Chapter 13: Impulse Control Disorders

   Mr. Baker is a 27-year-old married accountant who arrives at the outpatient psychiatry clinic complaining of difficulty in managing his anger. He has no prior psychiatric history, but reports that he has had difficulty controlling his temper since adolescence. He reports that he is easily angered by small occurrences, such as his wife's failing to make coffee or a coworker's forgetting a pen at work. He reacts quickly and in a volatile way, describing it as “going from 0 to 60 before I know it.” Mr. Baker feels that he is unable to control his anger; on several occasions he has thrown objects and destroyed property in fits of rage, and has made threatening statements to his wife and coworkers in the past year. Because of these incidents, one coworker has recently threatened to pursue legal action.

Mr. Baker describes these episodes as brief, lasting only 10–15 minutes, and feels embarrassed shortly after the episode has transpired. He is concerned he may lose his job because of his behavior, and he worries about the fate of his relationships. He rarely drinks alcohol, and denies any history of illicit drug use.

What is his most likely diagnosis?

Based on Mr. Baker's history, his most likely diagnosis is intermittent explosive disorder. However, it is important to recognize that impulsivity is a common characteristic of other psychiatric diagnoses, and these must be ruled out prior to diagnosing a patient with this disorder.

What would be your recommended treatment?

Treatment for this disorder usually involves medications to treat impulsive aggression. These include selective serotonin reuptake inhibitors (SSRIs)—fluoxetine being the most studied—and mood stabilizers such as anticonvulsants and lithium. Individual psychotherapy is difficult and has limited efficacy given the nature of the disease and lack of individual control. However, cognitive-behavioral therapy (CBT) has been used in the treatment of anger management. Group therapy and/or family therapy may be useful to create behavior plans to help manage episodes.

What are associated laboratory findings?

In some impulsive individuals, cerebrospinal fluid testing shows low mean 5-hydroxyindoleacetic acid (5-HIAA) concentration. There may also be nonspecific electroencephalographic findings or abnormalities on neuropsychological testing.