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Explosive disorder affects 16 million

University Of Chicago : 25 June, 2007  (Technical Article)
Researchers from Harvard and the University of Chicago have found that one in 20 Americans may be susceptible to repeated, uncontrollable anger attacks in which they lash out in road rage, spousal abuse or other unjustifiably violent actions.
Their nationwide study suggests a condition called intermittent explosive disorder, or IED, is not the rare occurrence that psychiatrists had previously thought. Four to five percent of people in the study were found to have physically assaulted someone, threatened bodily harm or destroyed property in a rage an average of five times a year.

Intermittent explosive disorder is different from the common type of anger most people exhibit from time to time when they pout, throw a book down or walk out of a room, activities that are better described as mild temper tantrums. IED is defined as repeated and uncontrollable anger attacks that often become violent.

'Our new study suggests IED is really out there and that a lot of people have it,' Dr. Emil Coccaro, the U. of C.'s chief of psychiatry, said. 'That's the first step for the public to actually get treated for it, because if you don't think it's really a disorder, you're never going to get treated for it.'

Coccaro was the first to show, through a preliminary study, that IED might be an unrecognized major mental health problem. He also pioneered therapy designed to treat the disorder involving anti-depressants, mood disorder medications like lithium and cognitive therapy.

The new research, reported in the current issue of the Archives of General Psychiatry, involved person-to-person interviews of 9,282 people 18 years and older conducted from 2001 to 2003. The subjects were part of the National Comorbidity Survey Replication, a government-funded epidemiological study of mental health.

The authors said their findings suggest two disturbing trends that will require additional study, that IED is on the increase among teenagers and that it may set the stage for the onset of such other mental conditions as depression and alcoholism. Eight out of 10 people with IED subsequently develop other mental disorders, they found.

'Given its age of onset, identifying IED early, determining its causes and providing treatment might prevent some of the associated secondary disorders, such as anxiety and alcohol abuse,' said Ronald Kessler, a professor of health-care policy at Harvard.

The study found that the rage disorder typically begins at age 13 in boys and 19 in girls, increases rapidly in the teen years, is less prevalent among respondents in their 40s and becomes even less so among people in their 60s.

'Is there something profoundly important about how society is changing that's leading to this apparent increase in people not being able to control their emotions and lashing out at other people?' asked Kessler. 'Is it that we're bad parents and we're creating these little monsters? Is television doing it?

'We know there's an awful lot of young people who have it today and older people tell us they've never had it,' he said. 'Whether they're lying or not we don't know. But, obviously, now that it's on our radar screen, we're going to be monitoring it very carefully.'

Mental health research has concentrated on such problems as depression, schizophrenia, anxiety, panic attacks and substance abuse. Instead of being considered a mental health problem, anger was thought to be a matter of willpower.

But new brain imaging studies show that people with IED have abnormal brain signaling in areas that control anger responses, Coccaro said. When people with rage disorder are shown pictures of people with angry faces, their amygdala lights up far more than is seen in healthy subjects. The amygdala, deep in the center of the brain, governs emotional responses to threats.

At the same time, the front portion of their brain, which serves as an executive control over emotional urges, is less active than in normal people, Coccaro said, indicating that people with IED quickly lose control.

'People with this problem have a low threshold for exploding and that's probably genetically and biologically mediated,' he said.

People with rage disorder often misinterpret another person's harmless action as a personal threat and respond by slapping, hitting or threatening the other person, breaking things, punching holes in walls or trying to run the person down with a car, Coccaro said.

Two things generally set these people off, he said: perceived threats and frustrating situations. So the road rage person may explode for both reasons, he feels threatened by being cut off in traffic and frustrated because traffic congestion keeps him from getting to where he wants to go quickly.

While many people under similar conditions may honk their horn or yell, that's more like a temper tantrum than the potentially deadly kind of reaction of someone with rage disorder, Coccaro said.

The majority of men who engage in spousal abuse are sociopathic and could control their behavior, but about a third may suffer from IED and impulsively strike out, he said. The largest number of assaultive acts occur in interpersonal relationships, followed by social settings, home and work.

Terry, a 42-year-old Oak Lawn resident, said he used to get angry at work occasionally, but it never got physical until three years ago, when fights with his wife turned violent.

'The problem was when it got to the point of rage, then it just took over; there was no rational thought,' said Terry, who asked that his last name not be published. 'We would fight maybe once a week. I physically started grabbing my wife, and her being so petite she bruised easily. That wasn't a good thing.'

Seeking help two years ago at the U. of C. after hearing a radio advertisement for the rage study, Terry was diagnosed with IED. Medications and cognitive therapy reduced his impulse for violent outbursts, he said, and he got further help after joining Alcoholics Anonymous. 'It worked fine and I've been perfectly fine ever since.'

During a rage attack people often feel a sense of relief, but they mostly feel remorse afterward, Coccaro said. They run a high risk of getting divorced, losing friends, getting into trouble with the law and being fired from jobs, he said.

Anger attacks can be reduced with drug therapy to raise the threshold at which people explode or with cognitive behavioral intervention that teaches people how to relax when they feel tense and how to recognize that another person is not trying to hurt them, Coccaro said.

'The simplest coping skill is to get out of the encounter,' he said. 'If you feel you're going to explode you just walk away, take a timeout.'
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