A 22-year-old man is brought to the emergency department by his girlfriend after sustaining a hand injury. The two were waiting for a table at a crowded bar when the hostess inadvertently seated another couple that was behind them in line. The patient suddenly became enraged, started pacing back and forth, shouted at the hostess that she was "stupid and incompetent," and threw a nearby chair against the wall, causing damage to the wall and injuring his own hand. He is remorseful about his behavior, but his girlfriend says, "He can be moody, frequently gets defensive, and loses his temper with the slightest provocation." They have had several heated arguments during which he has thrown and broken objects. The patient has no medical history. Physical examination is unremarkable except for swelling and lacerations of the hand. Which of the following is the most likely diagnosis in this patient?

Question

A 22-year-old man is brought to the emergency department by his girlfriend after sustaining a hand injury.  The two were waiting for a table at a crowded bar when the hostess inadvertently seated another couple that was behind them in line.  The patient suddenly became enraged, started pacing back and forth, shouted at the hostess that she was "stupid and incompetent," and threw a nearby chair against the wall, causing damage to the wall and injuring his own hand.  He is remorseful about his behavior, but his girlfriend says, "He can be moody, frequently gets defensive, and loses his temper with the slightest provocation."  They have had several heated arguments during which he has thrown and broken objects.  The patient has no medical history.  Physical examination is unremarkable except for swelling and lacerations of the hand.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's pattern of impulsive, aggressive behavior is suggestive of intermittent explosive disorder (IED), an impulse control disorder. Patients with IED are unable to restrain their aggressive impulses, resulting in verbal or physical aggression that is out of proportion to the provocation. The violent, impulsive outburst is typically preceded by rising tension that escalates rapidly to a state of rage without thought to the consequences of the behavior. Episodes last <30 minutes and may provide an immediate sense of relief, usually followed by remorse, dysphoria, and embarrassment. Significant functional impairment due to interpersonal difficulties, job loss, school suspension, and legal problems is common. IED tends to be chronic and is associated with high rates of psychiatric comorbidity. It should not be diagnosed if the impulsive, aggressive behavior occurs exclusively in the context of another active psychiatric disorder (eg, acute manic episode in bipolar disorder). Treatment consists of cognitive-behavioral therapy and selective serotonin reuptake inhibitors. (Choice A) Although aggressive behavior is common in antisocial personality disorder, it is often premeditated with the goal of gaining an advantage or intimidating others. Other features of antisocial personality disorder include a pervasive pattern of breaking laws, deceiving others, behaving irresponsibly, and lacking remorse. (Choice B) Patients with bipolar disorder may have aggressive outbursts during a manic episode. However, manic episodes usually last days to months (unlike IED episodes, which last <30 minutes). In addition, this patient does not have other key manic symptoms (eg, elevated mood, increased energy, decreased need for sleep, pressured speech). (Choice C) Patients with borderline personality disorder may exhibit inappropriate anger and rages, but these outbursts typically occur in the context of an unstable relationship and are related to underlying fears of abandonment. This patient lacks other characteristic borderline features (eg, suicidal behavior, chronic feelings of emptiness, abandonment fears). (Choice D) Although disruptive mood dysregulation disorder may also present with disproportionate verbal or physical outbursts, diagnosis requires onset before age 10 and persistent irritability or anger between episodes. The diagnosis is not made after age 18. (Choice F) Although substance intoxication is associated with aggressive behavior, this patient's pattern of short-lived episodes and lack of signs of intoxication on examination is more consistent with IED. Educational objective: Intermittent explosive disorder is characterized by recurrent episodes of impulsive verbal or physical aggression. The aggressive behaviors are unplanned and out of proportion to the provocation. References: Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. (http://www.ncbi.nlm.nih.gov/pubmed/22535310) Psychosocial impairment in DSM-5 intermittent explosive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29627702)

A 22-Year-Old Man Is Brought to the Emergency Department by His