IED

I am always drawn to bizarre psychiatric anomalies, and managed to stumble across a rather strange disorder whilst perusing some of my lectures (I had some time to kill). I remember this story Jon told us about a patient one of his friends had. She was terrified at the time because she had to be escorted by three guards to go see this patient, whose chart said that he was diagnosed with rage. Neat hey, like so you think like this guy has probably bludgeoned a lady who had cut him off in rush hour traffic with his hood antennae, or maybe one of those grannies who insists on writing a cheque with far too many items in the express checkout at the supermarket, or maybe he choked the guy who can't quite figure out what he wants at KFC by shoving a drumstick down his throat. You know, something normal where he just snapped for a second and now he's gotta live with it, right?

No, this guy was the real deal - he makes a Mara Salvatrucha member look like Mary Poppins. To get into his cell, they had to order he lie facedown on the floor with his hands on his head, then the guards would cautiously enter his cell. One would pin him down to the floor and the other had to hold his belt to make sure he didn't bolt. He was ridiculously strong and could be set off by the most benign of comments.

I thought it was neat that this guy had uncontrollable rage, but didn't really think much of it. I stumbled across a peculiar disorder in my notes by the name of Intermittent Explosive Disorder. It's extremely rare, like 1-2% of those with conduct or impulse disorders are thought to actually have it. The DSM is puzzled by how to classify it, but basically say that it involves discrete aggressive episodes that are grossly out of proportion to a typical response, and result in assault or destruction of property. Nobody knows the neuropathophysiology behind it (there are some speculations about serotonin, testosterone, and catecholamines) but nothing conclusive.

Clinicians often don't know what to do with IED, and classify it as a conduct disorder or an impulse control disorder appended with terms like, "rage attacks" or "episodic dyscontrol". How cool, you could say something like "This guy destroyed a truck with his bare hands in a moment of episodic dyscontrol."

What I find most amazing is that this is a psychiatric disorder. One of the exclusion criterion in the DSM is that it cannot be a result of another mental disorder, substance abuse, or a general medical condition. These individuals have brains that have been wired in such a way that they physically manifest aggression as a regular emotion. These people are angered by the slighest provocation, and explode into a frenzy that is something like Rambo plus Charizard with a little bit of Arnold thrown in.

The brain is fascinating.