A 27-year-old man is brought to a family therapist by his wife following a violent outburst in which he nearly injured her. They were having what seemed like a minor argument over a miscommunication about her being late when he suddenly flew into a rage, started shouting, and threw several plates against the wall. His wife is now threatening to leave him because similar episodes keep happening despite his promise to control his anger. The patient is remorseful and says, "I have been getting into trouble because of my temper since high school. Once I get angry, I feel out of control and it's impossible to stop." The patient has no medical history. He drinks beer and uses cannabis to relax approximately 2-3 times a month. Which of the following is the most likely diagnosis in this patient?

Question

A 27-year-old man is brought to a family therapist by his wife following a violent outburst in which he nearly injured her.  They were having what seemed like a minor argument over a miscommunication about her being late when he suddenly flew into a rage, started shouting, and threw several plates against the wall.  His wife is now threatening to leave him because similar episodes keep happening despite his promise to control his anger.  The patient is remorseful and says, "I have been getting into trouble because of my temper since high school.  Once I get angry, I feel out of control and it's impossible to stop."  The patient has no medical history.  He drinks beer and uses cannabis to relax approximately 2-3 times a month.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This patient's repetitive outbursts of impulsive aggression that are grossly disproportionate to the situation is suggestive of intermittent explosive disorder (IED), an impulse control disorder. Patients with IED often feel a sense of heighted arousal or tension that quickly escalates to rage and uncontrollable impulses to be verbally or physically aggressive. Outbursts may provide an immediate sense of relief that is usually followed by remorse. Patients can be assaultive and destroy property, resulting in significant functional impairment due to interpersonal difficulties, school suspension, job loss, and legal problems. IED is not diagnosed if the violent behavior is premeditated or better explained as a manifestation of another disorder, such as a manic episode of bipolar disorder or substance intoxication. Treatment consists of cognitive-behavioral therapy and pharmacotherapy with selective serotonin reuptake inhibitors. (Choices A and D) Aggressive behavior is common in antisocial personality disorder and conduct disorder, but it is often premeditated with the goal of intimidating others. This patient's behavior is not premeditated, and he does not show other antisocial features such as lawbreaking, lying, chronic irresponsibility, and lack of remorse. Conduct disorder is diagnosed in children, whereas antisocial personality disorder is diagnosed in patients age ≥18. (Choice B) Patients with acute mania can be verbally or physically aggressive. However, this patient does not show other features of mania necessary for this diagnosis (ie, euphoric mood, increased energy and goal-directed activity, decreased need for sleep, pressured speech, grandiosity). (Choice C) Patients with borderline personality disorder may become enraged in response to interpersonal conflicts but are not typically aggressive physically. This patient lacks other characteristic borderline features (eg, suicidal behavior, feelings of emptiness, fears of abandonment). (Choice E) Patients with disruptive mood dysregulation disorder may also present with frequent verbal or physical outbursts. However, this is a childhood diagnosis that requires an onset age <10 and persistent irritability or anger between episodes. (Choice G) Phencyclidine intoxication can present with violent behavior and is typically associated with nystagmus. It is unlikely to explain his pattern of impulsive, angry outbursts since high school. Educational objective: Intermittent explosive disorder is characterized by recurrent episodes of explosive verbal or physical aggression. The aggressive behaviors are impulsive and grossly 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) Verbal versus physical aggression in intermittent explosive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/25534757) Psychosocial impairment in DSM-5 intermittent explosive disorder. (http://www.ncbi.nlm.nih.gov/pubmed/29627702)

A 27-Year-Old Man Is Brought to a Family Therapist by His