176 - 6C73 Intermittent explosive disorder

6C73 Intermittent explosive disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders some degree of control over the behavioural expressions of the arousal pattern, an additional diagnosis of compulsive sexual behavioural disorder is generally not warranted. If, however, the diagnostic requirements of both compulsive sexual behavioural disorder and a paraphilic disorder are met, both diagnoses may be assigned. Boundary with the effects of psychoactive substances, including medications Use of specific prescribed medications or illicit substances (e.g. dopamine agonists such as pramipexole for Parkinson disease or restless legs syndrome or illicit substances such as methamfetamine) can sometimes cause impaired control over sexual impulses, urges or behaviours due to their direct effects on the central nervous system, with onset corresponding to use of the substance or medication. Compulsive sexual behaviour disorder should not be diagnosed in such cases. Boundary with disorders due to substance use Episodes of impulsive or disinhibited sexual behaviour may occur during substance intoxication. At the same time, co-occurrence of compulsive sexual behaviour disorder and substance use is common, and some individuals with compulsive sexual behaviour disorder use substances with the intention of engaging in sexual behaviour or to enhance pleasure from it. Distinguishing between compulsive sexual behaviour disorder and repetitive patterns of substance use with associated sexual behaviour is therefore a complex clinical judgement based on an assessment of the sequencing, context and motivations of the relevant behaviours. A diagnosis of compulsive sexual behaviour disorder may be assigned together with a disorder due to substance use if the diagnostic requirements for both are met. Boundary with dementia and medical conditions not classified under mental, behavioural and neurodevelopmental disorders Some individuals with dementia, diseases of the nervous system or other medical conditions that have effects on the central nervous system may exhibit failure to control sexual impulses, urges or behaviours as a part of a more general pattern of disinhibition of impulse control due to neurocognitive impairment. A separate diagnosis of compulsive sexual behaviour disorder should not be assigned in such cases. Intermittent explosive disorder Essential (required) features • The presentation is characterized by a pattern of recurrent, brief, explosive episodes involving verbal aggression (e.g. verbally attacking another person, temper outbursts, yelling) or physical aggression in an individual who is at least 6 years of age – when inhibition of angry outbursts is expected to have been attained – or equivalent developmental level is required for diagnosis. Episodes of physical aggression may result in significant damage or destruction of property or physical assault involving personal injury; however, such outcomes are not required for the diagnosis. • The intensity of the outbursts or the degree of the aggressiveness is grossly out of proportion to the provocation or precipitating event or situation. 6C73 Impulse control disorders | Intermittent explosive disorder

531 Impulse control disorders • The explosive outbursts must occur regularly over an extended period of time (e.g. at least 3 months), representing a persistent pattern of aggressive behaviour. A lower frequency threshold (e.g. several times over the course of a year) may be used for high-intensity outbursts with serious negative consequences, such as physically assaulting another person, whereas a higher frequency threshold (e.g. two or more times per week) should be used for episodes characterized by verbal aggression or non-assaultive and non-destructive physical aggression. • The aggressive behaviours are clearly impulsive or reactive in nature, and represent a failure to control aggressive impulse. That is, the aggressive acts are not planned or instrumental in achieving a desired outcome. • The frequency and intensity of explosive episodes is outside the limits of normal variation expected for the individual’s age and developmental level. • The explosive outbursts are not better accounted for by another mental, behavioural or neurodevelopmental disorder (e.g. autism spectrum disorder, attention deficit hyperactivity disorder, oppositional defiant disorder with chronic irritability-anger, conduct-dissocial disorder, delirium). • The explosive outbursts are not due to the effects of a substance or medication on the central nervous system (e.g. amfetamines), including substance intoxication and withdrawal, or due to a disease of the nervous system. • The behaviour pattern results in significant distress for the individual with the disorder, or significant impairment in personal, family, social, educational, occupational or other important areas of functioning. Additional clinical features • Explosive episodes may be associated with affective symptoms (anger, irritability, rage) during aggressive outbursts. Sometimes the aggressive episodes are preceded by premonitory symptoms such as tremor or chest tightness, or a more general feeling of tension or arousal. • Explosive