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psychiatric diagnosis

Intermittent Explosive Disorder

Intermittent Explosive Disorder – More Than Just Anger

Intermittent Explosive Disorder (also called IED, that is appropriate as it can go off unexpectedly and cause significant damage)

Intermittent Hulk Explosive DisorderProbably everyone knows that teenage boy (or girl) who punched a hole through the wall.  Perhaps for some, this became a regular pattern of behavior during adolescence but most of those teenagers outgrew it.  In fact, at least one-quarter of teenage boys has done something dumb like punching a wall.

One boy I knew in high school even broke his hand by punching the roof of his car, and some boys were routinely doing stupid stuff.  Despite that, all of it was teenage angst and changes that can be attributed to the massive amounts of testosterone flowing through the male adolescent body – none of them had intermittent explosive disorder.

Intermittent Explosive Disorder is worse than punching a hole through a wall.

It typically is first identified in the early teens – but can be seen much earlier in some cases.    In order to be actually characterized as intermittent explosive disorder, an individual must have had three episodes of explosive behavior that is severely out of proportion to the stressor.

Intermittent Explosive Disorder HulkinsectThey must have broken or smashed something that is monetarily valuable (more than a few dollars), physically attacked or made explicit threats to attack someone with the intent of causing harm.  If these three episodes occur within the space of 12 months, the disorder is considered to be more severe.

Here is the catch.

How do you distinguish between IED, average – though extreme teenage behavior and other psychiatric conditions?  It turns out that IED is probably a diagnosis of “if nothing else fits” as other psychiatric disorders certainly overlap with similar symptoms – and you have to rule out the adolescent hormone issue.

Bipolar disorder may cause outbursts of extreme anger and agitation, Borderline personality disorder may cause outbreaks, ADHD patients can exhibit a severe lack of self-control, and drug abuse is always a potential cause.  Even though those diseases may cause IED-like events, a sustained behavior pattern is something to address.

Intermittent Explosive Disorder WarningA recent study reported by the National Institutes of Health shows that IED can actually affect up to 4 percent of adults and lead to an estimated 43 attacks over a lifespan.  The disorder may also increase that chance of depression, anxiety and substance abuse disorders.  People with IED have an obvious increased risk of legal trouble, financial difficulties, and divorce – that’s a no-brainer.

So the biggest problem for mental health professionals, like many other disorders, is to untangle all of the information leading in and out with a mix of behaviors and a mix of causes.  What came first – the chicken or the egg?  What came first – the drug abuse or the anger?  Which illness is more important – bipolar disorder or the IED?

One of the biggest clues may be in examining (or better, paying attention to) behavior that occurs before puberty.  In other words: What came first – the behavior or puberty?  Clearly if the behavior started before puberty, there was and is an issue.  If the behavior begins during adolescence – you have to wait (and hope) to see if the behavior goes away once the hormones are settled.

IED is not a simple diagnosis.

It requires a careful examination of an entire psychiatric and behavioral history – and the “ruling out” of a lot of other disorders that may be to blame.  Unfortunately, in the end – unless an underlying cause can be found, there is no medicationAnger management and cognitive behavioral therapy are likely the only answer – minimization of harm, not very satisfactory if it was your car window that got smashed in a fit of rage.

Melissa Lind

Is it Antisocial Personality Disorder?

Some teenagers act as if they have antisocial personality disorder

I once knew a family with a son who was diagnosed with antisocial personality disorder.  The “kid” had grown up in a wealthy subdivision with a father who was a former professional athlete.  The “kid” had everything that most “kids” would want.  In high school, he had a brand new car that he immediately totaled after a party.  He was in trouble with the law several times during high school.

When his father tried to put his foot down, his mother took the “kid’s” side.  She thought he would grow out of it.  Others said that his behavior was the result of “privilege”, which certainly didn’t help, but it is clear that not every wealthy kid is a spoiled brat – and a dangerous one at that.

Antisocial Personality DisorderRather than using his position and financial ability to go to college and earn a degree, he started doing drugs and got kicked out.  He was sent to a famous rehabilitation center where as soon as he “dried out”, he beat up a staff member and was thrown out.  He went home and beat up his girlfriend, but his mother hired the most expensive lawyer available, and he was given probation.  He was arrested with a sizeable amount of drugs – and again was bailed out by his mother.

This went on for a number of years – but the teenage behavior never stopped.  He finally exhausted the judge’s leniency and ended up in a state penitentiary.  Each time, he blamed his behavior on someone else.  He wouldn’t have gotten drunk if he hadn’t been so mad, he wouldn’t have beaten his girlfriend if she had just done what he said… and on and on.  This “kid” was 35 by the time he went to prison, but he never understood what he had done wrong.  It was still someone else’s fault.

When someone is disagreeable, people will often say “He is anti-social.”  What they are referring to is an actual psychiatric diagnosis, Antisocial Personality Disorder, but just because someone is disagreeable or even downright rude doesn’t mean they have the condition.

A personality disorder is a pervasive pattern of behavior that is not “acceptable” by cultural standards.  It is readily seen as abnormal behavior and usually starts in adolescence or early adulthood.  In order to qualify as a “disorder”, it must lead to personal distress or impairment.

Antisocial personality disorder cannot be diagnosed until the age of 18 because many of the “symptoms” seem like typical teenage behavior.  It is characterized by disregarding and violating the rights of other people.  Many teenagers act as if they have antisocial personality disorder – but they don’t.  In addition, in order to be labeled as “antisocial“, there must have been some conduct disorder symptoms before age 15 – or the time kids are often worst as teenagers.

Ashamed of Mental Health StigmasThings that kids do or say during the teen years, don’t count.

A person with antisocial personality disorder has a general disdain for the rights of other people and may violate those rights on a routine basis.  They may be charming, but ruthless and are likely to be irresponsible, irritable, and aggressive.  They are also likely to be in legal trouble and likely to abuse drugs or alcohol.

Antisocial Personality disorder also comes in a range of severity.  A person with mild antisocial personality disorder could be compared to a teenager who continuously borrows her mother’s jewelry when she has been told not to.  This would not be completely out of the norm in some teen girls, but in adults, it may indicate pathology.

People with more dangerous or harmful behavior are referred to as sociopaths or even psychopathsSociopaths have even less regard for someone else’s rights or property and may not even feel the need to argue if confronted – acting like a schoolyard bully.  Psychopaths are said to have a complete lack of conscience and are unable to recognize the violation and do not have the ability to empathize – something like “The Joker” in Batman.

People with antisocial behavior patterns are also extremely manipulative and splendid liars.  It is hard to tell what is true and what is not true.  They may appear to be friendly when they want something, or they may attempt suicide when they want something else.  It is a fine line to walk, whether to believe them or not.

Unfortunately, personality disorders are not something that can be changed through medication.  In this case, it is a failure of conscience, and there is no pill for that.  In some cases, therapy can work but the therapist must be very skilled in order to avoid being manipulated themselves.

Melissa Lind