Psychiatric comorbidity in Intermittent Explosive Disorder

Treating pediatric aggressive behaviors and comorbid conditions

INTRODUCTION

Aggressive behaviors in children and adolescents can significantly impair quality of life, leading to disruptions in both academic and social functioning. Despite decades of research, a standardized nosology for aggressive behaviors remains lacking, resulting in considerable variability in the design of treatment trials for aggression.

AREAS COVERED

A comprehensive literature review was conducted to identify studies evaluating pharmacological treatments for aggressive behaviors in children and adolescents. Articles were sourced from multiple databases, focusing studies that investigated the use of medications for treating aggression, conduct problems, and disruptive behaviors.

EXPERT OPINION

A significant barrier to effectively treating childhood aggression is the absence of a clear and standardized nosology. Aggression is frequently regarded as a symptom rather than a distinct clinical entity, complicating treatment decisions and hindering the ability to predict outcomes and develop targeted interventions. Notably, impulsive aggression has been the primary focus of research as a target for pharmacotherapy, highlighting the need to expand our understanding of aggression subtypes. A paradigm shift is necessary, emphasizing the development of operational definition of aggression diagnosis based on the type of aggressive behavior, the creation of screening tools, and the prediction of treatment outcomes to enhance both clinical practice and research.

Psychological and pharmacological treatments of intermittent explosive disorder: a meta-analysis protocol

INTRODUCTION

Intermittent explosive disorder (IED) is characterised by recurrent, sudden episodes of impulsive aggression that are disproportionate to the provocation. The condition's management remains challenging due to the variability in treatment efficacy and the absence of Food and Drug Administration-approved interventions specifically for IED. This meta-analysis aims to evaluate the effectiveness of existing treatments for IED.

METHODS AND ANALYSIS

Adhering to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a comprehensive literature search was conducted in November 2023, yielding 17 randomised controlled trials after screening and eligibility assessments. Studies were included based on participants' confirmed diagnosis of IED, sufficient statistical power and provision of data for effect size calculation. Interventions analysed included pharmacological treatments, psychotherapies and combination therapies, with an emphasis on cognitive-behavioural therapy and selective serotonin reuptake inhibitors. Quality assessment was performed using the Cochrane Risk of Bias Tool.

ETHICS AND DISSEMINATION

Given that our study is a synthesis of published data, ethical approval from a research ethics committee is not required. Nevertheless, the methodology of this review was designed to ensure full transparency and accountability. All efforts have been made to respect the confidentiality and intellectual property rights of the original data sources. Any ethical issues encountered during the data collection process were addressed in accordance with the guidelines of the Declaration of Helsinki. As this research involves the analysis of existing published data, there are no direct safety concerns related to patient interactions. Our primary focus has been on ensuring the secure handling and processing of data to uphold the ethical standards set by previous original studies. To ensure the findings of our meta-analysis reach both the academic community and the public effectively, we aim to submit our findings to peer-reviewed journals within the fields of psychology to ensure rigorous review and broad academic dissemination.

PROSPEO REGISTRATION NUMBER

CRD42024497587.

Salivary cortisol awakening levels are reduced in human subjects with intermittent explosive disorder compared with controls

BACKGROUND

The role of the hypothalamic-pituitary-adrenal (HPA) axis in human aggressive behavior is poorly characterized, though some studies report that, unlike depression, circulating or salivary levels of cortisol are low compared with controls.

METHODS

In this study, we collected three salivary cortisol levels (two in the morning and one in the evening) on three separate days in 78 adult study participants with (n = 28) and without (n = 52) prominent histories of impulsive aggressive behavior. Plasma C-Reactive Protein (CRP) and Interleukin-6 (IL-6) were also collected in most study participants. Aggressive study participants meet DSM-5 criteria for Intermittent Explosive Disorder (IED) while non-aggressive participants either had a history of a psychiatric disorder or no such history (Controls).

RESULTS

Morning, but not evening, salivary cortisol levels were significantly lower in IED (p < 0.05), compared with control, study participants. In addition, salivary cortisol levels correlated with measures of trait anger (partial r = -0.26, p < 0.05) and aggression (partial r = -0.25, p < 0.05) but not with measures of impulsivity, psychopathy, depression, history of childhood maltreatment, or other tested variables that often differ in individuals with IED. Finally, plasma CRP levels correlated inversely with morning salivary cortisol levels (partial r = -0.28, p < 0.05); plasma IL-6 levels showed a similar, though not statistically significant (rp = -0.20, p = 0.12) relationship with morning salivary cortisol levels.

