8.18: Intermittent Explosive Disorder
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Name: Matt Foley
Source: Saturday Night Live (TV series, early 1990s)
Matt Foley is a 35 year old, male motivational speaker. Physically he is severely overweight due to his steady diet of government cheese. This may lead to high blood pressure and other health complications. He also seems to have trouble breathing normally, not just during his “rage” episodes. He doesn’t speak of any interpersonal relationships, family or other, so family history and his childhood environment are unknown. Matt did admit openly that he is twice divorced and lives in a van down by the river, and he is very unsatisfied with these two facts. His social skills are very awkward. When he is around people he is loud and generally awkward, either not understanding social cues or (more likely) ignoring them. He becomes very physical with others, lifting them, invading “personal space” and so on. One episode he talked about began with shaking children to “drive his point home” that Santa wasn’t real (during this episode he was being paid to dress as Santa at The Mall. At time of evaluation he had been on a coffee binge, drinking it for four hours straight. With the exception of his coffee spree there is no evidence or admittance of harder drug use. He has little to no coping skills, often reverting to yelling to relieve tension. He generally frightens people with his behavior. And while his goal in life is to not live in a van by the river (and convincing young kids that they don’t want that, too) he seems unable to help himself in achieving that goal.
Description of the Problem
Matt Foley’s personality is off-setting. While he can seem overly enthusiastic, it is a façade to hide his short temper. His irritability is evidenced in all his mannerisms, from his constant fidgeting to the way his voice grows louder the more irritated he becomes. He constantly has to adjust his pants and shake out his arms to get rid of his temper “tingling” in his arms. He is very short with people who think differently than he does, choosing to be verbally demeaning instead of allowing them their own opinions. This is costing him his audience when he gives speeches and not allowing him to form connections. Not being able to make positive relationships is harming his work performance and not allowing him to advance on to higher positions. Higher positions would mean a pay increase and allow him to move into a more permanent habitation (such as an apartment or a house).
His explosive nature has also led him to destroy other individual’s property. While at a house for a job he annihilated a coffee table in the living room. He was sorry after the fact, but could not seem to say anything other than “whoopsie.” He also once forcefully suggested he move in with another person to set them on the right path. During another episode he yelled at a mother to “shut your cake hole!” and he promptly destroyed a Christmas scene set at The Mall. Yet another episode he discussed involved him interviewing a highly respected comedian/talk show host (Conon O’Brien). The interview included Matt yelling insults, such as threatening to use the studio’s curtains to “wipe (his) rear end with (them).” His episodes last about 6 minutes (specifically 5 minutes and 49 seconds) and occur sporadically.
Diagnosis is Intermittent Explosive Disorder, DSM-IV 312.34. Matt clearly shows an inability to control his impulses. His episodes last less than a half hour at time and usually result in a physical altercation or destruction of property. They are also grossly uncalled for as Matt loses control “at the drop of a hat.” His actions are neither planned nor used for personal gain, other than to relieve his anger. Having no history of drug abuse or suggestion of family history of mental health, it can be safely assumed that Matt is not under the influence of anything other than his own unchecked rage. That is, his actions are not accounted for by any other mental disorder or substance abuse. Since Matt is divorced he may have some unresolved anger issues, or he may have had a tense marriage where it was not unusual for him to go into episodes. Matt also says he is remorseful for the destruction of property, proving he does have a sense of what he’s doing is wrong. Similar episodes have occurred before, one time involving public property at The Mall, the other involving verbal abuse during an interview with a well-known comedian Conan O’Brien.
Accuracy of Portrayal
Intermittent Explosive disorder is an impulse disorder that is specifically a lack of restraining anger and aggression. Statistically men are more likely to have IMED than women. The episodes are grossly out of proportion to the situation, be it a yelling match or breaking something. These episodes are also not accounted for by another mental disorder, drug use, or by any physiological condition (such as brain injury, dementia, Alzheimer’s, and so on.). Matts episodes are short in duration (generally no longer than 20 minutes), which is consistent with the diagnosis for IMED. The breaking of the table and Christmas scene could also be accidental rather than purposeful, but it’s still accounted for by his episode. His “drug use” (coffee and espresso binge) is atypical, but not unheard of. His aggressive tendencies are interfering with his life and relationships, and will continue to do so until he gets a handle on his behavior. In all these ways, Matt is a perfect example of an individual who suffers with IMED.
As mental health professionals would agree, there are a few options for Matt Foley. Empirically supported treatment for Matt could include drug therapy such as β-Blockers, α(2)-agonists, anti-anxiety, anti-convulsion, ant-depressants, antipsychotics, and mood stabilizers. Drug therapy can be used with or separate from cognitive behavioral therapy. In cognitive behavior therapy individuals identify stressors that lead to episodes and how to cope or avoid them. Other forms of treatment include social skills training, in which the individual works on improving their interpersonal skills. Although social skill training is a form of treatment it is less effective than drug and/or cognitive behavioral therapy.
Matt Foley would benefit most from the combination of drug therapy and cognitive behavior therapy. Matt would be a good candidate for β-Blockers, because they specifically block the β 1 and 2 receptors that stimulate the body into “fight or flight” mode. They would also help to lower his blood pressure, which may further help to reduce his stress and anxiety by strengthening his health. In cognitive behavior therapy he and his therapist would work specifically on ways to control his anger or use it in more constructive ways. One strategy for controlling his anger would be to record specific instances that send him into episodes. Knowing these situations would allow him and his therapist to work on ways to reduce his rage should these situations ever occur again.
