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Pt is a 14 year old white male who had recurrent impulsive aggression, angry outburst, threatened the mother, property destruction. He was diagnosed with intermittent explosive disorder .His treatment plan consisted of psychotherapy and medications. The psychotherapy was CBT such as talk therapy and pharmacology were anticonvulsants, Selective serotonin reuptake inhibitors (SSRIs)


: “When I have anger outburst I threatened my mother and destroyed properties at home.”

Pt is a 14 year old Caucasian presents for ongoing management of his symptom after a recent inpatient psychiatric hospitalization Hospital. He came in for psychiatric evaluation following an episode of anger outburst with family members where he made threats to hurt his mom and sister. Mother reported of patient having property damage, for example threw things at the Television, screen broke, threw chairs on the wall in the house and slamming doors.Pt reports a diagnosis of MDD, and ADHD in 4


grade.Pt. complained of the incidence of the subsequent indications: nervous, suspicious poor concentration, impulsivity, decreased need for sleep, angry outburst and increased irritability, gets provoked easily. Symptom onset was had been within a 12 – month period. Pt reported that he is having problems forming social relationships because of his recurrent anger outbursts.

Medical history



: seasonal allergies, no known medication allergies.

Past psychiatric diagnosis

: Major Depressive Disorder (MDD), Attention – deficit /hyperactivity disorder (ADHD)

Past psychiatric medications

: Tripletail, Strattera with unknown dose

Psychosocial history

: lives with mother, father, sister.

Past substance abuse

: pt denies

Current substance abuse

: pt denies.

Reproductive Hx

:pt is single, in adolescence stage.

Mental status examination

Pt appeared at his stated age, pt. was able to move his extremities, and his affect was labile. He seems suspicious, nervous, irritable, angry and uncooperative. His mood was anger.He made minimal eye contact during the interview. His speech was in low tone with delayed response. During the interview, when pt. was asked about his anger outbursts, he became defensive. Pt selectively answered the questions at his interest.His thought content was no concern for others, and lack of empathy.He had a distractible concentration throughout the interview, his insight was poor.He denies any self-harm or suicidal ideations.Pt had no delusions, hallucinations and illusions noted as evidenced by no psychotic symptoms observed . He had an intact memory by remembering what occurred in the past and now.

Differential diagnosis:

Intermittent explosive disorder

Antisocial personality disorder or borderline personality disorder

Attention – deficit /hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder.

Intermittent explosive disorder

From DSM 5 criteria for diagnosing Intermittentexplosive disorder,there should be a recurrent behavioral outburstthat has a failureto control aggressive impulsesas manifested by the following: there is a verbal aggression , mypatient had verbal arguments with his mother andsister, threatensthe mother, always having temper tantrums,occurred for a period of 3 months and destroying propertyand slamming doors within a year.The repeated aggressive episodes are all impulsive, this comes from being extremely angry.My pt.’s mother reported that, pt. will being threatening them which are not premediated.Pt admitted that the repeated aggression outburst is negatively affecting his social relationships.My patient can be diagnosed with intermittent explosive disorder, because he is having recurrent explosive outbursts of extreme violence and anger and symptom onset was had been within a 12 – month period, not from any mental health disorders.

Antisocial personality disorder or borderline personality disorder

Individuals with antisocial personality disorder or borderline personality disorder normally show repeated, problematic impulsive aggressive outburst, in both antisocial personality disorder and borderline personality disorder, they act impulsively and also aggressive. On the other hand, the intensity of impulsive aggression in patients with antisocial or border personality disorder is lesser than that in individuals with intermittent explosive disorder (APA, 2013). The diagnosis for my patient is Intermittent Explosive disorder (IED) notantisocial personality disorder or borderline personality disorder, my patient had extreme outburst, impulsively angry and threatening his mother.

Attention – deficit /hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder.

