostic and Statistical Manual of Mental Disorders, 5 [sup]th edition (DSM 5) [sup][1] of bipolar disorder (BD) makes it necessary to meet the following criteria for a manic episode: distinct period of abnormally and persistently elevated, expansive, OR IRRITABLE MOOD… lasting at least one week and present most of the day, nearly everyday…. It is elation or irritation, along with three or four other symptoms. DSM 5 criteria for BD are applicable to all age groups with the same weightage. Irritable occupies a prominent place in the diagnostic criteria of many other disorders, especially childhood and adolescent disorders like oppositional defiant disorder; intermittent explosive disorder; conduct disorder; disruptive mood dysregulation disorder (DMDD); other and unspecified disruptive, impulse control, and conduct disorders; and attention deficit/hyperactivity disorder (ADHD) in the classificatory systems. With irritable sharing space in the diagnostic criteria of BD and several childhood and adolescent diagnostic disorders, there looms a possibility of over diagnosis of childhood adolescent bipolar disorder. misdiagnosis, whenever it occurs, hopefully less often, leads to a major therapeutic mismatch resulting in polypharmacy and treatment failures. National Institute of Mental Health research roundtable on prepubertal bipolar disorder, 2001 recommends that patients with grandiosity/elation be classified as bipolar I and irritability/rage be classified as bipolar NOS (DSM IV TR). There was always a doubt about reliability of irritability as a symptom criterion in the of mania as shown in this USA-UK study: USA-UK project (2005) Elation/grandiose - mania - 96.4% USA and 88.9% UK Irritability/rage - mania - 86.2% USA and 31.1% UK There is rather unacceptable poor concordance, with irritability as the criterion. A few valid arguments that merit attention are the following: *That delusions/hallucinations occur only in BD (true, but a significant majority of patients with BD do not have delusions/hallucinations). *Family H/O of BD favors of bipolar illness (yes, very valuable supporting point in those who have a family history). *BD is an episodic disorder, whereas other childhood disorders outlined above are all continuous in course. Is it true? Let us look at the existing data. Evidence Age of onset The greatest frequency of first attacks falls, however, in the period of development with its increased emotional excitability between the fifteenth and twentieth In rare cases, the first beginnings can be traced back even to before the tenth year…. - Kraepelin, 1921 In 28% of the BD patients recruited into the Systematic Treatment Enhancement Program for Bipolar Disorder (STEP-BD) study, age at onset was younger than 13, and in the Bipolar Collaborative Network study, 15% of patients had illness onset before the age of 13 years. younger age of onset in BD seems to be a well-documented fact. Diagnosis Some studies have defined mania by the presence of highly labile moods with intense irritability, rage, explosiveness and destructiveness; extreme agitation, and behavioral dysregulation. [sup][2],[3],[4],[5] picture that emerges from several independent research groups is that prepubertal children with BD typically have multiple daily mood swings and that irritability is much more common than euphoria. [sup][6],[7] Course Studies indicate a highly pernicious course with substantial chronicity. In 81% of a well-defined group of patients, Geller et al . [sup][6] reported continuous daily cycling from mania or hypomania to euthymia or depression. In this study, 1-year mania recovery rate stood at 37%. …

Mental Health Correlates of Past Homelessness in Latinos and Asians

Mental illness and addiction are strongly associated with homelessness, yet few studies have shown how these relationships vary across ethnic categories that are underrepresented in the homeless population. This study draws from the National Latino and Asian American Survey to examine mental health and substance abuse correlates of homelessness amongst Latinos and Asians living in the United States. Clinical and institutional factors associated with homelessness varied by ethnicity. Among Latinos, alcohol abuse or dependence, conduct disorder and intermittent explosive disorder were risk factors for homelessness, while attending a religious service more than once a week was a protective factor. Among Asians, mood disorder was a risk factor as were health problems and receiving welfare in the past. Understanding ethnicity-specific correlates of homelessness may guide culturally nuanced mental health prevention and intervention efforts.