CONCLUSION

The cortisol awakening response appears to be lower in individuals with IED compared with controls. In all study participants, morning salivary cortisol levels correlated inversely with trait anger, trait aggression, and plasma CRP, a marker of systemic inflammation. This suggests the present of a complex interaction between chronic-low level inflammation, the HPA axis, and IED that warrants further investigation.

Finding a Needed Diagnostic Home for Children with Impulsive Aggression

Aggressive behavior is one of the most common reasons for referrals of youth to mental health treatment. While there are multiple publications describing different types of aggression in children, it remains challenging for clinicians to diagnose and treat aggressive youth, especially those with impulsively aggressive behaviors. The reason for this dilemma is that currently several psychiatric diagnoses include only some of the common symptoms of aggression in their criteria. However, no single diagnosis or diagnostic specifier adequately captures youth with impulsive aggression (IA). Here we review select current diagnostic categories, including behavior and mood disorders, and suggest that they do not provide an adequate description of youth with IA. We also specifically focus on the construct of IA as a distinct entity from other diagnoses and propose a set of initial, provisional diagnostic criteria based on the available evidence that describes youth with IA to use for future evaluation.

Cognitive-Behavioral Versus Supportive Psychotherapy for Intermittent Explosive Disorder: A Randomized Controlled Trial

Few clinical trials have evaluated the efficacy of psychotherapy for Intermittent Explosive Disorder (IED). The present study tested the efficacy of a cognitive behavioral intervention (versus supportive psychotherapy) among adults with IED. In this randomized clinical trial, 44 participants with IED (22 men and 22 women) aged 20-55 years completed twelve 50-minute individual sessions of either a multi-component cognitive behavioral intervention for IED (n = 19) or a time equated supportive psychotherapy (n = 25). At baseline, posttreatment, and 3-month follow-up, all participants received the Overt Aggression Scale-Modified, which was conducted by an interviewer who was blind to the participant's study condition. During these visits, participants also completed self-report measures of relational aggression (Self-Report of Relational Aggression and Social Behavior), anger (State-Trait Anger Expression Inventory-2), cognitive biases (e.g., Social Information Processing Questionnaire Attribution and Emotional Response Questionnaire), and associated symptoms (e.g., Beck Depression Inventory). Primary study outcomes were aggressive behavior and anger. Though participants in both treatments tended to improve over time, the cognitive behavioral intervention was superior to supportive psychotherapy in decreasing aggressive behavior and relational aggression. These findings support the efficacy of a multicomponent cognitive behavioral intervention in treating aggression in IED.

Neuronal responses in social-emotional information processing in impulsive aggressive individuals

How we perceive and interpret signals from others' behavior, known as social-emotional information processing (SEIP), is key when responding to social threat. Impulsively aggressive individuals, behaviorally, demonstrate impaired SEIP for encoding relevant social stimuli, attribution of intent of the other person in the interaction, and responding negatively to potentially threatening social situations. In this study, we sought to explore how neural processing differs between healthy controls (HC) and individuals with impulsive aggressive behavior (individuals with Intermittent Explosive Disorder, I-IED), during a validated SEIP paradigm. Forty-five adults (19 I-IED, 26 HC) participants underwent a validated SEIP tasks during an fMRI scan. The task utilized video clips depicting a socially ambiguous, but possibly aggressive (AGG), act by one person to another and control video clips in which where possibly aggressive act does not occur (CON). Behavioral anomalies in SEIP are also manifest in altered neural activation in distributed networks/brain regions in each phase of SEIP examined. Overall, neural responses during the SEIP paradigm were characterized as reduced discrimination of the AGG vs. CON videos for I-IEDs compared to HCs. These data suggest the presence of compromised neural circuits underlying impaired social cognition in individuals with IED and highlights potential neural targets of intervention for impaired social cognition in I-IED and other behavioral disorders as well.

