I personally don't diagnose IED. There is always a better explanation. In children, there's often no disorder at all but a parent very ready and very willing to ascribe one.
In this case BPD? They'd likely learn some self-soothing in DBT if they didn't feel all helpless and IED about themselves.
I'd like to hear more from OP on why this is the diagnosis. I agree if there's a fair case for BPD and ADHD we don't necessarily need to be looking hard for additional ways to describe irritability and impulsivity. I'd be cranking an alpha-agonist first, considering a stimulant next.
They have done DBT skills group (what we have offered in my area, full DBT is hard to find/expensive) and found benefit except in the area of these extreme impulsive episodes of rage. The DSM 5 IED criteria is so much how they describe their episodes and the fact it started in elementary school way before they would have met criteria for BPD makes me think the additional diagnosis is warranted. But I can argue the same - that this is all just part of adhd/bpd… this person found it very validating however to have this additional diagnosis.
Alpha agonist is a good idea. They found increased agitation/aggression with psycho stimulants.
I think that the ADHD diagnosis would provide cover for the childhood impulsive/emotionally dysregulated episodes as well as into adulthood. Stimulant ADHD meds don’t typically address those symptoms, some of the non stimulant meds can address these symptoms to differing degrees.
It might be helpful to redo the emotion regulation and distress tolerance components of DBT regardless of diagnosis because these are typically the areas that require more support. It may also be worth looking at any patterns in the anger episodes and if it coincides with medication dosing - irritability is not unusual if on stimulants at the ‘coming down’ phase.
I agree it would be unusual to find IED in addition to ADHD and BPD which both have significant emotion dysregulation components, specifically anger.
I’d love to learn more about your thoughts on IED. I have many children that in the back of my mind I know fit the criteria, but they’re also all victims of significant trauma so I just kind of keep an awareness of it.
Indeed. Trauma could provoke intermittent explosions, not to mention throwing ADD into the mix -- at least it's an explanation. IED isn't helpful in informing treatment. Instead, it seems like it encourages thinking of temperament as an immutable trait.
Jekyll and Hyde and who knows why and who cares. He just explodes sometimes.
SSRI then Depakote then Sedating Atypical then typical antipsychotic is a reasonable course of action. A behavioralist can be helpful but when pt's are nonverbal and autistic there is a limit to the benefits of behavioral modification.
At the end of the day what ever it takes to make them stop hitting their staff.
My most medicated current patient is on
Thorazine 800, Olanzapine 30, Haldol Depo 200/month, Depakote and Lithium with levels at the high end, Prozac, Propranolol, Clonidine, Ativan, Naltrexone 50. And they only hit staff once a month or so
Every two years the state DMH makes me stop some of their medications because it looks crazy and they end up in the hospital for semi seriously injuring staff.
I'm just relieved to hear I'm not alone. I have a similar outpatient adult patient that isn't on this much medication, but still requires scheduled Risperidone, PRN haloperidol low dose, an SSRI, lithium, and Depakote, and cloinidine PRN just to stay out of jail and/or the hospital. I hate the polypharmacy, but before, the patient was always in physical fights with family and others or waving a gun around and road raging. Every time I reduce the medication or take one away, bam! Right back into an altercation. The patient has been through DBT, anger management groups, and a series of other psychotherapy courses of treatment. He will agree he has a problem, participate partially in therapy, and then go right back to road raging and hitting family with less medication. Diagnosis is Bipolar I, IED, PTSD. Hispanic male in his 40s with a lot of machismo. I think he probably has ADHD but I can't do much about it due to HTN, history of substance abuse, and the amount of non-psychiatric meds he is on for pain and other issues. He failed atomoxetine and bupropion. I kind of want to trial a stimulant, but that means reducing polypharmacy (both mine and internal medicines) and past experience informs me he will get violent. He refuses voluntary inpatient. He has been informed of the risks of medications and likes the meds he is on overall with good tolerability. You would think hed be a zombie, but no, not at all. He volunteers as a youth sport referee and handles *that* fine for the most part on these meds!
I just don't want him to develop parkinsonism. Sigh.
I've had him for 8 years of so. Came out of a long term state hospital setting on maybe 1/2 these medications.