Army Learning Complex FactorsAssociated With Soldier Suicides

Army Learning Complex FactorsAssociated With Soldier Suicides

Associations of Housing Mobility Interventions for Children in High-Poverty Neighborhoods With Subsequent Mental Disorders During Adolescence

Youth in high-poverty neighborhoods have high rates of emotional problems. Understanding neighborhood influences on mental health is crucial for designing neighborhood-level interventions. To perform an exploratory analysis of associations between housing mobility interventions for children in high-poverty neighborhoods and subsequent mental disorders during adolescence. The Moving to Opportunity Demonstration from 1994 to 1998 randomized 4604 volunteer public housing families with 3689 children in high-poverty neighborhoods into 1 of 2 housing mobility intervention groups (a low-poverty voucher group vs a traditional voucher group) or a control group. The low-poverty voucher group (n=1430) received vouchers to move to low-poverty neighborhoods with enhanced mobility counseling. The traditional voucher group (n=1081) received geographically unrestricted vouchers. Controls (n=1178) received no intervention. Follow-up evaluation was performed 10 to 15 years later (June 2008-April 2010) with participants aged 13 to 19 years (0-8 years at randomization). Response rates were 86.9% to 92.9%. Presence of mental disorders from the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) within the past 12 months, including major depressive disorder, panic disorder, posttraumatic stress disorder (PTSD), oppositional-defiant disorder, intermittent explosive disorder, and conduct disorder, as assessed post hoc with a validated diagnostic interview. Of the 3689 adolescents randomized, 2872 were interviewed (1407 boys and 1465 girls). Compared with the control group, boys in the low-poverty voucher group had significantly increased rates of major depression (7.1% vs 3.5%; odds ratio (OR), 2.2 [95% CI, 1.2-3.9]), PTSD (6.2% vs 1.9%; OR, 3.4 [95% CI, 1.6-7.4]), and conduct disorder (6.4% vs 2.1%; OR, 3.1 [95% CI, 1.7-5.8]). Boys in the traditional voucher group had increased rates of PTSD compared with the control group (4.9% vs 1.9%, OR, 2.7 [95% CI, 1.2-5.8]). However, compared with the control group, girls in the traditional voucher group had decreased rates of major depression (6.5% vs 10.9%; OR, 0.6 [95% CI, 0.3-0.9]) and conduct disorder (0.3% vs 2.9%; OR, 0.1 [95% CI, 0.0-0.4]). Interventions to encourage moving out of high-poverty neighborhoods were associated with increased rates of depression, PTSD, and conduct disorder among boys and reduced rates of depression and conduct disorder among girls. Better understanding of interactions among individual, family, and neighborhood risk factors is needed to guide future public housing policy changes.

Criminal Minds: Neuromodulation of the Psychopathic Brain

Criminal Minds: Neuromodulation of the Psychopathic Brain

Psychodynamic Psychotherapy for Double Depression and Intermittent Explosive Disorder

This is a single case study utilizing time-series analysis for a young adult man with major depressive disorder and dysthymic disorder (i.e., double depression [DD]) and intermittent explosive disorder (IED). Treatment consisted of long-term psychodynamic psychotherapy (LTPP) with an emphasis on facilitating emotional expression and fostering autonomy. During 13 months of therapy, the patient completed daily measures related to his presenting complaint, including overall distress and episodes of rage. These data were examined for clinically significant change across baseline and two phases of treatment using Simulation Modeling Analysis for time-series data. Results indicated improvement in overall distress and in rage episodes. In addition to daily measures, the patient completed a measure of general psychological functioning at monthly intervals throughout treatment, the results of which indicated no reliable change. Complicating factors and implications of treatment are discussed, including the efficacy of LTPP in the treatment of DD and IED.

