Intermittent Explosive Disorder: The New Rage?

Sorry, I couldn't resist the title.

Apparently, intermittent explosive disorder (IED) has hit the popular press. I've seen about 3 or 4 different references to it in the last week. The stories have been confusing it with road rage, but it's not. IED has been a diagnosis for years.

The whole thing follows a predictable arc:

1. An obscure diagnosis sits in the current Diagnostic and Statistical Manual.
2. Someone finds a way to use it to sell drugs. psychotherapy, or self-help books.
3. It catches the attention of the press.
3. It gets initials (e.g., IED) and becomes overdiagnosed and overtreated.
4. Warnings are issued about overdiagnosis.
5. Clinicians who benefit from the diagnosis argue that in the past it was underdiagnosed.
6. It continues to be overdiagnosed.
7. In some cases, associations get formed, and the diagnosis starts getting used as an excuse for underachievement or misbehavior.

We saw this with attention deficit disorder. Now Ritalin is rampant, and people with ADD get longer to take tests. A few years ago, oppositional defiant disorder followed the same arc, as did autism. Now, intermittent explosive disorder is hitting the same arc.

For the record, clinicians have been treating anger for many years. I recall diagnosing intermittent explosive disorder a few years ago, and having the insurance company kick the claim back saying they don't cover it. When this happens, clinicians always fall back on the same strategy. You avoid diagnoses that you don't get paid for.

That's not quite as dishonest as it sounds. A quick perusal of the Fourth Edition of the Diagnostic and Statistical Manual (DSM-IV) will show that multiple disorders manifest the same behavioral symptoms. For example, irritability and rage are the prime symptoms of intermittent explosive disorder, but, they are also associated with unipolar depression, bipolar disorder, attention deficit disorder, conduct disorder, and various personality disorders.

So, in the past, to assure payment, we treated anger as a symptom of another diagnosis. IED wasn't very common because no one was diagnosing it. I could be wrong here, but it's my recollection that when the Columbine School shootings occurred, more attention was brought to the problems associated with anger. We started to hear about "anger management," and I suspect this led to more diagnosis of intermittent explosive disorder.

So, two takeaways from this. First, diagnosis in mental health is not the same as in physical health. Despite all the huffing and puffing about biochemical imbalance, we have no clear understanding of the underlying mechanisms of depression or other mental illnesses. This means that ultimately "diagnosis" involves just summarizing what particular symptoms are being treated. It says nothing about etiology.

Second, diagnoses are influenced by social and economic factors. After Columbine, we stopped thinking that anger was just a matter of rudeness and immaturity. Now we think it's something serious that should be addressed, and our patterns of diagnosis have changed as a result. Let us not forget, however, that from spousal abuse to school shootings to office shootings to road rage, anger is a real problem.

I don't want to see it trivialized, either. I'm sure we'll soon hear, "I shouldn't be found guilty for running that man off the road because I have intermittent explosive disorder." That doesn't fly. IED is a serious problem and a treatable one, but it's not an excuse.