Individualswith childhood onset disorders such as ADHD, Conduct disorder, oppositional defiant disorder or autism spectrum disorder may exhibit impulsive aggressive outburst (APA, 2013).In ADHD, as a consequence of impulsive aggressive outbursts, for conduct disorders isindicated by the diagnostic condition of proactive and predatory.Individuals with oppositional defiant disorder, theory aggression is in the form of temper tantrums and verbal augments with authority persons (APA, 2013). However patients diagnosed with IED hasimpulsive aggressive outburstsin an response to a broader array of provocation and consist of physical assault and the degree of impulsive aggression exhibited by ADHD, Conduct disorder, oppositional defiant disorder or autism spectrum disorderwill be lower (APA, 2013) .


Intermittent explosive disorder (IED) reflects repeated acts of impulsive-aggressive outbursts (verbal or physical, against humans, animals or objects), which are clearly disproportionate to the given situation (Barra et al., 2022).IED ranged among the most commonly reported disorders among adolescents in the US Comorbidity Survey (Barra et al., 2022).

Intermittent Explosive disorder (IED) is a persistent , lasting form of impulsive aggression which ischallenging andcausesawide – ranging of dysfunction inlife-significancesin work – related , lawful , monetary, and societal areas (Hall and Coccaro , 2022).Patients diagnosed with IED are at more chance of presentingundesirable physical and psychological outcomes (Ciesinski et al., 2022). They have personal dysfunction in social, friendship, work settings.

When doing psychiatric evaluation, it is important to take into account, the patients’ medical, past and family history of any psychiatric diagnosis.If I am to interview this patient again, I will ask him about his environmental condition particularly any family history of IED and follow up with the mother.It is known that individuals with a history of physical and emotional trauma during the first two decades of life are at more risk for IED and also first – degree relatives of patients diagnosed with IEDand twin studies have demonstrated a substantial geneticinfluence for impulsive. (APA, 2013).

I will recommend inpatient psychiatric treatment for my patient if aggressive impulsive, threatening the mother, slamming doors continues. Inpatient psychiatric unit, his medications and therapy will be monitored, thereby increasing compliance with treatment.

When doing the interview, I considered his also his cultural background, gender, age.IED is low in some countries based on their cultural factors, is more prevalent in males and in younger individuals (APA, 2013).

Case formulation and Treatment:

A joined intervention of both pharmacological and psychotherapeutic method has the greatest probability of success (Sadock et al., 2015). Psychotherapy with individuals who have been diagnosed with intermittent explosive disorder is demanding,the reason is of their angry outbursts. Group psychotherapy may be helpful, and family therapy is useful, particularly when the explosive patient is an adolescent. The goal of therapy is to have the patient realize andvoice out thethinking of feelings that come firstbefore the explosive outbursts as an alternative for acting them out (Sadock et al., 2015)..Treatment for intermittent explosive disorder typically involves psychotherapy (talk therapy) focused on changing thoughts related to anger and aggression. Treatment may also include medication, depending on your age and symptoms.

The goal of treatment for IED is remission, which means that your symptoms (anger outbursts) go away or you experience improvement to the point that only one or two symptoms of mild intensity persist. For people who don’t achieve remission, a reasonable goal is stabilizing the safety of the person and others, as well as a substantial improvement in the number, intensity and frequency of anger outbursts

Psychotherapy (talk therapy) is usually the main treatment for intermittent explosive disorder, especially

Specific techniques mental health professionals use in CBT for intermittent explosive disorder include: cognitive restructuring, relaxation, coping skills training, relapse prevention.

The patient was prescribed Carbamazepine ER 400mg , extended release 12 hr., 1 tab orally 2 times in a day. Anticonvulsants have been used in treating explosive patients.In helpful in generally lessening aggressive behavior (Sadock et al., 2015).

Another medication was Sertraline 100mg, take 1 tab orally once in a day.

Selective serotonin reuptake inhibitors (SSRIs) are used to reduce impulsivity and aggression (Sadock et al., 2015).

My health promotion education that I gave to the patient was in promoting mental health and emotional well – being and sleep.Pt was educated on tools and resources to call for mental health assistance and adequate sleep helps with mental health as well as the wellbeing of an individual.Sleep difficulties have been postulated as a possible reason in the basis and managing of aggressive behavior (Hall and Coccaro, 2022).

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