Associations between DSM-IV mental disorders and diabetes mellitus: a role for impulse control disorders and depression.

No studies have evaluated whether the frequently observed associations between depression and diabetes could reflect the presence of comorbid psychiatric conditions and their associations with diabetes. We therefore examined the associations between a wide range of pre-existing Diagnostic Statistical Manual, 4th edition (DSM-IV) mental disorders with self-reported diagnosis of diabetes. We performed a series of cross-sectional face-to-face household surveys of community-dwelling adults (n = 52,095) in 19 countries. The World Health Organization Composite International Diagnostic Interview retrospectively assessed lifetime prevalence and age at onset of 16 DSM-IV mental disorders. Diabetes was indicated by self-report of physician's diagnosis together with its timing. We analysed the associations between all mental disorders and diabetes, without and with comorbidity adjustment. We identified 2,580 cases of adult-onset diabetes mellitus (21 years +). Although all 16 DSM-IV disorders were associated with diabetes diagnosis in bivariate models, only depression (OR 1.3; 95% CI 1.1, 1.5), intermittent explosive disorder (OR 1.6; 95% CI 1.1, 2.1), binge eating disorder (OR 2.6; 95% CI 1.7, 4.0) and bulimia nervosa (OR 2.1; 95% CI 1.3, 3.4) remained after comorbidity adjustment. Depression and impulse control disorders (eating disorders in particular) were significantly associated with diabetes diagnosis after comorbidity adjustment. These findings support the focus on depression as having a role in diabetes onset, but suggest that this focus may be extended towards impulse control disorders. Acknowledging the comorbidity of mental disorders is important in determining the associations between mental disorders and subsequent diabetes.

Elevated Plasma Inflammatory Markers in Individuals With Intermittent Explosive Disorder and Correlation With Aggression in Humans

Neurochemical studies in human aggression point to a modulatory role for a variety of central neurotransmitters. Some of these neurotransmitters play an inhibitory role, while others play a facilitatory role modulating aggression. Preclinical studies suggest a facilitatory role for inflammatory markers in aggression. Despite this, to our knowledge, no studies of aggression and inflammatory markers have been reported in psychiatric patients or in individuals with recurrent, problematic, impulsive aggressive behavior. To test the hypothesis that plasma inflammatory markers will correlate directly with aggression and will be elevated in individuals with recurrent, problematic, impulsive aggressive behavior. DESIGN, SETTING, AND PARTICIPANTS Case-control study in a clinical research program in impulsive aggressive behavior at an academic medical center. Participants were physically healthy individuals with intermittent explosive disorder (n = 69), nonaggressive individuals with Axis I and/or II disorders (n = 61), and nonaggressive individuals without history of an Axis I or II disorder (n = 67). Plasma levels of C-reactive protein and interleukin 6 were examined in the context of measures of aggression and impulsivity and as a function of intermittent explosive disorder. Both plasma C-reactive protein and interleukin 6 levels were significantly higher in participants with intermittent explosive disorder compared with psychiatric or normal controls. In addition, both inflammatory markers were directly correlated with a composite measure of aggression and, more specifically, with measures reflecting history of actual aggressive behavior in all participants. These data suggest a direct relationship between plasma inflammatory processes and aggression in humans. This finding adds to the complex picture of the central neuromodulatory role of aggression in humans.

Elevated Plasma Oxidative Stress Markers in Individuals With Intermittent Explosive Disorder and Correlation With Aggression in Humans

