Q. We have a client who has been diagnosed with "explosive disorder". Her behavior seems to reflect this term: unprovoked outbursts of violence. Her current daily medications are: 2500 mgs Eplim, 800 mgs Serequil, PRN Valium. We provide supported accommodation for people who have a psychiatric disability, and support them in community integration. I cannot find any information about this disorder, and would like to know more to enable better service provision for this lady. Can you help?

A. You may be outside the U.S., judging from the name of the medication (Eplim) that you mentioned. In the U.S., there is no such diagnosis as "explosive disorder". However, we do have the diagnosis of "Intermittent Explosive Disorder" (IED), which is probably what your client has been given.

I personally consider this a very unreliable and uninformative label, since it often hides an underlying neurological or mood disorder, in my view. For example, some individuals with subtle forms of epilepsy may have intermittent outbursts of aggression--and it is interesting that Eplim (a form of valproic acid) is an anti-seizure medication. Some individuals with so-called IED may actually have an undiagnosed bipolar disorder (manic-depressive illness) or psychotic disorder (Seroquel is actually an antipsychotic agent). Still others with this label have underlying structural brain damage related to head trauma.

Should you wish to read more about IED, you might see the article by Posternak and Zimmerman (J Clin Psychiatry 2002 Aug;63(8):665-72). You may also want to see the book by Dr. Jan Volavka, entitled, "The Neurobiology of Violence" (American Psychiatric Press). There is also a video you may be interested in (I have not seen it), entitled, "Managing Aggressive Behavior", available through JIBC Paramedic Academy (604- 528-5598).

However, I think the best service you could perform for your client is to ensure that she has had a very thorough medical, neurological, and psychiatric work-up to rule out other diagnoses. There are also other medications that could be helpful for her, in addition to behavioral therapy strategies that may reduce her violent outbursts. Consulting with a neuropsychiatrist and a behavioral psychologist would be a good start. Good luck with this challenging client.

May 2003

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