Episodic dyscontrol

Roy G Beran MD (Dr. Beran of Liverpool Hospital in New South Wales has no relevant financial relationships to disclose.)
C P Panayiotopoulos MD PhD, editor. (Dr. Panayiotopoulos of St. Thomas' Hospital has no relevant financial relationships to disclose.)
Originally released July 26, 2013; expires July 26, 2016
Notice: This article has expired and is therefore not available for CME credit.

This article includes discussion of episodic dyscontrol and intermittent explosive disorder. The foregoing terms may include synonyms, similar disorders, variations in usage, and abbreviations.

Overview

Episodic dyscontrol, also called "intermittent explosive disorder,” is listed in DMS-V. Diagnostic criteria include recurrent outbursts, disproportionate to any provocation without better explanation, that occur twice weekly for 3 months with less serious outbursts or thrice yearly for more destructive episodes. Studies reveal decreased frontal neocortical grey matter in association with possible temporal lobe epilepsy and with involvement of the orbitofrontal region, evoking impulsivity, effective instability, social detachment, and antisocial behavior. Multifocal etiology possibly includes frequent seizures treated with polypharmacy, past history of psychiatric disorder (either in the proband or first-degree relatives), and physical or emotional trauma before age 20 years. There is no definitive diagnostic test, but video telemetry may define its relationship to epilepsy. Episodic dyscontrol might respond to antiepileptic medications, mood stabilizers, atypical antipsychotics, or, where appropriate, lesionectomy.

Historical note and terminology

Episodic dyscontrol may incorporate a number of phenomena (Beran 2013). “Passive-aggressive personality, aggressive type” appeared in the 1st edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952 (American Psychiatric Association 1952). “Intermittent explosive disorder” first appeared in DSM-III in 1980 (American Psychiatric Association 1980). “Intermittent explosive disorder as a disorder of impulsive aggression” has now gained sufficient diagnostic validity to justify recognition and inclusion in DSM-5 (Coccaro 2012). There has been considerable research undertaken to differentiate children and adolescents with aggression and irritability from those with similar symptomatology but who experience bipolar disorder. This has particular relevance to child and adolescent psychiatry with expectation of the evolution of a new diagnostic entity, “disruptive mood dysregulation disorder” with aggressive episodes as part of a mood disorder, contrasted with an impulsive control disorder (Leibenheft 2011).

Although intermittent explosive disorder is recognized in DSM-IV (American Psychiatric Association 2000), this is not the case in the alternative classification, ICD-10 (World Health Organization 1990). Acknowledging the considerable evidence linking “episodic dyscontrol” with epilepsy, there also exist reports of episodic dyscontrol with a variety of other neurologic conditions, such as Tourette syndrome (Rainish and Sidku Balevant 2011) and various mood disorders responsive to mood stabilizers (Jones et al 2011). “Impulse-control disorder” also has particular relevance to forensic psychiatry (Pobocha 2012) and is included in ICD-10 as code F63 (World Health Organization 1990). Polish research, exploring “impulse control disorder” reviewed 143 pathological gamblers, 5 kleptomaniacs, and 3 subjects with trichotillomania (Pobocha 2012). This study also examined “court-referred and self-referred aggressive drivers” and found that such drivers were more likely to meet the criteria for intermittent explosive disorder.

Not only are epileptic seizures considered an integral component of intermittent explosive disorder (Beran 2013) but the effective treatment of epilepsy, causing “forced normalization,” is also considered an etiological contributor under the rubric of intermittent explosive disorder (Ntsanwisi 2011).

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