BackgroundAnimal and clinical studies suggest a link between inflammation and oxidative stress. Because oxidative stress is an inherent part of inflammation, and inflammation is associated with behavioral aggression in lower mammals and humans, we hypothesized that markers of oxidative stress would be related to aggression in human subjects. In this case-control study, markers of oxidative stress and aggression were assessed in human subjects with histories of recurrent, problematic, impulsive aggressive behavior and in nonaggressive comparator subjects. MethodsPlasma levels of 8-hydroxy-2′-deoxyguanosine and 8-isoprostane were examined in the context of measures of aggression and impulsivity in physically healthy subjects with intermittent explosive disorder (n = 69), nonaggressive subjects with Axis I or II disorders (n = 61), and nonaggressive subjects with no history of Axis I or II disorders (n = 67). ResultsLevels of plasma 8-hydroxy-2′-deoxyguanosine and 8-isoprostane were significantly higher in subjects with intermittent explosive disorder compared with psychiatric or normal control subjects. In addition, both oxidative stress markers correlated with a composite measure of aggression; more specifically, 8-hydroxy-2′-deoxyguanosine correlated with measures reflecting a history of actual aggressive behavior in all subjects. ConclusionsThese data suggest a positive relationship between plasma markers of oxidative stress and aggression in human subjects. This finding adds to the complex picture of the central neuromodulatory role of aggression in human subjects.

Risk Factors for Physical Violence against Partners in the U.S.

To examine unique and relative predictive values of demographic, social learning, developmental, psychopathology, and dyadic variables as risk factors for perpetration of intimate partner physical aggression in a national sample of married or cohabitating individuals. Men (n=798) and women (n=770) were selected from the public use data file of the 2003 National Comorbidity Survey Replication (NCS-R) which used a multi-stage cluster sampling design. Eight percent of women and 5% of men reported perpetrating physical aggression in the past year. Based on multivariable regression analyses, among men, the unique risk factors for perpetrating physical aggression were parental violence, dating before age 14, dating aggression, Intermittent Explosive Disorder (IED) before and after age 20, and being victimized by partner. Among women, significant risk factors were younger age, dating aggression, IED before age 20, cohabiting, victimization by partner, and marital/relationship strain. A number of social learning, developmental, adult psychopathology, and dyadic factors were significant. Two dyadic variables, victimization and marital strain, had by far the strongest associations with perpetration of partner aggression. Given that dating aggression and early IED were risk factors for male and female IPV much later in life suggests early interventions for those at risk.

Impulse control disorders in elderly patients

ObjectiveThere is no epidemiological study on the prevalence of impulse control disorders (ICDs) in the elderly population. The studies on ICDs in elderly patients are limited and some of them are case reports about pathological gambling and kleptomania. The comorbidity of other psychiatric disorders makes diagnosis difficult and has negative effects on both treatment and the prognosis of ICDs. The aim of this study was to determine the prevalence of ICDs among elderly patients and to evaluate the related sociodemographic and clinical features. MethodA total of 76 patients aged 60 and over who have been referred to our outpatient clinics in a one-year period were included in the study. A demographic data form was completed. The Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV) was used to determine axis I psychiatric disorders. The prevalence of ICDs was investigated by using the modified version of the Minnesota Impulse Disorders Interview (MIDI). Impulsivity was measured with the Barratt Impulsiveness Scale Version 11 (BIS-11). The Mini-Mental State Examination (MMSE) test was performed to evaluate the cognitive status of patients and to exclude the diagnosis of dementia. In addition, all patients completed Symptom Check List-90 (SCL-90). ResultsThe prevalence rate of at least one comorbid ICD in our sample was 17%. When patients with a diagnosis of ICDs not otherwise specified (ICD-NOS) were included, the prevalence rate increased to 22.4%. The most common ICD was intermittent explosive disorder (15.8%), followed by pathological gambling (9.2%). The majority of the sample was men (54%), married (80%), had a high school education (51%), and mid-level socioeconomic status (79%). The only statistically significant difference between the sociodemographic characteristics of patients with or without ICDs was gender. The lifetime prevalence of ICDs was 34.1% in men and 8.6% in women. The prevalence of childhood conduct disorder was significantly higher in the group with ICD. There was no statistically significant difference in the number of suicide attempts, history of physical illness and family history of psychiatric disorders between the groups with or without ICDs. Comorbidity of alcohol/substance abuse was found to be 17.6% in patients with ICD whereas no cases were found in the group without ICD. ConclusionThe result of this study has shown that approximately one fifth of patients over 60years had at least one lifetime ICD comorbidity. The prevalence rates of ICDs seem to decrease with aging. The male gender and childhood conduct disorder are related with higher prevalence rates of ICDs in elderly.