outbursts in intermittent explosive disorder are typically triggered by perceived threats in social settings (even when there is no real threat but, for example, threat is perceived based on an inaccurate attribution of hostility to others), or by frustration when facing obstacles in the course of daily life. • A wide array of aggressive behaviours could fulfil the requirements for intermittent explosive disorder, ranging from verbal aggression to physical assault and destruction of property. • After the explosive episode, the individual often, but not always, experiences depressed mood or fatigue, or other negative emotions such as regret, remorse, guilt or shame. • Some individuals with intermittent explosive disorder exhibit nonspecific abnormalities on neurological examination (e.g. “soft signs”) and in EEGs that do not constitute a diagnosable disease of the nervous system. In the presence of such findings, intermittent explosive disorder may still be diagnosed if the diagnostic requirements are met. • Many individuals with intermittent explosive disorder have a history of exposure to traumatic events, witnessing violence, or childhood physical abuse. • Intermittent explosive disorder often co-occurs with depressive disorders, anxiety and fear-related disorders, disorders due to substance use, and eating disorders (especially those involving binge eating). Impulse control disorders | Intermittent explosive disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders Boundary with normality (threshold) • Aggressive outbursts – particularly verbal ones – are common, especially when an individual is under stress, and are not in themselves indicative of psychopathology. The mere occurrence of one or two isolated explosive episodes is not sufficient for the diagnosis, regardless of the severity or consequences of the behaviour. This diagnosis should only be considered when the intensity of the outbursts or the degree of the aggressiveness is grossly out of proportion to the provocation or precipitating event or situation, and the outbursts occur regularly over an extended period of time, representing a persistent pattern of aggressive behaviour. Course features • The mean age of onset of intermittent explosive disorder is between 10 and 16 years. Age of onset is typically earlier than common co-occurring disorders such as depressive disorders, anxiety and fear-related disorders, eating disorders and disorders due to substance use. • Intermittent explosive disorder tends to exhibit a persistent course over many years. Aggressive behaviour in general tends to diminish over time, and the prevalence of intermittent explosive disorder correspondingly diminishes over the lifespan. Developmental presentations • Early in the course of intermittent explosive disorder, children typically display temper tantrums associated with verbal outbursts and aggression against objects, although typically without serious destruction of objects or assault against others. • During adolescence, explosive outbursts often escalate to include destruction of objects or property, or physical assault against others. Culture-related features • Variation in prevalence of intermittent explosive disorder may be related to cultural norms regarding emotion regulation. Some cultures emphasize emotional restraint, equanimity, interpersonal harmony and social conformity such that individuals suppress or mute overt expressions of hostility or anger. In other cultures, freer expressions of negative affect are more typical. Whether or not a verbal expression is considered aggressive should be evaluated within the context of what is normative within the individual’s culture. Impulse control disorders | Intermittent explosive disorder

533 Impulse control disorders • Societies vary in the degree to which they consider anger a harmful emotion, associated with substantial personal and social risk. Some cultural concepts of distress are attributed to pent-up anger, such as ataque de nervios (attack of nerves) in Latin America and hwabyung (anger illness) in the Republic of Korea. It may be appropriate to apply a diagnosis of intermittent explosive disorder to some behavioural patterns of ataque de nervios involving paroxysmal violence and destruction of property. • The typical level of expressed emotionality varies cross-culturally, including by gender and age. Cultural minorities, immigrants or individuals in post-conflict settings may be at risk of being mislabelled as excessively angry because of this variation. Moreover, clinicians may misattribute anger to a single triggering event when it is in reaction to the accumulation of multiple environmental stressors (e.g. discrimination, losses, displacement, limited social support, powerlessness, injustice). Clinicians should consider the larger social context and how it may be related to the expression of anger before assigning a diagnosis. Sex- and/or gender-related features • Although it was originally believed that intermittent explosive disorder was much more prevalent among males, recent community surveys suggest similar prevalence rates by gender. However, serious physical assault is a more common manifestation of the disorder in