Intermittent explosive disorder

Last updated
Intermittent explosive disorder
Dante Gabriel Rossetti - Christina Rossetti in a Tantrum.jpg
Cartoon of Christina Rossetti in a fit of anger, drawn by her brother Dante (1862).
Specialty Psychiatry
Symptoms explosive outbursts of anger and/or violence, often to the point of rage, that are disproportionate to the situation at hand
Usual onsetimpulsive shouting, screaming or excessive reprimanding triggered by relatively inconsequential events
Diagnostic method DSM-5
Treatment CBT
Medication psychotropic medication
Frequency3%

Intermittent explosive disorder (sometimes abbreviated as IED, also referred to as episodic dyscontrol syndrome) is a behavioral disorder characterized by explosive outbursts of anger and/or violence, often to the point of rage, that are disproportionate to the situation at hand (e.g., impulsive shouting, screaming or excessive reprimanding triggered by relatively inconsequential events). Impulsive aggression is not premeditated, and is defined by a disproportionate reaction to any provocation, real or perceived. Some individuals have reported affective changes prior to an outburst, such as tension, mood changes, energy changes, etc. [1]

Contents

The disorder is currently categorized in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) under the "Disruptive, Impulse-Control, and Conduct Disorders" category. The disorder itself is not easily characterized and often exhibits comorbidity with other mood disorders, particularly bipolar disorder. [2] Individuals diagnosed with IED report their outbursts as being brief (lasting less than an hour), with a variety of bodily symptoms (sweating, stuttering, chest tightness, twitching, palpitations) reported by a third of one sample. [3] Aggressive acts are frequently reported to be accompanied by a sensation of relief and in some cases pleasure, but often followed by later remorse.

Pathophysiology (Intermittent Explosive Disorder)

Impulsive behavior, and especially impulsive violence predisposition, have been correlated to a low brain serotonin turnover rate, indicated by a low concentration of 5-hydroxyindoleacetic acid (5-HIAA) in the cerebrospinal fluid (CSF). This substrate appears to act on the suprachiasmatic nucleus in the hypothalamus, which is the target for serotonergic output from the dorsal and median raphe nuclei playing a role in maintaining the circadian rhythm and regulation of blood sugar. A tendency towards low 5-HIAA may be hereditary. A putative hereditary component to low CSF 5-HIAA and concordantly possibly to impulsive violence has been proposed. Other traits that correlate with IED are low vagal tone and increased insulin secretion. A suggested explanation for IED is a polymorphism of the gene for tryptophan hydroxylase, which produces a serotonin precursor; this genotype is found more commonly in individuals with impulsive behavior. [4]

IED may also be associated with damage or lesions in the prefrontal cortex, with damage to these areas, including the amygdala and hippocampus, increasing the incidences of impulsive and aggressive behavior and the inability to predict the outcomes of an individual's own actions. Lesions in these areas are also associated with improper blood sugar control, leading to decreased brain function in these areas, which are associated with planning and decision making. [5] A national sample in the United States estimated that 16 million Americans may fit the criteria for IED. [6]

Diagnosis (Intermittent Explosive Disorder)

DSM-5 diagnosis

The current DSM-5 criteria for Intermittent Explosive Disorder include: [7]

It is important to note that DSM-5 now includes two separate criteria for types of aggressive outbursts (A1 and A2) which have empirical support: [8]

DSM-IV diagnosis

The past DSM-IV criteria for IED were similar to the current criteria, however, verbal aggression was not considered as part of the diagnostic criteria. The DSM-IV diagnosis was characterized by the occurrence of discrete episodes of failure to resist aggressive impulses that result in violent assault or destruction of property. Additionally, the degree of aggressiveness expressed during an episode should be grossly disproportionate to provocation or precipitating psychosocial stressor, and, as previously stated, diagnosis is made when certain other mental disorders have been ruled out, e.g., a head injury, Alzheimer's disease, etc., or due to substance use or medication. [2] Diagnosis is made using a psychiatric interview to affective and behavioral symptoms to the criteria listed in the DSM-IV.[ citation needed ]

The DSM-IV-TR was very specific in its definition of Intermittent Explosive Disorder which was defined, essentially, by the exclusion of other conditions. The diagnosis required:

  1. several episodes of impulsive behavior that result in serious damage to either persons or property, wherein
  2. the degree of the aggressiveness is grossly disproportionate to the circumstances or provocation, and
  3. the episodic violence cannot be better accounted for by another mental or physical medical condition.

