Intermittent explosive disorder — a controversial mental illness marked by outbursts of uncontrollable rage — is so common among adolescents it affects one in 12 teens, a large new study finds.
Harvard Medical School researchers, in a study based on in-person interviews with more than 10,000 adolescents ages 13 to 17, found that about eight per cent met the criteria for intermittent explosive disorder, or IED.
The findings suggest the disorder is affecting hundreds of thousands of youths — close to six million in the U.S. alone, according to a statement released with the study.
But observers worry it could trigger a "manufactured epidemic" of mental illness among teens and lead to extreme but predictable teenage behaviour being labelled as symptoms of a mental illness requiring treatment — including mood-altering drugs.
According to the Diagnostic and Statistical Manual of Mental Disorders — psychiatry's official catalogue of mental illness, now undergoing its first major revision in nearly two decades — IED's central feature is impulsive aggression grossly out of proportion to the situation. People lose control, break or smash things and attack or threaten to hurt someone.
The study, published this week in the journal of Archives of General Psychiatry, is being described as the first to estimate the prevalence of IED in American adolescents. The researchers believe their findings could be extrapolated to Canada.
"If we can detect IED early and intervene with effective treatment right away, we can prevent a substantial amount of future violence perpetration and associated psychopathology," senior author Ronald Kessler, professor of health care policy at Harvard, said in a statement.
But Christopher Lane, author of Shyness: How Normal Behaviour Became a Sickness, said IED has been a source of controversy since it was formally approved as a mental disorder in 1980.
"Uncontrollable anger and domestic violence are, of course, serious concerns requiring attention," said Lane.
But equally concerning, he said, is the risk of "medicalizing" adolescence itself.
Disorders in the DSM are defined by a list of diagnostic criteria. A person can qualify for a certain diagnosis based on how many criteria they meet for that illness.
But there isn't agreement on just how many "episodes" or outbursts of aggression are necessary for a diagnosis of IED. As well, some have proposed broadening the criteria to include outbursts that don't involve threatened or actual violence, but do involve verbal aggression — insults or arguments "out of proportion to provocation."
The new study is based on a national mental health survey conducted in the U.S. between February 2001 and January 2004.
Nearly two-thirds — 63 per cent — of the adolescents surveyed reported at least one anger attack in their lifetime involving either destroying property or threatening or engaging in violence.
About one-third of those who reported attacks (29 per cent) had only one or two attacks in their lifetime; another one-third only had attacks that were either in line with the "provoking circumstances" or not out of control.
The remainder was made up of those with IED, the authors write.
Teens had to report three or more anger attacks in their lifetime to meet the criteria for IED.
When the Harvard team narrowed it to three attacks in a single year, with at least one attack involving violence or destroying property, 5.5 per cent met a diagnosis of IED.
Youth who had other problems associated with aggression, including attention-deficit/hyperactivity disorder, conduct disorder and bipolar disorder, were excluded. "We wanted to be sure we were really capturing something that wasn't already accounted for by another diagnosis," said co-author Katie McLaughlin, an assistant professor of pediatrics and psychiatry at Boston Children's Hospital.
While some of the IED-diagnosed youths had been treated for emotional problems in the year before their interview, only 6.5 per cent received treatment specifically for anger.
"IED is one of the least-studied of the mental disorders, despite the fact that it's quite common," McLaughlin said.
But Lane, author of the Psychology Today blog "Side Effects", said the results show otherwise — "that a significant number of teenagers have relatively few problems with impulse control and anger management."
Even for the teens who met criteria for IED, "it's still a big, unsettled question whether their periodic anger and threatened or actual violence should be considered a lifelong mental disorder," Lane said, "rather than a psychological crisis involving major life-stressors such as job loss, poverty, home foreclosure, debt issues and drug and alcohol addiction."
Dr. Allen Frances, former chair of the psychiatry department at Duke University's School of Medicine, chaired the task force that wrote the current edition of the DSM. He called IED an "unstudied" and "inherently unreliable category that probably shouldn't be in the DSM at all.
"It most certainly should not be reified into a manufactured teenage epidemic of mental disorder that is allegedly affecting millions of kids," he said.
"The suggestion that we institute prevention programs is a wildly premature over-promise until much more solid research demonstrates that there is real need and proven effectiveness."
http://www.montrealgazette.com/health/rage+psychiatrists+battle+over+teen+anger+diagnosis/6872781/story.html
