According to the APA, intermittent explosive disorder is characterized by angry aggressive outbursts that occur in response to relatively minor provocation.
This particular label has an interesting history in successive editions of the DSM.
DSM I (1952)
Intermittent explosive disorder does not appear as such in the first edition of DSM, but the general concept is clearly discernible in “passive-aggressive personality, aggressive type”:
“A persistent reaction to frustration with irritability, temper tantrums, and destructive behavior is the dominant manifestation.” (p 37)
Note the term “reaction” in the definition, implying that the temper tantrums are being conceptualized as a reaction to a frustrating experience, rather than an illness, as such.
By DSM-II, the diagnosis had acquired free-standing status as a “personality disorder”, and was called “explosive personality (Epileptoid personality disorder)”. Here’s the definition:
“This behavior pattern is characterized by gross outbursts of rage or of verbal or physical aggressiveness. These outbursts are strikingly different from the patient’s usual behavior, and he may be regretful and repentant for them. These patients are generally considered excitable, aggressive and over-responsive to environmental pressures. It is the intensity of the outbursts and the individual’s inability to control them which distinguishes this group. Cases diagnosed as ‘aggressive personality’ are classified here. If the patient is amnesic for the outbursts, the diagnosis of Hysterical neurosis, Non-psychotic OBS [Organic Brain Syndrome] with epilepsy or Psychosis with epilepsy should be considered.” (p 42-43)
There are three notable features of this definition.
Firstly, the term “reaction” has been eliminated. With the benefit of hindsight, it is clear that the term “reaction” which was used extensively in DSM-I became an embarrassment for psychiatry. In 1952, I believe that many psychiatrists would have acknowledged that the problems they encountered in their work were not illnesses in any biological sense of the term. By 1960, however, the drugs were beginning to come on stream, and the promise was emerging that psychiatrists, if they made some conceptual adjustments, could ride pharma’s bandwagon and become “real” doctors. And one of the conceptual adjustments that had to be made was the elimination of the word “reaction” and all that it entailed. So, eliminate it, they did. They offered no explanation, but there is this charmingly candid little quote on page ix of DSM-II:
“Consider, for example, the mental disorder labeled in this Manual as ‘schizophrenia,’ which, in the first edition, was labeled ‘schizophrenic reaction.’ The change of label has not changed the nature of the disorder, nor will it discourage continuing debate about its nature or causes. Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it.”
Secondly, the notion that the person is unable to control the aggressive impulses is introduced as a distinguishing feature of the “diagnosis”. This is a particularly interesting development, in that it is impossible to determine whether a person is, or is not, unable to control his aggression. All that can be determined is whether a person did or did not control aggressive impulses on any given occasion.
Thirdly, the definition clearly allows the “diagnosis” to be made on the basis of verbal aggressiveness.
Side note on “epileptoid Personality disorder”: During the first half of the 1900’s, and even as late as the 70’s, there were frequent references in psychiatric writings to epileptic (or sometimes epileptoid) personality disorder. It was widely believed that people with epilepsy tended to be generally impulsive, explosive, and egocentric. The notion was given a good deal of credence and attention. Psychiatric research purported to identify the traits involved, and causative theories were developed and promoted. Most epilepsy specialists today consider the research to have been questionable, and the supporting observations to have been cases of people “seeing” what they had been taught to expect: a lesson that psychiatry generally seems unable to assimilate.
In DSM-III, “intermittent explosive disorder” appears as an entry in the category “Disorders of Impulse Control Not Elsewhere Classified.” Here are the criteria:
“A. Several discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property.
B. Behavior that is grossly out of proportion to any precipitating psychosocial stressor.
C. Absence of Signs of generalized impulsivity or aggressiveness between episodes,
D. Not due to Schizophrenia, Antisocial Personality Disorder, or Conduct Disorder,” (p 297)
Notice that the criteria are fairly simple, and that, even allowing for the vagueness of language, what’s being described is relatively severe and serious: “…serious assault or destruction of property.” In other words, DSM-II’s acceptance of verbal aggressiveness as a criterion item has been eliminated: a rare instance of the APA actually tightening their criteria. The effect of this, however, was probably minimal, as the “diagnosis” was still described under Prevalence as “very rare”.
The diagnostic criteria in DSM-III-R (1987) were essentially similar to those in DSM-III, though the list of exclusions was expanded to: “…a psychotic disorder, Organic Personality Syndrome, Antisocial or Borderline Personality Disorder, Conduct Disorder, or intoxication with a psychoactive substance.” (p 322)
Prevalence is still shown as “apparently very rare”.