Clinical reappraisal of the Composite International Diagnostic Interview Screening Scales (CIDI‐SC) in the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS)

A clinical reappraisal study was carried out in conjunction with the Army Study to Assess Risk and Resilience in Servicemembers (Army STARRS) All-Army Study (AAS) to evaluate concordance of the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) diagnoses based on the Composite International Diagnostic Interview Screening Scales (CIDI-SC) and post-traumatic stress disorder (PTSD) checklist (PCL) with diagnoses based on independent clinical reappraisal interviews (Structured Clinical Interview for DSM-IV [SCID]). Diagnoses included: lifetime mania/hypomania, panic disorder, and intermittent explosive disorder; six-month adult attention-deficit/hyperactivity disorder; and 30-day major depressive episode, generalized anxiety disorder, PTSD, and substance (alcohol or drug) use disorder (abuse or dependence). The sample (n = 460) was weighted for over-sampling CIDI-SC/PCL screened positives. Diagnostic thresholds were set to equalize false positives and false negatives. Good individual-level concordance was found between CIDI-SC/PCL and SCID diagnoses at these thresholds (area under curve [AUC] = 0.69-0.79). AUC was considerably higher for continuous than dichotomous screening scale scores (AUC = 0.80-0.90), arguing for substantive analyses using not only dichotomous case designations but also continuous measures of predicted probabilities of clinical diagnoses.

Gender, Traumatic Events, and Mental Health Disorders in a Rural Asian Setting

Research shows a strong association between traumatic life experience and mental health and important gender differences in that relationship in the western European Diaspora; but much less is known about these relationships in other settings. We investigate these relationships in a poor rural Asian setting that recently experienced a decade-long armed conflict. We use data from 400 adult interviews in rural Nepal. The measures come from World Mental Health survey instruments clinically validated for this study population to measure depression, posttraumatic stress disorder, and intermittent explosive disorder. Our results demonstrate that traumatic life experience significantly increases the likelihood of mental health disorders in this setting, and that these traumatic experiences have a larger effect on the mental health of women than men. These findings offer important clues regarding the potential mechanisms producing gender differences in mental health in many settings.

A Test of the Unique and Interactive Roles of Anger Experience and Expression in Suicidality

This study examined the unique and interactive roles of anger experience and expression in suicidality (suicidal ideation, plans, and attempts) in a large, nationally representative sample. Participants included 5692 adults from the National Comorbidity Survey-Replication, a nationally representative survey. Anger experience was assessed through a continuous measure, whereas anger expression problems were determined by the presence of an intermittent explosive disorder diagnosis. Tests of unique associations revealed that for the overall sample, anger experience and expression each predicted a unique variance in all outcomes of suicidality. Among the individuals reporting lifetime suicidal ideation, anger experience and expression were uniquely related to suicide attempts. Analyses also revealed anger experience and expression to interact in the prediction of suicidal ideation, suggesting that these have independent and additive effects on risk for suicide. The findings suggest that both anger experience and expression contribute to suicidality and the progression from suicidal ideation to plans and attempts.

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.

Suicidal behaviours are common among US adolescents and are associated with mental health disorders

Question: What is the prevalence of non-fatal suicidal behaviours among US adolescents and what is their association with mental health disorders? Population: About 6483 adolescents aged 13-18 years and their...

Do Men Experience Depression Differently From Women?