Mapping the neurocircuitry of impulsive aggression through the pharmacologic review of anti-impulsive aggressive agents

Impulsive aggression, in contradistinction to premeditated aggression in humans or predatory aggression in animals, corresponds to defensive aggression in animal models. At the core of the neurocircuitry of impulsive aggression, from murine to feline to human species, it is the medial amygdala-mediobasal hypothalamus-dorsal periaqueductal gray pathway. Here, we update current knowledge on the neurocircuitry of impulsive aggression by placing the neurocircuitry and its neurophysiological substrates into the top-down/bottom-up hypothesis of impulsive aggression. We then reverse the neurotranslational approach, which applies neuroscience to developing therapeutic drugs, and apply current understanding of potential mechanisms of anti-impulsive aggression agents to further clarify, at least heuristically and hypothetically, the dynamic biochemical components of the neurocircuitry of impulsive aggression. To do this, we searched the medical literature for studies attempting to clarify the neurobiological and neurochemical effects of the five most widely studied anti-impulsive aggressive agents, particularly as they pertain to the top-down/bottom-up hypothesis. Multiple different mechanisms are discussed, all of which fitting in the hypothesis by way of either promoting the "top-down" part (i.e., enhancing inhibitory neurotransmitters), or suppressing the "bottom-up" part (i.e., decreasing excitatory neurotransmitters). The hypothesis appears consistent with the current psychopharmacological understanding of these agents, as well as to account for the likely multifactorial etiology of the condition. Limitations of the hypothesis and future directions are finally discussed.

Posttraumatic Stress Disorder and Anxiety-Related Conditions

PURPOSE OF REVIEW

This article provides a synopsis of current assessment and treatment considerations for posttraumatic stress disorder (PTSD) and related anxiety disorder characteristics. Epidemiologic and neurobiological data are reviewed as well as common associated symptoms, including sleep disruption, and treatment approaches to these conditions.

RECENT FINDINGS

PTSD is no longer considered an anxiety-related disorder in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition classification and instead is associated with trauma/stressor-related disorders. PTSD symptoms are clustered into four domains including intrusive experiences, avoidance, mood, and arousal symptoms. Despite this reclassification, similarities exist in consideration of diagnosis, treatment, and comorbidities with anxiety disorders. PTSD and anxiety-related disorders are heterogeneous, which is reflected by the neural circuits involved in the genesis of symptoms that may vary across symptom domains. Treatment is likely to benefit from consideration of this heterogeneity.Research in animal models of fear and anxiety, as well as in humans, suggests that patients with PTSD and generalized anxiety disorder have difficulty accurately determining safety from danger and struggle to suppress fear in the presence of safety cues.Empirically supported psychotherapies commonly involved exposure (fear extinction learning) and are recommended for PTSD. Cognitive-behavioral therapy has been shown to be effective in other anxiety-related disorders. Selective serotonin reuptake inhibitors (SSRIs) and serotonin norepinephrine reuptake inhibitors (SNRIs) are commonly used in the treatment of PTSD and anxiety disorders in which pharmacologic intervention is supported. Treating sleep disruption including sleep apnea (continuous positive airway pressure [CPAP]), nightmares, and insomnia (preferably via psychotherapy) may improve symptoms of PTSD, as well as improve mood in anxiety disorders.

SUMMARY

PTSD has a lifetime prevalence that is close to 10% and shares neurobiological features with anxiety disorders. Anxiety disorders are the most common class of mental conditions and are highly comorbid with other disorders; treatment considerations typically include cognitive-behavioral therapy and pharmacologic intervention. Developing technologies show some promise as treatment alternatives in the future.

The Overt Aggression Scale Modified (OAS-M) for clinical trials targeting impulsive aggression and intermittent explosive disorder: Validity, reliability, and correlates

While aggressive behavior is common, and a disorder of impulsive aggression has been defined in the DSM-5 (Intermittent Explosive Disorder: IED), there are no currently FDA approved interventions to reduce these behaviors. One obstacle to the development of interventions to treat aggression is the paucity of psychometrically valid measures to assess aggressive behavior in the context of clinical trials, especially those in the outpatients setting. While there are many assessment of trait aggression, very few attempt to assess current aggressive behavior over time and/or in individuals not in a closed setting. The Overt Aggression Scale Modified (OAS-M) was developed to fill this void and this paper reviews its development along with presenting new data on its validity, reliability, and correlates with related constructs. Overall, the OAS-M is a valid and reliable measure of state (e.g., week to week) aggression, has good psychometric properties, and shows evidence of change in clinical trials of agents with putative anti-aggressive efficacy.