Differential diagnosis

Many psychiatric disorders and some substance use disorders are associated with increased aggression and are frequently comorbid with IED, often making differential diagnosis difficult. Individuals with IED are, on average, four times more likely to develop depression or anxiety disorders, and three times more likely to develop substance use disorders. [9] Bipolar disorder has been linked to increased agitation and aggressive behavior in some individuals, but for these individuals, aggressiveness is limited to manic and/or depressive episodes, whereas individuals with IED experience aggressive behavior even during periods with a neutral or positive mood. [10]

In one clinical study, bipolar and IED disorders co-occurred 60% of the time. Patients report manic-like symptoms occurring just before outbursts and continuing throughout. According to a study, the average onset age of IED was around five years earlier than the onset age of bipolar disorder, indicating a possible correlation between the two. [9]

Similarly, alcoholism and other substance use disorders may exhibit increased aggressiveness, but unless this aggression is experienced outside of periods of acute intoxication and withdrawal, no diagnosis of IED is given. For chronic disorders, such as PTSD, it is important to assess whether the level of aggression met IED criteria before the development of another disorder. In antisocial personality disorder, interpersonal aggression is usually instrumental in nature (i.e., motivated by tangible rewards), whereas IED is more of an impulsive, unpremeditated reaction to situational stress. [11]

Treatment

Although there is no cure, treatment is attempted through cognitive behavioral therapy and psychotropic medication regimens, though the pharmaceutical options have shown limited success. [12] Therapy aids in helping the patient recognize the impulses in hopes of achieving a level of awareness and control of the outbursts, along with treating the emotional stress that accompanies these episodes. Multiple drug regimens are frequently indicated for IED patients. Cognitive Relaxation and Coping Skills Therapy (CRCST) has shown preliminary success in both group and individual settings compared to waitlist control groups. [12] This therapy consists of 12 sessions, the first three focusing on relaxation training, then cognitive restructuring, then exposure therapy. The final sessions focus on resisting aggressive impulses and other preventative measures. [12]

In France, antipsychotics such as cyamemazine, levomepromazine and loxapine are sometimes used.[ citation needed ]

Tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs, including fluoxetine, fluvoxamine, and sertraline) appear to alleviate some pathopsychological symptoms. [1] [13] GABAergic mood stabilizers and anticonvulsive drugs such as gabapentin, lithium, carbamazepine, and divalproex seem to aid in controlling the incidence of outbursts. [1] [14] [15] [16] Anxiolytics help alleviate tension and may help reduce explosive outbursts by increasing the provocative stimulus tolerance threshold, and are especially indicated in patients with comorbid obsessive-compulsive or other anxiety disorders. [14]

Epidemiology

Two epidemiological studies of community samples approximated the lifetime prevalence of IED to be 4–6%, depending on the criteria set used. [6] [17] A Ukrainian study found comparable rates of lifetime IED (4.2%), suggesting that a lifetime prevalence of IED of 4–6% is not limited to American samples. [18] One-month and one-year point prevalences of IED in these studies were reported as 2.0% [17] and 2.7%, [6] respectively. Extrapolating to the national level, 16.2 million Americans would have IED during their lifetimes and as many as 10.5 million in any year and 6 million in any month.

Among a clinical population, a 2005 study found the lifetime prevalence of IED to be 6.3%. [19]

Prevalence appears to be higher in men than in women. [14]

Of US subjects with IED, 67.8% had engaged in direct interpersonal aggression, 20.9% in threatened interpersonal aggression, and 11.4% in aggression against objects. Subjects reported engaging in 27.8 high-severity aggressive acts during their worst year, with 2–3 outbursts requiring medical attention. Across the lifespan, the mean value of property damage due to aggressive outbursts was $1603. [6]

A study in the March 2016 Journal of Clinical Psychiatry suggests a relationship between infection with the parasite Toxoplasma gondii and psychiatric aggression such as IED. [20]

History

In the first edition of the American Psychiatric Association's Diagnostic and Statistical Manual (DSM-I), a disorder of impulsive aggression was referred to as a passive-aggressive personality type (aggressive type). This construct was characterized by a "persistent reaction to frustration are "generally excitable, aggressive, and over-responsive to environmental pressures" with "gross outbursts of rage or of verbal or physical aggressiveness different from their usual behavior".[ citation needed ]