Back to table of contents Previous article Next article Clinical and Research NewsFull AccessDo Men Experience Depression Differently From Women?Mark MoranMark MoranSearch for more papers by this authorPublished Online:4 Oct 2013https://doi.org/10.1176/appi.pn.2013.10a24AbstractMen appear to endorse “externalizing” symptoms—such as irritability, anger, risk taking, and substance abuse—more than women, but one expert says there is no evidence that those symptoms are equivalent to depression.When certain alternative, “externalizing” symptoms of depression that appear to be more common among men are used to assess for depression, then men are more likely to meet depression criteria, and the long-established disparities in the prevalence of depression between men and women appear to be eliminated.This is the conclusion of researchers at the University of Michigan who performed a secondary analysis of the National Comorbidity Study Replication (NCS-R) that appeared online August 28 in JAMA Psychiatry.Subjects in the NCS-R were a national representative sample of 10,000 men and women.“Although men were likely to endorse many traditional depression symptoms, men were significantly more likely to report symptoms of anger attacks/aggression, irritability, substance abuse, and risk-taking behaviors over symptoms such as withdrawal from friends, sleep problems, and feelings of complaintiveness,” wrote Lisa Martin, Ph.D., of the Women’s and Gender Studies and Health Policy Studies at the University of Michigan, and colleagues in the report. “These results suggest that relying only on men’s disclosure of traditional symptoms could lead to an underdiagnosis of depression in men and that clinicians should consider other clues when assessing depression in men.”For the purposes of the analysis, Martin and colleagues developed two scales for assessing “externalizing” symptoms endorsed by subjects in the NCS-R. The two scales they developed—the Male Symptoms Scale (MSS) and the Gender Inclusive Depression Scale (GIDS)—were derived from two other scales tested and validated in Europe (the Gotland Male Depression Scale and the Masculine Depression Scale).To create the new scales, researchers conducted an extensive literature review to construct a list of alternative male-type depression symptoms and then compared this list against the NCS-R questionnaire and dataset to determine whether appropriate variables capturing the desired symptoms could be identified. Symptoms were excluded from the scales for one of three possible reasons: symptoms were deemed inappropriate, equivalent items were not available, or the number of people for whom data were available for a symptom was too small to be useful for the analysis The MSS included only the alternative male-type symptoms of depression: irritability, anger attacks/aggression, sleep disturbance, alcohol/other drug abuse, risk-taking behavior, hyperactivity, stress, and loss of interest in pleasurable activities. The GIDS combined these symptoms with six traditional symptoms of depression, including sad/depressed mood, loss of vitality, tiredness, ambivalence, anxiety/uneasiness, and complaintiveness.The researchers found that when using the MSS scale for only alternative, male-type symptoms of depression, a higher proportion of men (26.3 percent) than women (21.9 percent) met criteria for depression. Analyses using the GIDS showed that men and women met criteria for depression in almost equal proportions: 30.6 percent of men and 33.3 percent of women.Men endorsed the following items at significantly higher rates than did women: anger attacks/aggression, substance abuse, and risk-taking behavior. Women endorsed four symptoms at significantly greater rates than men: stress, irritability, sleep problems, and loss of interest in things you usually enjoy, such as work, hobbies, and personal relationships.“This is the first study, to our knowledge, to assess the implications of considering alternative, male-type symptoms of depression for sex differences in the prevalence of depression in a nationally representative sample of U.S. adults,” the researchers stated. APA Director of Research Darrel Regier, M.D., M.P.H., who reviewed the report, said the assertion that the alternative “externalizing” symptoms are the equivalent of the depressive disorders requires additional validation.“Such validators would include the kind of antecedent, concurrent, and predictive validators that were used to assess the most appropriate grouping of disorders in DSM-5,” Regier said. “The DSM-5 Task Force did not find [depression and these externalizing symptoms] to be equivalent disorders.” He added, “The authors of this paper simply assert that these externalizing symptoms are male equivalents of depression. But there is no evidence provided that they are equivalent—only that they are more prevalent in men than they are in women. An alternative conclusion has been that men have different mental disorder prevalence rates of specific disorders than women—that is, women have higher rates of depression, and men have higher rates of substance use disorders, antisocial personality disorder, and intermittent explosive disorder. It isn’t clear why the authors believe that these latter conditions are male equivalents of depression.” ■“The Experience of Depression in Men and Women: An Analysis of the National Comorbidity Study Replication” is posted at http://archpsyc.jamanetwork.com/article.aspx?articleid=1733742. ISSUES NewArchived

