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Sharon Kirkey

The Ottawa Citizen
Date Published: Tuesday, July 3, 2012
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Intermittent explosive disorder — a controversial mental illness marked by outbursts of uncontrollable  rage — is so common among adolescents it affects one in 12 teens, a large new  study finds.

Harvard Medical School researchers, in a study based on in-person interviews  with more than 10,000 adolescents ages 13 to 17, found that about eight per cent  met the criteria for intermittent explosive disorder, or IED.

The findings suggest the disorder is affecting hundreds of thousands of  youths — close to six million in the U.S. alone, according to a statement  released with the study.

But observers worry it could trigger a "manufactured epidemic" of mental  illness among teens and lead to extreme but predictable teenage behaviour being  labelled as symptoms of a mental illness requiring treatment — including  mood-altering drugs.

According to the Diagnostic and Statistical Manual of Mental Disorders — psychiatry's official catalogue of mental illness, now undergoing its first  major revision in nearly two decades — IED's central feature is impulsive  aggression grossly out of proportion to the situation. People lose control,  break or smash things and attack or threaten to hurt someone.

The study, published this week in the journal of Archives of General  Psychiatry, is being described as the first to estimate the prevalence of IED in  American adolescents. The researchers believe their findings could be  extrapolated to Canada.

"If we can detect IED early and intervene with effective treatment right  away, we can prevent a substantial amount of future violence perpetration and  associated psychopathology," senior author Ronald Kessler, professor of health  care policy at Harvard, said in a statement.

But Christopher Lane, author of Shyness: How Normal Behaviour Became a  Sickness, said IED has been a source of controversy since it was formally  approved as a mental disorder in 1980.

"Uncontrollable anger and domestic violence are, of course, serious concerns  requiring attention," said Lane.

But equally concerning, he said, is the risk of "medicalizing" adolescence  itself.

Disorders in the DSM are defined by a list of diagnostic criteria. A person  can qualify for a certain diagnosis based on how many criteria they meet for  that illness.

But there isn't agreement on just how many "episodes" or outbursts of  aggression are necessary for a diagnosis of IED. As well, some have proposed  broadening the criteria to include outbursts that don't involve threatened or  actual violence, but do involve verbal aggression — insults or arguments "out of  proportion to provocation."

The new study is based on a national mental health survey conducted in the  U.S. between February 2001 and January 2004.

Nearly two-thirds — 63 per cent — of the adolescents surveyed reported at  least one anger attack in their lifetime involving either destroying property or  threatening or engaging in violence.

About one-third of those who reported attacks (29 per cent) had only one or  two attacks in their lifetime; another one-third only had attacks that were  either in line with the "provoking circumstances" or not out of control.

The remainder was made up of those with IED, the authors write.

Teens had to report three or more anger attacks in their lifetime to meet the  criteria for IED.

When the Harvard team narrowed it to three attacks in a single year, with at  least one attack involving violence or destroying property, 5.5 per cent met a  diagnosis of IED.

Youth who had other problems associated with aggression, including  attention-deficit/hyperactivity disorder, conduct disorder and bipolar disorder,  were excluded. "We wanted to be sure we were really capturing something that  wasn't already accounted for by another diagnosis," said co-author Katie  McLaughlin, an assistant professor of pediatrics and psychiatry at Boston  Children's Hospital.

While some of the IED-diagnosed youths had been treated for emotional  problems in the year before their interview, only 6.5 per cent received  treatment specifically for anger.

"IED is one of the least-studied of the mental disorders, despite the fact  that it's quite common," McLaughlin said.

But Lane, author of the Psychology Today blog "Side Effects", said the  results show otherwise — "that a significant number of teenagers have relatively  few problems with impulse control and anger management."

Even for the teens who met criteria for IED, "it's still a big, unsettled  question whether their periodic anger and threatened or actual violence should  be considered a lifelong mental disorder," Lane said, "rather than a  psychological crisis involving major life-stressors such as job loss, poverty,  home foreclosure, debt issues and drug and alcohol addiction."

Dr. Allen Frances, former chair of the psychiatry department at Duke  University's School of Medicine, chaired the task force that wrote the current  edition of the DSM. He called IED an "unstudied" and "inherently unreliable  category that probably shouldn't be in the DSM at all.

"It most certainly should not be reified into a manufactured teenage epidemic  of mental disorder that is allegedly affecting millions of kids," he said.

"The suggestion that we institute prevention programs is a wildly premature  over-promise until much more solid research demonstrates that there is real need  and proven effectiveness."