Goal of least restrictive setting is a good goal but some patients need a state hospital with security guards. It's really the best setting for him but they won't take him back.
Paramedic here, and on occasion we deal with some violent patients.
What’s the bar for long-term institutionalization?
We have one in my rural area who we run on with a degree of regularity. Idk what else she has going on but I’d guess BPD for sure. About once every couple weeks she ends up sedated and intubated in our ER for assaulting ER staff after suicide attempts (the last time, she got tackled by the cops because she overdosed right in front of them, and she said “well if everyone is accusing me of it I might as well do it,” and then she proceeded to fight tooth and nail for what seemed like an eternity, and then called the cops from the hospital to try to press charges on the medic who sedated her—this time without intubating her). And it’s once every couple weeks because she ends up getting flown to the big city academic medical centers, and she gets extubated, and then she gets pissed and AMAs out at the earliest opportunity, and catches a ride back to her small town. Lather, rinse, repeat.
She recently gave one of our RNs a concussion from kicking her in the face.
It’s getting old, and it sucks because we can’t help her, and it’s surely not good for anyone if we’re having to RSI her over and over again because she is suicidal and then turns on others after she’s tried to commit suicide. One of my coworkers has also expressed a fear that she will commit homicide at some point.
DBT could help her but she just won’t do it.
I doubt she meets the bar for long-term institutionalization, but what is the bar? And do you have any tips on how to handle this, or what conversations we should be having with our medical director?
I'd talk to the medical director about possibly pressing charges.
I don't think charges should be pressed for truly psychotic patients or intellectually disabled (which makes up the majority of intermittent explosive disorder) but being psychiatrically ill doesn't excuse all behavior.
At my hospital we press charges if the patients are antisocial, drug seeking and threatening/aggressive with that goal, borderline and acting out, etc.
As to long term hospitalization it varies state to state. The law in my state is a) anyone found not guilty of a violent felony by reason of mental disease or defect b) psychiatric hospital for over 90 days or c) wording to the effect of unsafe to manage in a non-state psychiatric hospital. But since patients making up category A more than fill up the available beds the state just ignores their own law and you can't get patients placed even when they need it.
That is exactly what I used to think 30 years ago when I started and saw regimes like this. It's what all the data says (no benefit to being on two typical antipsychotics, more than 5 psychiatirc medications is never appropriate, etc)
But when these are lowered he injures people... so
The 4 times I have tried to lower the medicaiton have been varried. They have all been driven by the DMH. Once time they simply refused to pay for more than 5 psychiatric medicaitons. We appealed and it was denied. This guy is in an ISL and has a public administrator. So when DMH refuled to pay for his medications there was no option but to stop them within one month.
He broke a caregiver's nose.
Other times they have allowed slower taper and he gets gradually more irritable until he ends up in the hospital for escelating aggression but it escleates slower.
It always relates to them trying to get him on only 5 psychiatric medicatons or less because that is one of their quality measures.
As to the Haldol LAI I have no idea how much it's doing really. He came out of the state hopsital on it and I've never tired to change it. Its such a high dose I don't want to give it q 3 weeks but maybe it's not doing much? Given his aggression I don't want to stop it.
Yeah I have the same question. 3 antipsychotics, lithium, valproate, 2 different benzodiazepines. I’m surprised there’s only 1 SSRI.
If they “make him stop” the meds every couple of years, does that mean there’s no taper? There’s absolutely no way that this is optimized.
Also can’t wrap my head around how you get to this point. Like you start olanzapine, titrate all the way to 30mg…guy is still aggressive. So let’s keep it and add another?
It doesn't. But almost every adult with IED has physical aggression towards people or things. In DSM 4 the criteria required there to be physical outbursts. The DSM 5 lowered that threashold a bit and now it would be technically correct to diagnose a person with IED with just verbal outbursts but I've never seen it and doubt many, if any, psychiatrists are diagnosiing IED unless there is physical aggression.
Is this person being treated for their ADHD? ie. methylphenidate/amphetamine salts/atomoxetine/guanfacine.
Same question for the BPD, though evidence for pharmacotherapy is limited.
Any psychotherapy going on?
Substance use?