In the third edition (DSM-III), this was for the first time codified as intermittent explosive disorder and assigned clinical disorder status under Axis I. However, some researchers saw the criteria as poorly operationalized. [21] About 80% of individuals who would now be diagnosed with the disorder would have been excluded.[ citation needed ]

In the DSM-IV, the criteria were improved but still lacked objective criteria for the intensity, frequency, and nature of aggressive acts to meet criteria for IED. [11] This led some researchers to adopt alternate criteria set with which to conduct research, known as the IED-IR (Integrated Research). The severity and frequency of aggressive behavior required for the diagnosis were clearly operationalized, the aggressive acts were required to be impulsive in nature, subjective distress was required to precede the explosive outbursts, and the criteria allowed for comorbid diagnoses with borderline personality disorder and antisocial personality disorder. [22] These research criteria became the basis for the DSM-5 diagnosis.

In the current version of the DSM (DSM-5), the disorder appears under the "Disruptive, Impulse-Control, and Conduct Disorders" category. In the DSM-IV, physical aggression was required to meet the criteria for the disorder, but these criteria were modified in the DSM-5 to include verbal aggression and non-destructive/noninjurious physical aggression. The listing was also updated to specify frequency criteria. Further, aggressive outbursts are now required to be impulsive in nature and must cause marked distress, impairment, or negative consequences for the individual. Individuals must be at least six years old to receive the diagnosis. The text also clarified the disorder's relationship to other disorders such as ADHD and disruptive mood dysregulation disorder. [23]

See also

Related Research Articles

Bipolar I disorder is a type of bipolar spectrum disorder characterized by the occurrence of at least one manic episode, with or without mixed or psychotic features. Most people also, at other times, have one or more depressive episodes.

<i>Diagnostic and Statistical Manual of Mental Disorders</i> American psychiatric classification

The Diagnostic and Statistical Manual of Mental Disorders is a publication by the American Psychiatric Association (APA) for the classification of mental disorders using a common language and standard criteria. It is the main book for the diagnosis and treatment of mental disorders in the United States and Australia, while in other countries it may be used in conjunction with other documents. The DSM-5 is considered one of the principal guides of psychiatry, along with the International Classification of Diseases (ICD), Chinese Classification of Mental Disorders (CCMD), and the Psychodynamic Diagnostic Manual. However, not all providers rely on the DSM-5 as a guide, since the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions.

<span class="mw-page-title-main">Borderline personality disorder</span> Personality disorder of emotional instability

Borderline personality disorder (BPD), also known as emotionally unstable personality disorder (EUPD), is a personality disorder characterized by a pervasive, long-term pattern of significant interpersonal relationship instability, a distorted sense of self, and intense emotional responses. Individuals diagnosed with BPD frequently exhibit self-harming behaviours and engage in risky activities, primarily due to challenges in regulating emotional states to a healthy, stable baseline. Symptoms such as dissociation—a feeling of detachment from reality, a pervasive sense of emptiness, and an acute fear of abandonment are prevalent among those affected.

<span class="mw-page-title-main">Conduct disorder</span> Developmental disorder

Conduct disorder (CD) is a mental disorder diagnosed in childhood or adolescence that presents itself through a repetitive and persistent pattern of behavior that includes theft, lies, physical violence that may lead to destruction, and reckless breaking of rules, in which the basic rights of others or major age-appropriate norms are violated. These behaviors are often referred to as "antisocial behaviors", and is often seen as the precursor to antisocial personality disorder; however, the latter, by definition, cannot be diagnosed until the individual is 18 years old. Conduct disorder may result from parental rejection and neglect and can be treated with family therapy, as well as behavioral modifications and pharmacotherapy. Conduct disorder is estimated to affect 51.1 million people globally as of 2013.

Antisocial personality disorder is a personality disorder characterized by a limited capacity for empathy and a long-term pattern of disregard or violation of the rights of others. Other notable symptoms include impulsivity and reckless behavior, a lack of remorse after hurting others, deceitfulness, irresponsibility, and aggressive behavior.

<span class="mw-page-title-main">Obsessive–compulsive personality disorder</span> Personality disorder involving orderliness

Obsessive–compulsive personality disorder (OCPD) is a cluster C personality disorder marked by a spectrum of obsessions with rules, lists, schedules, and order, among other things. Symptoms are usually present by the time a person reaches adulthood, and are visible in a variety of situations. The cause of OCPD is thought to involve a combination of genetic and environmental factors, namely problems with attachment.