DSM-IV made two changes to the criteria.
1. Item C from DSM-III-R, which had read: “There are no signs of generalized impulsiveness or aggressiveness between the episodes”, was eliminated. Up till DSM-III-R, the “diagnosis of intermittent explosive disorder” was given only to individuals who were generally even-keeled, but who exhibited episodes of explosive anger that were apparently out of character. DSM-IV offered no explanation for the removal of this item, stating only: “The DSM-III-R criterion excluding this diagnosis in the presence of generalized impulsiveness or aggressiveness has been deleted.” Obviously this deletion widens the scope of the “diagnosis”, and allows a great many more people to be given this label than was formerly the case.
2. As in DSM-III-R, the “diagnosis” is not to be given if the episodes “…occur during the course of…intoxication with a psychoactive substance”. DSM-IV added the clarification that this included the effects of “medication” – an implied acknowledgement that psychiatric drugs can precipitate outbursts of violence and destructiveness.
DSM-IV also amended the prevalence from “very rare” to “rare”, though in fact, Kessler et al (2006), using DSM-IV’s criteria, reported a lifetime prevalence rate of 7.3%, and a previous 12-month-rate of 3.9%. A lifetime prevalence rate of 7.3% is approximately one person in fourteen. This is hardly rare!
In DSM-III and IV, a diagnosis of intermittent explosive disorder required several episodes of serious assaults or serious destruction of property.
But DSM-5 changed all that. Here’s criterion A:
“A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:
- Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
- Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.” (p 466)
Note the word “either” in the lead in, and the proliferation of “ors” in 1 and 2. This makes for labored reading, but one thing is crystal clear: under DSM-5 rules, a person can be assigned this psychiatric label on the grounds of “verbal aggression” occurring twice weekly, on average, for a period of three months. A person can also be so labeled on the grounds of physical aggression that does not result in property damage or physical injury.
Essentially what this means is that a person who, say, habitually rants aggressively and obnoxiously at other motorists while driving is actually mentally ill. Prior to DSM-5, he wasn’t mentally ill; he was just rude and vituperative. But now, thanks to the endlessly inspired creativity of psychiatry, he is mentally ill, and can be cured of this malady by ingesting a few pills every day for the rest of his (probably shortened) life.
The authors of DSM-5 offer no explanation for this change.
“The primary change in Intermittent explosive disorder is in the type of aggressive outbursts that should be considered: DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria.” (p 815) [Emphasis added]
Note also the specification: “twice weekly, on average, for a period of three months.” These kinds of frequency statements occur occasionally in DSM-5, and were included, presumably in an attempt to rescue the “diagnosis” in question from the charge of vagueness and unreliability. What’s not usually recognized, however, is that the frequency criteria are entirely arbitrary. Why not three times weekly for a period of two months? Or four times weekly for four months? The answer, of course, is because the APA says so. There is no evidence, nor can there ever be any evidence, supporting one over the other.
Age of Onset
Age of onset has been an interesting issue across the various editions.
DSM-I and II made no reference to age of onset.
DSM-III: “The disorder may begin at any state of life, but more commonly begins in the second or third decade” (p 296) [Emphasis added]
DSM-III-R: The same as DSM-III.
DSM-IV: “Limited data are available on the age at onset of Intermittent Explosive Disorder, but it appears to be from late adolescence to the third decade of life.” (p 611) [Emphasis added]
DSM-5: “The onset of recurrent, problematic, impulsive aggressive behavior is most common in late childhood or adolescence and rarely begins for the first time after age 40 years.” (p 467) [Emphasis added]. Also, Criterion E states: “Chronological age is at least 6 years old.” [Emphasis added]
So the usual age of onset has progressed from “second or third decade”, to “late adolescence”, to “late childhood”, and as young as 6 years old!
What’s particularly noteworthy in all of this is the progressive loosening of the criteria across time, especially the elimination in DSM-5 of the requirement for serious damage or serious assault. The lowering of the age of onset is also telling, and DSM-5’s criterion that “chronological age is at least 6 years” is chillingly consistent with psychiatry’s present promotion of the need for “early intervention”. Here’s a quote from Kessler et al 2006:
“Intermittent explosive disorder is a much more common condition than previously recognized. The early age at onset, significant associations with comorbid mental disorders that have later ages at onset, and low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment.” [Emphasis added]
Promising, one is tempted to ask, for whom?