Name: James Howlett (Wolverine), Logan, formerly Weapon Ten, Death, Mutate #9601, Jim Logan, Patch, Canucklehead, Emilio Garra, Weapon Chi, Weapon X, Experiment X, Agent Ten, Canada, Wildboy, Peter Richards, many others, but primarily claiming Logan as his primary name.
Source: Marvel Comics (As Wolverine, cameo) Incredible Hulk #180 (1974), (as Wolverine, fully) Incredible Hulk #181 (1974), (as Patch) Marvel Comics Presents #1 (1988), (as Weapon X) Marvel Comics Presents #72 (1991), (as Death) Astonishing X-Men #1 (1999)
Logan is more than one hundred years of age, although he has the appearance and health of a man roughly 35-40 years of age. Born James Howlett, he was a frail boy of poor health from Alberta, Canada during the late 19th Century. He was the second son of wealthy landowners John and Elizabeth Howlet. His mother, who was institutionalized for a time following the death of her first son, John Jr., in 1897, largely neglected James. Elizabeth later committed suicide. He spent most of his early years on the estate grounds and had two playmates that lived on the Howlett estate with him: Rose, a red-headed girl who was brought in from town to be a companion to young James, and a boy nicknamed “Dog” who was the son of the groundskeeper, Thomas Logan. James assumed the name “Logan” while living incognito following a violent incident involving his companion Rose, who was consequently wrongly accused of murder. Logan is a veteran of several conflicts and wars including World War II. He has served in covert government operations working under the title Weapon X as an assassin. Logan worked as a miner in British Columbia for a time and was highly regarded as being a hard worker. He has also worked as an adventurer, instructor, bartender, bouncer, spy, government operative, mercenary, soldier, and sailor. Logan has an almost immunity to the intoxicating effects of alcohol, but no evidence of use or abuse of any other substances is apparent. Logan tends to make friends easily enough, but due to his violent and tragic past has difficulties with trust. Logan’s romantic relationships are often complicated and tedious, frequently becoming situations where either his love cannot be displayed, or his love is for someone committed to someone else. Logan’s difficulty with interpersonal relationships as well as his propensity toward violent outbursts often causes him to withdraw and spend a lot of time alone. This isolation often serves as a means of coping.
Description of the Problem
Logan has a strong and often forceful demeanor. He often engages in aggressive competitive behaviors, as well as being somewhat of a bully when in certain company. He seems to be tender toward women, but sees other males as either competition, or subordinates. Logan shows a generally hostile disposition, as well as a tendency to engage in aggressive forms of humor in the limited instances in which he interacts with others. When engaged in conversation, he is often abrupt and bordering on rude.
Logan’s (Wolverine’s) skeleton includes six retractable one-foot long bone claws, three in each arm, that are housed beneath the skin and muscle of his forearms. Logan can, at will, release these slightly curved claws through his skin beneath the knuckles on each hand. This ability coupled with Logan’s short fuse and incredible physical ability often makes him dangerous.
Intermittent Explosive Disorder, DSM-IV 312.34. Logan displays a number of impulsively violent outbursts, many of which last only a short time, but are extremely severe and destructive. Logan often displays violent outburst of temper, threatening others, even peers with physical harm, as well as considerable destruction of property both with his claws as well as other means. Logan is quick to anger and aggress and is often severe in his reactions to perceived threats to his safety. During one of his altercations with another male from his past, Logan inadvertently killed his childhood companion, Rose, by impaling her with his claws. One form of aggression, known as amok, is characterized by acute, unrestrained violence, typically associated with amnesia. This is primarily seen southeastern Asia but has also been seen in Canada and the United States. Unlike IED, amok does not occur frequently but in a single episode. One reason for suspecting that Logan may be suffering from this is due to two factors:
- Logan has extreme memory loss due to having had his memories “wiped” from his consciousness after his service as Weapon-X
- Logan possesses memories of being a Samurai in Japan. Perhaps during his travels in the Far East, he found himself in southeastern Asia.
The only reason for mentioning this is due to Logan’s chronological age being much longer than that of a non-mutant human.
Accuracy of Portrayal
Being male, Logan is more at risk of having developed IED. IED is one of the impulse-control disorders that involve the inability to control impulses of anger, or rage and often results in violent physical outbursts or violent verbal attacks. Logan definitely displays these tendencies. Logan doesn’t seem to have any other mental disorders such as schizophrenia, bipolar, affecting him, however during the process of “wiping” his memory, a degree of brain injury may have occurred. Logan’s extremely reactive nature and his severity during his explosive episodes is often maladaptive and causes him to have to be transient in nature, drifting from location to location, rarely settling down into one specific location. His romantic relationships have been complicated by his angry outbursts as well. Enemies he has made in the past due to his mercenary work and covert government work have caused the death of at least one potential life mate.
Since few controlled studies exist involving treatment of IED, Logan would probably benefit from cognitive behavioral therapy (CBT), helping him to identify triggers for his outbursts. Teaching him coping skills such as diaphragmic breathing, counting, and also the keeping of a stress and incident journals to help him identify what triggered specific incidents and what to do to avoid them or possibly handle them differently if a similar situation arises. Anger management and group therapy could also be effective as well. If these were unsuccessful, or only marginally effective, then the use of certain medications such as anti-convulsion, anti-anxiety, mood regulators, anti-depressants, antipsychotics, beta-blockers, alpha (2)-agonists, or phenytoin could be indicated.