A New Look at Borderline Personality Disorder and Related Disorders: Hyper-Reactivity in the Limbic System and Lower Centers

Borderline Personality Disorder (BPD) has been often described recently as a condition characterized by emotional dysregulation. Several other conditions share this attribute; namely, Bipolar Disorder (BD), Attention-Deficit/Hyperactivity Disorder (ADHD), Intermittent Explosive Disorder (IED), and Major Depressive Disorder (MDD). The dysregulation is not always in the same direction: BPD, BD, ADHD, and IED, for example, show over-reactivity or "hyperactivity" of emotional responses, whereas patients with MDD show emotional sluggishness and underactivity. At the clinical/descriptive level the "over-reactive" conditions appear separate and distinct. BPD constitutes a large domain within the psychopathological arena, appearing to contain within it a variety of etiologically diverse subtypes. Among the latter is a type of BPD linked closely with Bipolar Disorder; family studies of either condition show an overrepresentation of both: BPD patients with bipolar relatives; Bipolar patients with BPD relatives. A significant percentage of children with ADHD go on to develop either BPD or BD as they approach adulthood. If one shifts the spotlight to neurophysiology, as captured by MRI studies, however, it emerges that an important subtype of BPD, and also BD, ADHD, and IED-share common features of abnormalities and peculiarities in the limbic system and in the cortex, especially the prefrontal cortex. Deeper subcortical regions such as the periaqueductal gray may also be implicated in strong emotional reactions. The diversity of clinical "over-reactive" conditions appear to harken back to a kind of unity at the brain-change level. There are therapeutic implications here, such as the advisability of mood stabilizers in many cases of BPD, not just for Bipolar Disorder.