The affective spectrum is a spectrum of affective disorders. It is a grouping of related psychiatric and medical disorders which may accompany bipolar, unipolar, and schizoaffective disorders at statistically higher rates than would normally be expected. These disorders are identified by a common positive response to the same types of pharmacologic treatments. They also aggregate strongly in families and may therefore share common heritable underlying physiologic anomalies.

Adult Attention Deficit Hyperactivity Disorder is the persistence of attention deficit hyperactivity disorder (ADHD) in adults. It is a neurodevelopmental disorder, meaning symptoms must have been present in childhood except for when ADHD occurs after a traumatic brain injury. Specifically, multiple symptoms must be present before the age of 12, according to DSM-5 diagnostic criteria. The cutoff age of 12 is a change from the previous requirement of symptom onset, which was before the age of 7 in the DSM-IV. This was done to add flexibility in the diagnosis of adults. ADHD was previously thought to be a childhood disorder that improved with age, but recent research has disproved this. Approximately two-thirds of childhood cases of ADHD continue into adulthood, with varying degrees of symptom severity that change over time, and continue to significantly affect individuals' daily functioning in multiple domains.

Impulse-control disorder (ICD) is a class of psychiatric disorders characterized by impulsivity – failure to resist a temptation, an urge, or an impulse; or having the inability to not speak on a thought. Many psychiatric disorders feature impulsivity, including substance-related disorders, behavioral addictions, attention deficit hyperactivity disorder, autism spectrum disorder, fetal alcohol spectrum disorders, antisocial personality disorder, borderline personality disorder, conduct disorder and some mood disorders.

Oppositional defiant disorder (ODD) is listed in the DSM-5 under Disruptive, impulse-control, and conduct disorders and defined as "a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness". This behavior is usually targeted toward peers, parents, teachers, and other authority figures, including law enforcement officials. Unlike conduct disorder (CD), those with ODD do not generally show patterns of aggression towards random people, violence against animals, destruction of property, theft, or deceit. One-half of children with ODD also fulfill the diagnostic criteria for ADHD.

<span class="mw-page-title-main">Sadistic personality disorder</span> Former personality disorder involving sadism

Sadistic personality disorder was a proposed personality disorder defined by a pervasive pattern of sadistic and cruel behavior. People with this disorder were thought to have desired to control others. It was believed they accomplish this through the use of physical or emotional violence. This diagnosis appeared in an appendix of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R). The later versions of the DSM do not include it. It was removed as psychiatrists believed it would be used to legally excuse sadistic behavior.

<span class="mw-page-title-main">DSM-5</span> 2013 edition of the Diagnostic and Statistical Manual of Mental Disorders

The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is the 2013 update to the Diagnostic and Statistical Manual of Mental Disorders, the taxonomic and diagnostic tool published by the American Psychiatric Association (APA). In 2022, a revised version (DSM-5-TR) was published. In the United States, the DSM serves as the principal authority for psychiatric diagnoses. Treatment recommendations, as well as payment by health care providers, are often determined by DSM classifications, so the appearance of a new version has practical importance. However, not all providers rely on the DSM-5 for planning treatment as the ICD's mental disorder diagnoses are used around the world and scientific studies often measure changes in symptom scale scores rather than changes in DSM-5 criteria to determine the real-world effects of mental health interventions. The DSM-5 is the only DSM to use an Arabic numeral instead of a Roman numeral in its title, as well as the only living document version of a DSM.

<span class="mw-page-title-main">Impulsivity</span> Tendency to act on a whim without considering consequences

In psychology, impulsivity is a tendency to act on a whim, displaying behavior characterized by little or no forethought, reflection, or consideration of the consequences. Impulsive actions are typically "poorly conceived, prematurely expressed, unduly risky, or inappropriate to the situation that often result in undesirable consequences," which imperil long-term goals and strategies for success. Impulsivity can be classified as a multifactorial construct. A functional variety of impulsivity has also been suggested, which involves action without much forethought in appropriate situations that can and does result in desirable consequences. "When such actions have positive outcomes, they tend not to be seen as signs of impulsivity, but as indicators of boldness, quickness, spontaneity, courageousness, or unconventionality." Thus, the construct of impulsivity includes at least two independent components: first, acting without an appropriate amount of deliberation, which may or may not be functional; and second, choosing short-term gains over long-term ones.

