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Ask the Mental Health Expert Archives 2001-2004

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Intermittent Explosive Disorder

Q. I am an attorney representing a juvenile who has been diagnosed with Intermittent Explosive Disorder. I need to know if this disorder is a basis for judging someone "not responsible by reason of mental defect." Could you point me to online resources? Does a person who suffer from this order have control over his/her actions? This case is in Wisconsin, can you recommend any experts on this subject close by?

A. Intermittent Explosive Disorder (IED) is one of the so-called "Impulse-Control Disorders, Not Elsewhere Classified" in the DSM-IV (Diagnostic and Statistical Manual of Mental Disorders, 4th ed.). IED is characterized "...by discrete episodes of failure to resist aggressive impulses resulting in serious assaults or destruction of property." (DSM-IV p. 609). The degree of aggressiveness is "...grossly out of proportion to any provocation or precipitating psychological stressor".

The diagnosis of IED is not made if the behavior in question is better explained by another psychiatric (or medical) condition, such as a manic episode, brain trauma, etc. Very often, individuals with IED describe a build-up of tension before the aggressive behavior, followed by a sense of relief after the explosive act, which in turn may be followed by a period of guilt or remorse. IED remains a rather murky diagnosis, and in all likelihood, represents a collection of different conditions with different etiologies.

For example, some individuals with IED may show nonspecific abnormalities on their EEG (electroencephalogram), whereas others do not; some may have abnormalities in levels of the neurotransmitter serotonin, whereas others do not, etc. The issue of how much control individuals with IED have is clearly very controversial, and may differ widely from person to person. One interesting study of brain function in a population of predatory violent offenders found evidence of reduced brain metabolic activity in frontal regions. The authors concluded that such individuals "...are less able to regulate and control aggressive impulses." (see Raine et al, Behav Sci Law 1998 Summer;16:319-32). Note that the authors did not say, "are unable" to regulate these impulses. (It is also interesting that the DSM-IV says that in IED, the individual "fails to resist" aggressive impulses, rather than "is unable to resist").

This point is taken up in a paper you may want to see, by SJ Morse (Bull Am Acad Psychiatry Law 1994;22:159-80). Morse distinguishes between causation and excuse, and relates this to forensic issues surrounding impulsive behaviors. A related paper is by JC Beck MD, in Behav Sci Law 1998;16:375-89. I don't know of experts in Wisconsin, but you may want to contact the Bazelon Center of Mental Health Law (http://www.bazelon.org/). I would guess they will have some more detailed suggestions for you. Good luck with your case.

March 2002

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