An 11-Year-Old Boy With Asperger’s Disorder Presenting With Aggression

“Alan” is an 11-year-old boy who was first seen in our clinic 3 years ago. His parents’ chief complaint at admission was Alan’s physically aggressive behavior at home, in particular toward his mother, as well as fights with children and teachers at school. Alan reportedly met his early developmental motor and cognitive milestones, but he showed difficulties with temper control and frustration tolerance as a toddler, having “significant fits” and biting other children. In preschool, Alan’s behavior was generally without significant aggression exceptwhen hismother was there to volunteer. In kindergarten, his parents reported, his behavior was managed with the help of a teacher who was very consistent with discipline and structure, but the followingyear,hisfirst-grade teacher providedmuch less structure, and Alan started getting into fights again with other children. His behavior also worsened at home; for instance, he would fight a neighbor boy and “the kids would scratch each other bloody.” The parents started family counseling at that time, which did not reduce the problem behaviors. In second grade, at the end of the first trimester, Alan reportedly “lost it.” After a family session, he “cleared the entire desk of the therapist” and “threatened to hurt the therapist.” At home, he would take knives from kitchen drawers and threaten family members. He would “shut down” and not talk about his feelings or thoughts. He was referred by the outpatient psychotherapist to the emergencydepartment and was subsequently treated in a day hospital program, which did reduce his outbursts. He was not put on medication. Discharge diagnoses were mood disorder not otherwise specified, rule out depressive disorder, and rule out anxiety disorder. After discharge, Alan was referred to our clinic. He continued to struggle with aggressive outbursts. When he was told to do minor chores or homework, he “would never do it.” Sometimes he would be “good” in themorning, but hismoodwasusually irritable, and little things would set off explosive outbursts, with yelling, throwing things, and punching people around him, resulting inbruises;his parentshad someconcern about the safety of Alan’s sibling, as well as their own safety. He had such outbursts approximately four times per week, each lasting 30 to 45 minutes. His parents also reported an apparent “female authority problem”; Alan responded much better to male authority figures than to women. During a review of Alan’s developmental history, his parents reported that their son had poor eye contact since early age and that he would “suppress” emotions and had a flat affect. They also noted that Alan did well approaching adults but did not attach emotionally to other children and struggled with making same-age friends. His own perception, however, was that he had many friends. Alan was always very much interested in science and was an expert in dinosaurs and rocks. “While other kids look at things in museums and move on,” he would read all the information he could get. Alan excelled in memorizing other people’s names and faces and after years would recognize someone he had seen only once. He was also noted to struggle with change in routines and to fidget with his hands. There was no history of abuse, contact with drugs or alcohol, mania, anxiety, ormajormedical illness. The family environmentwas reported as stable. Alan has one sibling, and no psychiatric family history was reported. Alan had never been hospitalized; he had been seen by three outpatient family therapists in the past, and, as noted, he had been in day hospital treatment. Alan himself reported that at times he did “not feel good,” but he denied depression or anxiety. He acknowledged having fights with other children but did not elaborate on circumstances. He reported hearing “animal voices” fromunder his bed or from the closet, but he could not really make them out. He felt there were ghosts and monsters in his room, and he was afraid of somebody pulling him down under his bed. When he looked, he reported seeing a lot of “stuff under his bed,” but denied seeing monsters. On further questioning, Alan said he thought those voices could be from the wind or his parents, but he was not certain about the absence of monsters. He had these experiencesmostly in thedarkness, atnight.Hedenied paranoia or ideas of reference.

Intermittent Explosive Disorder amongst Women in Conflict Affected Timor-Leste: Associations with Human Rights Trauma, Ongoing Violence, Poverty, and Injustice

IntroductionWomen in conflict-affected countries are at risk of mental disorders such as posttraumatic stress disorder and depression. No studies have investigated the association between experiences of abuse and injustice and explosive anger amongst women in these settings, and the impact of anger on women's health, family relationships and ability to participate in development.MethodsA mixed methods study including an epidemiological survey (n = 1513, 92.6% response) and qualitative interviews (n = 77) was conducted in Timor-Leste. The indices measured included Intermittent Explosive Disorder, posttraumatic stress disorder; severe distress; days out of role (the number of days that the person was unable to undertake normal activities); gender-specific trauma; conflict/violence; poverty; and preoccupations with injustice.ResultsWomen with Intermittent Explosive Disorder (n = 184, 12.2%) were more disabled than those without the disorder (for >5 days out of role, 40.8% versus 31.5%, X2 (2) = 12.93 p = 0.0016). Multivariable associations with Intermittent Explosive Disorder, controlling for the presence of PTSD, psychological distress and other predictors in the model, included the sense of being sick (OR 1.73; 95% CI 1.08–2.77); victimization as a result of helping the resistance movement (OR 2.33, 95% CI 1.48–3.68); war-related trauma specific to being a woman (OR 1.95, 95%, CI 1.09–3.50); ongoing family violence and community conflict (OR 1.88, 95% CI 1.27–2.77); extreme poverty (OR 1.23, 95%, CI 1.08–1.39); and distressing preoccupations with injustice (relating to 2/3 historical periods, OR 2.10, 95% CI 1.35–3.28). In the qualitative study, women elaborated on the determinants of anger and its impact on their health, family and community functioning, child-rearing, and capacity to engage in development. Women reflected on the strategies that might help them overcome their anger.ConclusionsIntermittent Explosive Disorder is prevalent and disabling amongst women in conflict-affected Timor-Leste, impacting on their health, child-rearing and ability to participate fully in socio-economic development.