At the risk of stating the obvious, what psychiatrists call “intermittent explosive disorder” is not an illness in any ordinary sense of the term. There are rare instances where brain damage can precipitate episodes of extreme anger, and these should indeed be considered illnesses. But in the vast majority of temper tantrums, there is no neural pathology, but rather the simple fact that the individual hasn’t acquired the habit of controlling his/her temper.
To previous generations, the need to train/school children in this regard was considered a self-evident part of normal child-rearing.
But psychiatry needs illnesses to legitimize medical intervention. And where no illnesses exist, they have no hesitation in inventing them. And since they invented them in the first place, they have no difficulty in altering them to suit their purposes. Of course, almost all the alterations are in the direction of lowering the thresholds, and thereby increasing the prevalence.
The idea of medical professionals arbitrarily inventing, and changing, the criteria for the “illnesses” that they treat sounds so preposterous that most people find it hard to believe. It is widely assumed that psychiatrists have valid, scientifically-based reasons for making these changes. But in fact, intermittent explosive disorder is nothing more, and nothing less, than what the APA says it is. And over the years, in successive revisions of the catalog, they have made these changes, culminating in the sea-change of DSM-5.
And remember, DSM-5 was also the birthplace of “disruptive mood dysregulation disorder” – a pathologizing label for children (aged 6 and over) who are persistently bad-tempered. In intermittent explosive disorder, the psychiatrists also have an “illness” for children (aged 6 and over) who are intermittently bad-tempered. In psychiatry, as in fishing: the bigger the net, the bigger the catch.
The great “breakthrough” for psychiatry in this regard was DSM-III’s definition of a mental disorder:
“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).” (p 6)
DSM-III-R expanded this to:
“…a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painful symptom) or disability (impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (p xxii)
If you strip away the verbiage, and note the frequent use of the word “or”, what this actually means is: any significant problem of thinking, feeling, and/or behaving. This was Robert Spitzer’s “great” achievement: defining mental disorder/illness in such a way that it could include virtually any and all problems. It was this simple contrivance that made it possible to expand the psychiatric net more or less indefinitely. And Dr. Spitzer’s definition has been dutifully retained, with only minor verbal changes, by both DSM-IV and DSM-5. After all: “if it ain’t broke, don’t fix it.” Though it should be noted that DSM-5 did manage to relax Dr. Spitzer’s definition even further by the ingenious use of the word “usually”: “…usually associated with significant distress…” “Usually” means not necessarily.
It might be asked: how can they do this? How can they just invent illnesses for themselves to treat? And the answer is simple: they did it gradually and imperceptibly; and nobody stopped them. Protesters were marginalized and ridiculed as unscientific blamers and stigmatizers, while the psychiatric juggernaut inched forward year by year, decade by decade, increasing its territory, expanding its scope, selling ever more drugs for pharma and – in the process – destroying people’s brains, and undermining our cultural resilience.
In this regard, here are some interesting quotes:
Intermittent explosive disorder: Treatment and drugs, at Mayo Clinic:
“Different types of drugs may help in the treatment of intermittent explosive disorder. These medications include:
- Antidepressants, such as fluoxetine (Prozac) and others
- Anticonvulsants, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), topiramate (Topamax) and lamotrigine (Lamictal)
- Anti-anxiety agents in the benzodiazepine family, such as lorazepam (Ativan) and clonazepam (Klonopin)
- Mood stabilizers, such as lithium (Lithobid)”
Treating intermittent explosive disorder, from Harvard Medical School:
“A number of medications are known to reduce aggression and prevent rage outbursts, including antidepressants (namely selective serotonin reuptake inhibitors, or SSRIs), mood stabilizers (lithium and anticonvulsants), and antipsychotic drugs.”
Intermittent Explosive Disorder, Child Mind Institute, under the subheading “Treatment”:
“…a variety of medications have been used to help people with IED, including antidepressants and anti-anxiety medications, as well as anticonvulsants and other mood regulators. After a careful evaluation, a psychiatrist will prescribe the appropriate type of medication for an individual case.”
This is not the practice of medicine; this is drug-pushing in the guise of medicine. Whatever effectiveness the drugs might have in reducing aggression, is far outweighed by the spurious message to the individual, that he is incapable of controlling his aggression without “meds”, and to parents, that their 6-year-old’s temper tantrums are symptoms of a serious lifelong illness that needs prompt psychiatric attention.
This is not the practice of medicine. This is a hoax.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.