Explosive rage not as rare as once thought

CHICAGO — One in 20 Americans may be susceptible to uncontrollable anger attacks in which they lash out in road rage, spousal abuse or other severe transgressions that are totally unjustified, researchers from Harvard and the University of Chicago have found.

Their nationwide study found that the condition called intermittent explosive disorder, or IED, is not the rare occurrence that psychiatrists had previously thought. Four to five percent of people in the study were found to have physically assaulted someone, threatened bodily harm or destroyed property in a rage an average of five times a year.

Intermittent explosive disorder is different from the common type of anger most people exhibit from time to time when they pout, throw a book down or walk out of a room, activities that are better described as mild temper tantrums. IED is defined as repeated and uncontrollable anger attacks that often become violent.

"Our new study suggests IED is really out there and that a lot of people have it," said Dr. Emil Coccaro, the University of Chicago's chief of psychiatry. "That's the first step for the public to actually get treated for it, because if you don't think it's really a disorder, you're never going to get treated for it."

The new research, reported in the current issue of the Archives of General Psychiatry, involved person-to-person interviews of 9,282 people 18 years and older conducted between 2001 and 2003.

The authors said their findings suggest two disturbing trends that will require additional study — that IED is on the increase among teenagers and that it may set the stage for the onset of other mental conditions such as depression and alcoholism. Eight out of 10 people with IED subsequently develop other mental disorders, they found.

"Given its age of onset, identifying IED early, determining its causes and providing treatment might prevent some of the associated secondary disorders, such as anxiety and alcohol abuse," said Ronald Kessler, a professor of health-care policy at Harvard.

The study found that the rage disorder typically begins at age 13 in boys and 19 in girls, increases rapidly in the teen years, is less prevalent among respondents in their 40s and becomes even less so among people in their 60s.

"Is there something profoundly important about how society is changing that's leading to this apparent increase in people not being able to control their emotions and lashing out at other people?" Kessler asked. "Is it that we're bad parents and we're creating these little monsters? Is television doing it?

"We know there's an awful lot of young people who have it today and older people tell us they've never had it," he said. "Whether they're lying or not we don't know. But, obviously, now that it's on our radar screen we're going to be monitoring it very carefully."

Mental-health research has concentrated on such problems as depression, schizophrenia, anxiety, panic attacks and substance abuse. Instead of being considered a mental-health problem, anger was thought to be a matter of willpower.

But new brain-imaging studies show that people with IED have abnormal brain signaling in areas that control anger responses, Coccaro said. When people with rage disorder are shown pictures of people with angry faces, their amygdala lights up far more than is seen in healthy subjects. The amygdala, deep in the center of the brain, governs emotional responses to threats.

At the same time, the front portion of their brain, which serves as an executive control over emotional urges, is less active than in normal people, Coccaro said, indicating that people with IED quickly lose control.

"People with this problem have a low threshold for exploding and that's probably genetically and biologically mediated," he said.

Two things generally set these people off, he said: perceived threats and frustrating situations. So the road-rage person may explode for both reasons — he feels threatened by being cut off in traffic and frustrated because traffic congestion keeps him from getting to where he wants to go quickly.

The majority of men who engage in spousal abuse are sociopathic and could control their behavior, but about a third may suffer from IED and impulsively strike out, Coccaro said.

Anger attacks can be reduced with drug therapy to raise the threshold at which people explode, or with cognitive behavioral intervention that teaches a person how to relax when they feel tense and how to recognize that another person is not trying to hurt them, Coccaro said.

"The simplest coping skill is to get out of the encounter," he said. "If you feel you're going to explode you just walk away, take a timeout."