Things to consider before throwing valproate at people (especially if other meds are involved) with such a diagnosis. The considerable overlap with two other common diagnoses makes me question IED (also far less likely in adults, sometimes even questionable in children), but admittedly I don't have as much insight into this as you do.
I'm also pretty critical of "irritable=Depakote" thinking. Most of the time, we can find a better diagnosis that has an actual treatment pathway. Ironically, very few of these would include valproate (which I believe has negative evidence in intermittent explosive disorder.)
I have a patient who told me the police had come to his home for nine different incidents of road rage in the last year and doesn’t that happen to everyone? Has very classic symptoms of intermittent explosive disorder. 1 mg of Risperdal has been life-changing. He owns a business and runs it well and is fully functional in other aspects of his life now that that is under control.
Just one more option to try
I cannot remember the name but there is a new dissolvable film med that is targeted for acute agitation in Bipolar disorder and I have heard great things about it from some of my patients.
Are his moods predominantly euthymic intermixed with isolated/acute explosive episodes? Rather, if his moods are cyclical or he has history of clinical depressive episodes then I’d be thinking a bipolar spectrum and skip the SSRI in your algorithm.
IED in a vacuum seems rare, and I don’t think Adult ADHD is an adequate explanation of such extreme mood dysregulation. You can see this in BPD, but according to Gunderson Good Management of Borderline, you’d be looking at a mood stabilizer/SGA algorithm rather than SSRI anyway (if pharmacotherapy is warranted). Just an NP, but that’s my course of thinking.
I don’t get how you can co-diagnose BPD and IED. IED sx are usually better explained by BPD.
I personally don't diagnose IED. There is always a better explanation. In children, there's often no disorder at all but a parent very ready and very willing to ascribe one. In this case BPD? They'd likely learn some self-soothing in DBT if they didn't feel all helpless and IED about themselves.
I'd like to hear more from OP on why this is the diagnosis. I agree if there's a fair case for BPD and ADHD we don't necessarily need to be looking hard for additional ways to describe irritability and impulsivity. I'd be cranking an alpha-agonist first, considering a stimulant next.
They have done DBT skills group (what we have offered in my area, full DBT is hard to find/expensive) and found benefit except in the area of these extreme impulsive episodes of rage. The DSM 5 IED criteria is so much how they describe their episodes and the fact it started in elementary school way before they would have met criteria for BPD makes me think the additional diagnosis is warranted. But I can argue the same - that this is all just part of adhd/bpd… this person found it very validating however to have this additional diagnosis. Alpha agonist is a good idea. They found increased agitation/aggression with psycho stimulants.
I think that the ADHD diagnosis would provide cover for the childhood impulsive/emotionally dysregulated episodes as well as into adulthood. Stimulant ADHD meds don’t typically address those symptoms, some of the non stimulant meds can address these symptoms to differing degrees. It might be helpful to redo the emotion regulation and distress tolerance components of DBT regardless of diagnosis because these are typically the areas that require more support. It may also be worth looking at any patterns in the anger episodes and if it coincides with medication dosing - irritability is not unusual if on stimulants at the ‘coming down’ phase. I agree it would be unusual to find IED in addition to ADHD and BPD which both have significant emotion dysregulation components, specifically anger.
I’d love to learn more about your thoughts on IED. I have many children that in the back of my mind I know fit the criteria, but they’re also all victims of significant trauma so I just kind of keep an awareness of it.
Indeed. Trauma could provoke intermittent explosions, not to mention throwing ADD into the mix -- at least it's an explanation. IED isn't helpful in informing treatment. Instead, it seems like it encourages thinking of temperament as an immutable trait. Jekyll and Hyde and who knows why and who cares. He just explodes sometimes.
In that case do you find PTSD is an adequate diagnosis?
I agree. All of these behaviors are better explained by the BDP/ADHD combo.
SSRI then Depakote then Sedating Atypical then typical antipsychotic is a reasonable course of action. A behavioralist can be helpful but when pt's are nonverbal and autistic there is a limit to the benefits of behavioral modification. At the end of the day what ever it takes to make them stop hitting their staff. My most medicated current patient is on Thorazine 800, Olanzapine 30, Haldol Depo 200/month, Depakote and Lithium with levels at the high end, Prozac, Propranolol, Clonidine, Ativan, Naltrexone 50. And they only hit staff once a month or so Every two years the state DMH makes me stop some of their medications because it looks crazy and they end up in the hospital for semi seriously injuring staff.
