Intermittent Explosive Disorder and the Like: Overappreciated?

In "Intermittent Explosive Disorder: Common but Underappreciated"(Psychiatric Times, January 2007), Arline Kaplan wrote that intermittent explosive disorder (IED) "is not just another name for bad behavior." She quoted Dr Coccaro from the University of Chicago as asserting that patients with IED who react with rage to minor irritants have been shown to have reduced down-regulation of certain cortical nuclei that should be reined in by inhibitory stimuli from the frontal cortex.

Can it not be argued that in every case of disproportionate emotional or behavioral reaction some CNS circuit has failed to be properly modulated-whether current neuroimaging techniques can demonstrate it or not? Are we not moving ever closer to converting all "bad behavior" into psychiatric pathologies?

It is my impression from working in correctional facilities that most "domestic violence" defendants can claim to be reacting to provocation with responses so out of proportion that they later regret it. In fact, one such defendant reported to me that he had been told he suffered from "rage disorder" and planned to plead to reduced criminal responsibility.

I worry that psychiatry, as a specialty, may succumb to a universal medicalization of behaviors that should retain their status as being the responsibility of those who exercise them.

Ole J. Thienhaus, MD, MBA
Las Vegas