<span class="mw-page-title-main">Prevalence of mental disorders</span> Worldwide prevalence of mental health disorders

The prevalence of mental disorders has been studied around the world, providing estimates on how common mental disorders are. Different criteria or thresholds of severity have sometimes been used.

Personality disorders (PD) are a class of mental disorders characterized by enduring maladaptive patterns of behavior, cognition, and inner experience, exhibited across many contexts and deviating from those accepted by the individual's culture. These patterns develop early, are inflexible, and are associated with significant distress or disability. The definitions vary by source and remain a matter of controversy. Official criteria for diagnosing personality disorders are listed in the sixth chapter of the International Classification of Diseases (ICD) and in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM).

Several factors complicate the diagnosis of Asperger syndrome (AS), an autism spectrum disorder (ASD). Like other ASD forms, Asperger syndrome is characterized by impairment in social interaction accompanied by restricted and repetitive interests and behavior; it differs from the other ASDs by having no general delay in language or cognitive development. Problems in diagnosis include disagreement among diagnostic criteria, the controversy over the distinction between AS and other ASD forms or even whether AS exists as a separate syndrome, and over- and under-diagnosis for non-technical reasons. As with other ASD forms, early diagnosis is important, and differential diagnosis must consider several other conditions.

<span class="mw-page-title-main">Disruptive mood dysregulation disorder</span> Medical condition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children and adolescents characterized by a persistently irritable or angry mood and frequent temper outbursts that are disproportionate to the situation and significantly more severe than the typical reaction of same-aged peers. DMDD was added to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-V) as a type of depressive disorder diagnosis for youths. The symptoms of DMDD resemble many other disorders, thus a differential includes attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder (IED), major depressive disorder (MDD), and conduct disorder.

Other specified feeding or eating disorder (OSFED) is a subclinical DSM-5 category that, along with unspecified feeding or eating disorder (UFED), replaces the category formerly called eating disorder not otherwise specified (EDNOS) in the DSM-IV-TR. It captures feeding disorders and eating disorders of clinical severity that do not meet diagnostic criteria for anorexia nervosa (AN), bulimia nervosa (BN), binge eating disorder (BED), avoidant/restrictive food intake disorder (ARFID), pica, or rumination disorder. OSFED includes five examples:

Externalizing disorders are mental disorders characterized by externalizing behaviors, maladaptive behaviors directed toward an individual's environment, which cause impairment or interference in life functioning. In contrast to individuals with internalizing disorders who internalize their maladaptive emotions and cognitions, such feelings and thoughts are externalized in behavior in individuals with externalizing disorders. Externalizing disorders are often specifically referred to as disruptive behavior disorders or conduct problems which occur in childhood. Externalizing disorders, however, are also manifested in adulthood. For example, alcohol- and substance-related disorders and antisocial personality disorder are adult externalizing disorders. Externalizing psychopathology is associated with antisocial behavior, which is different from and often confused for asociality.

Passive–aggressive personality disorder, also called negativistic personality disorder, is characterized by procrastination, covert obstructionism, inefficiency and stubbornness. The DSM-5 no longer uses this phrase or label, and it is not one of the ten listed specific personality disorders. The previous edition, the revision IV (DSM-IV) describes passive–aggressive personality disorder as a proposed disorder involving a "pervasive pattern of negativistic attitudes and passive resistance to demands for adequate performance" in a variety of contexts. Passive–aggressive behavior is the obligatory symptom of the passive–aggressive personality disorder.