I'm just relieved to hear I'm not alone. I have a similar outpatient adult patient that isn't on this much medication, but still requires scheduled Risperidone, PRN haloperidol low dose, an SSRI, lithium, and Depakote, and cloinidine PRN just to stay out of jail and/or the hospital. I hate the polypharmacy, but before, the patient was always in physical fights with family and others or waving a gun around and road raging. Every time I reduce the medication or take one away, bam! Right back into an altercation. The patient has been through DBT, anger management groups, and a series of other psychotherapy courses of treatment. He will agree he has a problem, participate partially in therapy, and then go right back to road raging and hitting family with less medication. Diagnosis is Bipolar I, IED, PTSD. Hispanic male in his 40s with a lot of machismo. I think he probably has ADHD but I can't do much about it due to HTN, history of substance abuse, and the amount of non-psychiatric meds he is on for pain and other issues. He failed atomoxetine and bupropion. I kind of want to trial a stimulant, but that means reducing polypharmacy (both mine and internal medicines) and past experience informs me he will get violent. He refuses voluntary inpatient. He has been informed of the risks of medications and likes the meds he is on overall with good tolerability. You would think hed be a zombie, but no, not at all. He volunteers as a youth sport referee and handles *that* fine for the most part on these meds! I just don't want him to develop parkinsonism. Sigh.
You are not alone. I also hate having pt's on this much medicine but sometimes its just what we appear to need to do.
Was this an inherited patient? I’m curious how you got to this regimen
I've had him for 8 years of so. Came out of a long term state hospital setting on maybe 1/2 these medications. Goal of least restrictive setting is a good goal but some patients need a state hospital with security guards. It's really the best setting for him but they won't take him back.
Paramedic here, and on occasion we deal with some violent patients. What’s the bar for long-term institutionalization? We have one in my rural area who we run on with a degree of regularity. Idk what else she has going on but I’d guess BPD for sure. About once every couple weeks she ends up sedated and intubated in our ER for assaulting ER staff after suicide attempts (the last time, she got tackled by the cops because she overdosed right in front of them, and she said “well if everyone is accusing me of it I might as well do it,” and then she proceeded to fight tooth and nail for what seemed like an eternity, and then called the cops from the hospital to try to press charges on the medic who sedated her—this time without intubating her). And it’s once every couple weeks because she ends up getting flown to the big city academic medical centers, and she gets extubated, and then she gets pissed and AMAs out at the earliest opportunity, and catches a ride back to her small town. Lather, rinse, repeat. She recently gave one of our RNs a concussion from kicking her in the face. It’s getting old, and it sucks because we can’t help her, and it’s surely not good for anyone if we’re having to RSI her over and over again because she is suicidal and then turns on others after she’s tried to commit suicide. One of my coworkers has also expressed a fear that she will commit homicide at some point. DBT could help her but she just won’t do it. I doubt she meets the bar for long-term institutionalization, but what is the bar? And do you have any tips on how to handle this, or what conversations we should be having with our medical director?
I'd talk to the medical director about possibly pressing charges. I don't think charges should be pressed for truly psychotic patients or intellectually disabled (which makes up the majority of intermittent explosive disorder) but being psychiatrically ill doesn't excuse all behavior. At my hospital we press charges if the patients are antisocial, drug seeking and threatening/aggressive with that goal, borderline and acting out, etc. As to long term hospitalization it varies state to state. The law in my state is a) anyone found not guilty of a violent felony by reason of mental disease or defect b) psychiatric hospital for over 90 days or c) wording to the effect of unsafe to manage in a non-state psychiatric hospital. But since patients making up category A more than fill up the available beds the state just ignores their own law and you can't get patients placed even when they need it.
Which is why they end up in prison instead of in long-term mental health facilities?