males, whereas less serious physical and verbal aggression is more characteristic of females. Boundaries with other disorders and conditions (differential diagnosis) Boundary with autism spectrum disorder Explosive outbursts with aggressive behaviours may occur in some individuals with autism spectrum disorder. These outbursts are usually associated with a specific trigger that is related to the core symptoms of autism spectrum disorder (e.g. a change in routine, aversive sensory stimulation, anxiety, rigidity when the individual’s thoughts or behaviours are interrupted). Individuals with intermittent explosive disorder do not exhibit other features of social communication difficulties and restricted or repetitive behaviours that are characteristic of autism spectrum disorder. Boundary with attention deficit hyperactivity disorder Intermittent explosive disorder and attention deficit hyperactivity disorder are both characterized by impulsive behaviour. However, intermittent explosive disorder is specifically characterized by intermittent severe aggressive outbursts rather than ongoing generalized behavioural impulsivity that may be seen in attention deficit hyperactivity disorder. Both diagnoses may be assigned if the full diagnostic requirements for each are met. Boundary with oppositional defiant disorder Regularly occurring severe temper outbursts that are grossly out of proportion in intensity or duration to the provocation may also occur in the context of oppositional defiant disorder with chronic irritability-anger, particularly in response to demands by authority figures. In such cases, Impulse control disorders | Intermittent explosive disorder

Clinical Descriptions and Diagnostic Requirements for ICD-11 Mental, Behavioural or Neurodevelopmental Disorders an additional diagnosis of intermittent explosive disorder should not be assigned. Individuals with oppositional defiant disorder with chronic irritability-anger typically display other features of oppositional defiant disorder, including defiant, headstrong or vindictive behaviours, which are not characteristic of intermittent explosive disorder. In addition, individuals with intermittent explosive disorder are more likely to exhibit significant physical aggression. Boundary with conduct-dissocial disorder People with intermittent explosive disorder may come into conflict with other people and with law enforcement because of their explosive outbursts, but these episodes do not constitute a more general pattern of antisocial behaviour characteristic of conduct-dissocial disorder (e.g. rule violations, lying, theft). In addition, intermittent explosive disorder is characterized by impulsive aggression, while aggression in conduct-dissocial disorder is often premeditated and instrumental. Boundary with personality disorder Due to interpersonal, occupational and other consequences of a recurrent pattern of verbal and physical aggression, some individuals with intermittent explosive disorder are likely to meet the diagnostic requirements for personality disorder with prominent features of disinhibition. Both diagnoses may be assigned if the full diagnostic requirements for each are met, but the utility of assigning an additional diagnosis of personality disorder in such cases depends on the specific clinical situation. Boundary with other mental, behavioural and neurodevelopmental disorders Aggressive outbursts may occur as a part of a number of mental disorders (e.g. disorders specifically associated with stress, mood disorders, schizophrenia and other primary psychotic disorders). In general, an additional diagnosis of intermittent explosive disorder should not be given when the outbursts are better accounted for by another disorder. Boundary with the effects of psychoactive substances, including medications Explosive aggressive behaviours may occur during substance intoxication or withdrawal. Intermittent explosive disorder should not be diagnosed if the outbursts are solely attributable to intoxication or the disinhibiting effects of alcohol, drugs or medication. However, among individuals with intermittent explosive disorder, alcohol and substance use are commonly associated with episodes of aggressive behaviour. In these situations, the distinction should be made based on the presence of features of intermittent explosive disorder at times other than during episodes of intoxication. Boundary with malingering Some individuals who engage in recurrent acts of verbal or physical aggression may falsely report additional symptoms consistent with a diagnosis of intermittent explosive disorder, with the intent of obtaining a mental disorder diagnosis to avoid criminal charges or other negative consequences. Intermittent explosive disorder should not be diagnosed in such cases. Boundary with dementia and other medical conditions The diagnosis of intermittent explosive disorder should not be assigned when the impulsive aggressive behaviours are entirely explained by dementia, a disease of the nervous system – including stroke – or another medical condition not classified under mental, behavioural and neurodevelopmental disorders (e.g. a brain tumour). Impulse control disorders | Intermittent explosive disorder