References

  1. 1 2 3 McElroy SL (1999). "Recognition and treatment of DSM-IV intermittent explosive disorder". J Clin Psychiatry. 60 (Suppl 15): 12–6. PMID   10418808.
  2. 1 2 McElroy SL, Soutullo CA, Beckman DA, Taylor P, Keck PE (April 1998). "DSM-IV intermittent explosive disorder: a report of 27 cases". J Clin Psychiatry. 59 (4): 203–10, quiz 211. doi:10.4088/JCP.v59n0411. PMID   9590677.
  3. ↑ Tamam, L., Eroğlu, M., Paltacı, Ö. (2011). "Intermittent explosive disorder". Current Approaches in Psychiatry, 3(3): 387–425.
  4. ↑ Virkkunen M, Goldman D, Nielsen DA, Linnoila M (July 1995). "Low brain serotonin turnover rate (low CSF 5-HIAA) and impulsive violence". J Psychiatry Neurosci. 20 (4): 271–5. PMC   1188701 . PMID   7544158.
  5. ↑ Best M, Williams JM, Coccaro EF (June 2002). "Evidence for a dysfunctional prefrontal circuit in patients with an impulsive aggressive disorder". Proc. Natl. Acad. Sci. U.S.A. 99 (12): 8448–53. Bibcode:2002PNAS...99.8448B. doi: 10.1073/pnas.112604099 . PMC   123087 . PMID   12034876.
  6. 1 2 3 4 Kessler RC, Coccaro EF, Fava M, Jaeger S, Jin R, Walters E (June 2006). "The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication". Arch. Gen. Psychiatry. 63 (6): 669–78. doi:10.1001/archpsyc.63.6.669. PMC   1924721 . PMID   16754840. Archived from the original on 2011-10-10.
  7. ↑ American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
  8. ↑ Coccaro, EF, Lee, R, & McCloskey, MF (2014). Validity of the new A1 and A2 criteria for DSM-5 intermittent explosive disorder. Comprehensive Psychology, 55(2). doi : 10.1016/j.comppsych.2013.09.007.
  9. 1 2 Coccaro, E.F. (2012). Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. "American Journal of Psychiatry," 169. 577-588.
  10. ↑ Coccaro, EF (2000). Intermittent explosive disorder. Current Psychiatry Reports, 2:67-71.
  11. 1 2 Aboujaoude, E., & Koran, L. M. (2010). Impulsive control disorders. Cambridge University Press: Cambridge.
  12. 1 2 3 McCloskey, M.S., Noblett, K.L., Deffenbacher, J.L, Gollan, J.K., Coccaro, E.F. (2008) Cognitive-Behavioral Therapy for Intermittent Explosive Disorder: A Pilot Randomized Clinical Trial. 76(5), 876-886.
  13. ↑ Goodman, W. K., Ward, H., Kablinger, A., & Murphy, T. (1997). Fluvoxamine in the Treatment of Obsessive-Compulsive Disorder and Related Conditions. J Clin Psychiatry, 58(suppl 5), 32-49.
  14. 1 2 3 Boyd, Mary Ann (2008). Psychiatric nursing: contemporary practice. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. pp.  820–1. ISBN   978-0-7817-9169-4.
  15. ↑ Bozikas, V., Bascilla, F., Yulis, P., & Savvidou, I. (2001). Gabapentin for Behavioral Dyscontrol with Mental Retardation. Am J Psychiatry, 158(6), 965.
  16. ↑ Coccaro EF, et al. "A Double-Blind, Randomized, Placebo-Controlled Trial of Fluoxetine in Patients With Intermittent Explosive Disorder," Journal of Clinical Psychiatry (April 21, 2009): Vol. 70, No. 5, pp. 653–62.
  17. 1 2 Coccaro EF, Schmidt CA, Samuels JF et al. Lifetime and one-month prevalence rates of intermittent explosive disorder in a community sample. J Clin Psychiatry 65:820–824, 2004.
  18. ↑ Bromet EJ, Gluzman SF, Paniotto VI et al. Epidemiology of psychiatric and alcohol disorders in Ukraine: Findings from the Ukraine World Mental Health survey. Soc Psychiatry Psychiatr Epidemiol 40:681–690, 2005.
  19. ↑ Coccaro EF, Posternak MA, Zimmerman M (October 2005). "Prevalence and features of intermittent explosive disorder in a clinical setting". J Clin Psychiatry. 66 (10): 1221–7. doi:10.4088/JCP.v66n1003. PMID   16259534. Archived from the original on 2012-07-01.
  20. ↑ Coccaro EF, Lee R, Groer MW, Can A, Coussons-Read M, Postolache TT (March 2016). "Toxoplasma gondii Infection: Relationship With Aggression in Psychiatric Subjects" Archived 2016-03-24 at the Wayback Machine . J Clin Psychiatry 77(3): 334–341.
  21. ↑ Felthous et al., 1991
  22. ↑ Coccaro et al., 1998
  23. ↑ "Highlights of Changes from DSM-IV-TR to DSM-5" (PDF). American Psychiatric Association. 2013. Retrieved 6 July 2022.
This page is based on this Wikipedia article
Text is available under the CC BY-SA 4.0 license; additional terms may apply.
Images, videos and audio are available under their respective licenses.