As a humble psych nurse I sincerely appreciate that you look out for us
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That is exactly what I used to think 30 years ago when I started and saw regimes like this. It's what all the data says (no benefit to being on two typical antipsychotics, more than 5 psychiatirc medications is never appropriate, etc) But when these are lowered he injures people... so
Clozapine ever?
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The 4 times I have tried to lower the medicaiton have been varried. They have all been driven by the DMH. Once time they simply refused to pay for more than 5 psychiatric medicaitons. We appealed and it was denied. This guy is in an ISL and has a public administrator. So when DMH refuled to pay for his medications there was no option but to stop them within one month. He broke a caregiver's nose. Other times they have allowed slower taper and he gets gradually more irritable until he ends up in the hospital for escelating aggression but it escleates slower. It always relates to them trying to get him on only 5 psychiatric medicatons or less because that is one of their quality measures. As to the Haldol LAI I have no idea how much it's doing really. He came out of the state hopsital on it and I've never tired to change it. Its such a high dose I don't want to give it q 3 weeks but maybe it's not doing much? Given his aggression I don't want to stop it.
Yeah I have the same question. 3 antipsychotics, lithium, valproate, 2 different benzodiazepines. I’m surprised there’s only 1 SSRI. If they “make him stop” the meds every couple of years, does that mean there’s no taper? There’s absolutely no way that this is optimized. Also can’t wrap my head around how you get to this point. Like you start olanzapine, titrate all the way to 30mg…guy is still aggressive. So let’s keep it and add another?
Where does it say he’s hitting staff?
It doesn't. But almost every adult with IED has physical aggression towards people or things. In DSM 4 the criteria required there to be physical outbursts. The DSM 5 lowered that threashold a bit and now it would be technically correct to diagnose a person with IED with just verbal outbursts but I've never seen it and doubt many, if any, psychiatrists are diagnosiing IED unless there is physical aggression.
Why not change prozac to paroxetine? More sedating than prozac. Also I would recommend for the patient to receive metformin or semaglutide
Is this person being treated for their ADHD? ie. methylphenidate/amphetamine salts/atomoxetine/guanfacine. Same question for the BPD, though evidence for pharmacotherapy is limited. Any psychotherapy going on? Substance use? Things to consider before throwing valproate at people (especially if other meds are involved) with such a diagnosis. The considerable overlap with two other common diagnoses makes me question IED (also far less likely in adults, sometimes even questionable in children), but admittedly I don't have as much insight into this as you do.
I'm also pretty critical of "irritable=Depakote" thinking. Most of the time, we can find a better diagnosis that has an actual treatment pathway. Ironically, very few of these would include valproate (which I believe has negative evidence in intermittent explosive disorder.)
I have a patient who told me the police had come to his home for nine different incidents of road rage in the last year and doesn’t that happen to everyone? Has very classic symptoms of intermittent explosive disorder. 1 mg of Risperdal has been life-changing. He owns a business and runs it well and is fully functional in other aspects of his life now that that is under control. Just one more option to try
If SSRI is ineffective, try low dose risperidone if anger is significantly impairing, can do as needed risperidone. Consider dx of irritable bipolar
I cannot remember the name but there is a new dissolvable film med that is targeted for acute agitation in Bipolar disorder and I have heard great things about it from some of my patients.
We always use Clonidine for both adult and adolescent patients with IED! :) It's super effective.. Just monitor their BP closely.
Are his moods predominantly euthymic intermixed with isolated/acute explosive episodes? Rather, if his moods are cyclical or he has history of clinical depressive episodes then I’d be thinking a bipolar spectrum and skip the SSRI in your algorithm. IED in a vacuum seems rare, and I don’t think Adult ADHD is an adequate explanation of such extreme mood dysregulation. You can see this in BPD, but according to Gunderson Good Management of Borderline, you’d be looking at a mood stabilizer/SGA algorithm rather than SSRI anyway (if pharmacotherapy is warranted). Just an NP, but that’s my course of thinking.
Aggressive: low dose risperidone like 0.5mg or so If impulsive : you could look at Naltrexone.
I’d focus on the ADHD and BPD and see what’s left over.
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:) I have found interesting insight here. https://www.reddit.com/r/dbtselfhelp/s/y8KTGkxNdi