Study focuses on explosive disorder in teens

Nearly two-thirds of adolescents admitted to having anger attacks that involved destroying property or threatening or engaging in violence and one-in-12 of those adolescents meet criteria for Intermittent Explosive Disorder (IED), according to a recent study.

The study, funded by the National Institute of Mental Health, is among the first to measure the prevalence of IED in teens. The survey of teens 13-17 and their parents published this summer in the Archives of General Psychiatry found that the disorder has an early age onset – age 12 on average.

Study leader and epidemiologist Ronald C. Kessler, Ph.D., department of health care policy, Harvard Medical School, says the findings show IED is a common adolescent mental health disorder.

Kessler says many clinicians “don’t really believe IED exists.”

“So we really bent over backwards to throw out everything that could conceivably be thrown out,” he says, noting that researchers excluded anger attacks in the context of depression, substance abuse, ADHD, bipolar disorder and other disorders to ensure IED was not diagnosed among respondents whose symptoms could be better accounted for by another DSM-IV disorder.

“When we did that, I was kind of expecting we’d find a small number…that if we throw out all these other syndromes, nothing else would be left. So it was surprising to me a portion as high as (7.8 percent) remained even when we threw out everything else under the sun we could throw out.”

The study found that fewer than seven percent of teens with signs of IED were actually being treated for their anger. Many were getting psychiatric help for other conditions such as depression or alcohol abuse.

Kessler says anger attacks are often coded as more of a criminal justice problem than a mental health problem.

“The kids who have IED who are in treatment, the vast majority of them said the reason they were in treatment was for something else and they were not getting help for their anger attacks,” he says.

Psychologist Katie A. McLaughlin, Ph.D., one of the co-authors of the study and director, Stress & Development Laboratory, Boston Children’s Hospital, says she hopes the findings stimulate more research for IED risk factors and treatments.

“One of the big things to take away is, these anger attacks appear to be a very prominent problem that we aren’t currently capturing within the context of other diagnoses,” she says.

“We don’t know much at all about whether the risk factor is different for this and other  disorders and we don’t know if the kinds of treatment methods we use (for other disorders) are effective or useful for adolescents who meet criteria for IED or have the kind of anger attacks in the study.”

McLaughlin says there’s converging evidence that early adolescence appears to be a risk period for the first onset of these kinds of attacks. McLaughlin suggests clinicians take IED into consideration if they see adolescents with aggression or conduct problems. She notes that if clinicians are more aware of IED, “treatment approaches that we use quite commonly, like cognitive behavior therapy, I imagine would be quite helpful.”

Because the age of onset is young, it’s possible that IED is a risk factor for the subsequent onset of other co morbid diseases, she says.

Kessler notes clinicians should routinely ask youth about anger attacks and recognize that it’s not just kids with conduct problems, but also those who have internalizing problems, are sad, worried or have panic issues.

Kessler drew a comparison between anger attacks, which appear to be more prevalent in boys and panic attacks, which are more prevalent in girls. “Both of them are these out-of-proportion uncontrollable things where they explode and the explosion goes in one way or the other, either lashing out or being scared to death.”

McLaughlin says that while this study and others appear to show anger attacks and IED as more common than panic attacks and panic disorder, the amount of research done on panic disorder exponentially dwarfs the number of studies on IED.

“As a result, we’ve come up with quite effective treatment for panic disorder,” she says “It just speaks to the fact that we really need more research to understand risk factors for anger attacks and IED and most importantly, treatment approaches.”