Intermittent explosive disorder overlooked
(August/September 2006 Issue)

Ronald C. Kessler, Ph.D., a professor at Harvard Medical School, was the lead author of a study that concluded intermittent explosive disorder (IED) affects five to seven percent of Americans. (photo by Tom Croke)

By Ami Albernaz

Anger, some psychologists say, has long been misdiagnosed and misunderstood, its role in problems such as substance abuse and troubled relationships underestimated. Findings from a recent study, though, are shedding light on anger as a core issue underlying others and raising hopes that early diagnosis can lessen its effects.

The study, reported in the June issue of Archives of General Psychiatry, focused on intermittent explosive disorder (IED), a condition characterized by outbursts of aggressive acts or threats that are out of proportion to a given situation. The study found the disorder is much more common than previously thought, having affected about five to seven percent of Americans at one time or another. The findings were based on a face-to-face survey of more than 9,000 adults between 2001 and 2003.

What is significant about the findings, says Ronald C. Kessler, Ph.D., lead author of the study and a professor in the department of health care policy at Harvard Medical School, is that the majority of the respondents meeting IED criteria had not received treatment for anger, their therapy having focused instead on other emotional disorders or substance abuse.

"Seldom is anger the focus of treatment," Kessler says. "People will be going through a divorce or say they're depressed or anxious. I think we have to realize that this extreme variant of anger is more prevalent than people are aware of, and that clinicians have to probe for it."

Anger has not been studied to the degree that depression and anxiety have and has largely been overlooked from a diagnostic standpoint, says Raymond Tafrate, Ph.D., of the Department of Criminology & Criminal Justice at Central Connecticut State University and co-author of the newly released book "Understanding Anger Disorders." "There really is no category for anger," he says. Noting the difficulty that some clinicians have in identifying anger, he says his research has shown that psychologists and psychiatrists presented with two cases - a client afflicted with anger and another with anxiety - have more trouble diagnosing the angry client.

The nature of IED itself and what it is as a diagnostic category has been unclear, Tafrate adds. "IED has been a default for people with anger problems. But it doesn't mention anger - it's a diagnostic category that mentions explosive, aggressive behavior, but not anger per se … The current IED category is not inclusive enough to be more relevant. Some people experience intense anger, but through verbal outbursts, which are the most common expressions of anger. I don't think IED addresses that."

Tafrate and others say that cognitive-behavioral therapy has worked reasonably well for people afflicted with IED and other anger disorders. In the men's and women's anger management program at the Ambulatory Psychiatry Clinic of the University of Massachusetts Medical School, director Lynn Dowd, Psy.D., helps participants learn to reframe stressful situations in order to diminish anger.

"A big piece [of anger management] is helping people to slow things down, to think things through," she says. "If you look at a person with 'road rage,' they feel disrespected, they think people are in their way, they hate to wait … There's a recalibration of what the expectations are and what the options are."

Dowd adds that once people are able to manage their anger, co-morbid problems such as drinking and substance abuse tend to diminish as well.

Delores Kemper, LCPC, a therapist consultant who leads anger management groups at the Aroostook Mental Health Center in Caribou, Maine agrees that a crucial component of treatment is that people take responsibility for their behavior. "Anger is a normal emotion and we should accept that every now and then we're going to have feelings of rage," she says. "We can accept that while knowing that how we act on those feelings is our responsibility."

Yet until the varied forms that anger can take are better recognized, it is likely that many people who might benefit from treatment will not seek it out. Tafrate notes that some who experience chronic episodes of anger show resentment or passive aggressive behavior. Identifying anger displayed in this way is dependent on self-report, as current diagnostic categories don't capture it. "There needs to be better agreement with what an anger disorder looks like," Tafrate says.

Still, he sees Kessler and his colleagues' study as a step toward psychologists understanding anger better. "It is probably the common emotional issue in distressed families … It deserves recognition as a problem," he says. Kessler, meanwhile, believes that if clinicians become better at diagnosing anger - particularly early on in people's lives - it could prevent a host of problems, helping not only those who might be afflicted down the road, but also their families and others in their lives.

"From a public health perspective, not only is [IED] common, but most of the time it's first found during the school years," he says. "Assuming it can be treated, it then, with screening, can be nipped in the bud."

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