While most teens have a violent, angry outburst at some point during their adolescence, nearly 8 percent have regular violent outbursts that would fall into the category of a mental health disorder. That’s according to a Harvard Medical School finding published online Monday in the Archives of General Psychiatry, one of the first studies to measure the prevalence of the disorder— called intermittent explosive disorder—in teens.
“To our surprise, it turns out to be one of the most common mental health disorders in adolescents,” said study leader and Harvard epidemiologist Ronald Kessler, whose previous research noted a similar prevalence in adults. The new study, funded by the National Institute of Mental Health, is based on a survey of more than 10,000 teenagers and parents, which found the disorder starts early in life, by age 12 on average, and is two to three times more common in boys than girls.
But some mental health providers question whether intermittent explosive disorder is even a true illness in teens and are fighting to keep it out of the latest edition of the handbook of psychiatric diagnoses, called DSM-V, which is due out next year.
A draft of the DSM-V released in May defines intermittent explosive disorder as recurrent outbursts that lead to physical injury or the destruction of valuable property and that the outbursts must be “grossly out of proportion to the provocation” or life circumstances; the draft also specifies that a person must be at least 18 years of age in most cases to receive the diagnosis. It does note, though, that the diagnosis can be made in teens who have attention-deficit/hyperactivity disorder or other behavioral disorders.
“The problem rests in trying to determine what’s out of proportion to what’s happening in the circumstances,” said Jerome Wakefield, a professor of psychiatry and social work at New York University and author of the Loss of Sadness. “Rage often is cumulative and something that may have irritated you 25 times in the past can cause you to blow your top on the 26th time.”
Adolescents, in particular, put a high premium on looking good in front of their peers, Wakefield added, so they may be more likely than adults to lash out when feeling humiliated or threatened.
It’s often tough for doctors to distinguish between everyday anger and physical skirmishes that mark the high school years and violent outbursts that might lead a teen to bring a gun to school. But Kessler, who has served as a paid consultant for pharmaceutical manufacturers, said it’s vital for physicians to recognize the warning signs and refer teens for psychiatric care before they develop the depression, anxiety, and substance abuse problems that often go along with the disorder and can make violent tendencies worse.
“We’re talking about dysfunctional anger and destructive behavior that may cause injuries that require medical attention or destroying things of non-trivial value,” said Kessler. “A lot of kids have anger attacks, but those with this disorder have a chronic problem that’s likely due to a biological predisposition.”
His new study found that teens who had the disorder were far more likely to have mothers who had a history of panic attacks, though this was just an association and not necessarily a definitive cause.
Treatment generally includes individual or group anger management therapy and/or mood-altering drugs such as antidepressants like selective serotonin reuptake inhibitors (Paxil, Prozac, Celexa). Some psychologists also use cognitive behavioral therapy to help identify specific situations or behaviors that might trigger an aggressive response and to help the brain control the anger impulse through relaxation exercises.
Slightly less than half of those who are treated with drugs or therapy experience significant improvement in their behaviors, said Dr. Emil Coccaro, chair of the psychiatry department at the University of Chicago. “We usually combine the two therapies to achieve a better success rate, but we don’t have the studies to confirm that we’re getting more improvement,” he said, since the government has declined to provide funding for them.
The Harvard study found that fewer than 7 percent of teens who had signs of intermittent explosive disorder were actually being treated for their anger. Most were getting psychiatric help for other conditions such as depression or alcohol abuse, which Kessler said may have resulted from the anger condition.