Emotional Pro

Remember the name! Dr. Emil Coccaro, chairman of psychiatry at the University of Chicago’s medical school, funded by the National Institute of Mental Health, and two of his medical colleagues, has just given us evidence from biology and cognitive science that Intermittent Explosive Disorder is a real “illness,” for which people can be diagnosed, medicated and put on disability payments! At least, this is what is being announced in newspapers and on television and radio all over our country today. Anyone who reads the morning papers can agree that we have a problem in our society with people who explode violently, with minimal or no apparent reason, and hurt others. It is no surprise, then, to hear that this disorder is “much more common than previously thought,” part of the reported conclusion of the study “Prevalence and Features of Intermittent Explosive Disorder in a Clinical Setting” reported by Emil F. Coccaro, M.D., A. Posternak, M.D., and Mark Zimmerman, M.D., in the Journal of Clinical Psychiatry (2005; 66:1221-1227).
Today’s media is making its usual frenzy about this report, talking about how “Intermittent Explosive Disorder” is now a real disease! Check the DSM-IV, the Diagnostic Manual which guides us clinicians and psychotherapists in putting what we encounter into a code that our fellow clinicians understand in a matter of numbers: Intermittent Explosive Disorder (numbered 312.34 in my manual, published in 1994) has been “a real disease,” officially recognized, for 12 years!
What iis different is that Dr. Coccaro, et al, have painstakingly demonstrated in their research with “1300 individuals presenting for outpatient psychiatric treatment at Rhode Island Hospital in Providence” that a goodly number of people have the problem, and that it has associated chemical and neurobiological behaviors and features. Our media is leaving out a very important part of the conclusion stated by the investigators, i.e., “DSM-IV IED in psychiatric samples is far more common than previously thought. DSM-IV IED develops early in life, especially in male patients, and its development may be independent of most other disorders.” In other words, the conclusions that are being touted by the media as if they are reflective of the entire population were drawn from a group of outpatient psychiatric patients! The investigators are very responsible to report their specific findings. Within hours, the actual conclusion has been “dramatically altered” to make compelling news, subtly shifting results taken from a psychiatric patient population and applying them to the population-at-large.
Dr. Coccaro and his team began their investigation in order to study “aggression.” They created their hypotheses based on research that had begun in the mid-1970’s That research was done with prison (some violent offenders) and psychiatric patients, more select groups. They looked at both suicidology and aggression and violence, connecting low levels of serotonin and “serotonin dumping” to outbursts of violence. These studies, by Brown, Stanley, Newman and others, demonstrated a possible link with serotonin imbalance in the brain and outbursts of temper and rage. This research appears to have been carefully completed, building one study and one outcome after another, upon those studies preceding.
Here’s where we come to the “chicken or the egg” question, however. This question has not yet been answered and will take a number of years to complete, once started. The question is this: Were those people (predominantly males) demonstrating Intermittent Explosive Disorder (IED) born with serotonin level problems, did they develop such imbalanced chemistry. Also, were they genetically predisposed to such problems; or, did they develop the imbalance as a result of their life experiences and the consequent chemical changes? To these questions, we do not yet have the answers.
Because we don’t have firm answers to these questions, we have room to theorize. Let’s look at some important areas. First of all, as reported in my morning paper, the average age of onset for IED is 14 (especially in male patients–see study conclusion). What is happening in life at around the age of 13-14-15? These young people are exploring issues of personal power, asking the world the question “How far can I extend and exert my power?” As any parent of a teenage boy in this range can tell you, there is a lot of “testing” behavior, especially against the parent of the same sex, at this age. “Are you strong enough to handle me, Old Man?” the testing teenage boy demands of his father.
But wait! How many boys in our culture have been growing up without a father in the home? What do studies show about the relative percentage of boys who get into trouble when raised in a mother-led household? In this culture, we have been depriving children of their fathers, every time we relegate fathers to the “reasonable visitation” category, where they are unable to spend much meaningful time or have much influential interaction with their children. So what happens to a teenage boy who begins to “strut his stuff” and “test” his limits, when the people around him do not have, or do not exercise, the power to contain him, drawing and keeping firm limits? Well, in my experience as a psychotherapist, he begins to roar, scream, throw things, have outbursts, and generally get his way by bullying the people around him with what can only be called “raw testosterone.” Voila! Intermittent Explosive Disorder!
Even with fathers in the home, they can be too busy, uninvolved in child care, “parenting by guilt” (giving in and giving gifts to make up for prolonged absence), fearful of being labeled “abusive,” etc. Bluntly put, boys in our society are not being given the “container” their developing power, bodies and testosterone levels need in order to develop in a balanced manner. I am interested in the studies that show what happens to a boy’s brain chemistry when given firm limits and consequences along with love, versus what happens to brain chemistry when this normal exploration of personal power is uncontained and allowed to run amok. Remember, too, that on this earth almost everything has its opposite. For power, its opposite has been identified as sadism. To develop true power, we must explore both these sides. We do not, however, want to stay stuck on the sadistic side, perhaps eventually unbalancing our serotonin and needing medication and long-term therapy for our now “official” IED.
Let’s not leave girls out. Women also need to develop their power, also need someone against whom to test. At least in part because of the way we have been raising our girls, however, this testing has been done in different ways that are less likely to lead to early-onset IED. Girls have been taught to cry, manipulate (because they have no power to get what they want directly!), run away, and a variety of other behaviors, different from those that create IED. They also test with the parent of the same sex, and that parent is around more often in divorce situations, given the numbers of mothers who are granted physical custody. Those mothers may not be strong enough for them, so we still have women developing the “IED problem,” but starting at a later time in life.
There are other factors as well. According to Dr. Jon Grant, associate professor of psychiatry at the University of Minnesota in Minneapolis, “In people with impulsive aggression, there’s more chaos in the front part of the brain.” This suggests a possible genetic link, though we still don’t know the answer to the “chicken and egg” question, because childhood abuse is also common in people with IED, meaning that what we experience in life may significantly de-activate serotonin production. As we write in our “Tao of Anger” course, tests show that there are psychological differences in “angry people,” including faulty perceptions about the intentions of others. Is this due to brain chemistry already out of balance; or is it created by years of holding anger inside, which alters brain chemistry? Because experiments with treating IED with certain drugs aimed at balancing the serotonin levels has shown some benefit, we have hope. But specialists acknowledge that biologically, impulsive anger is still a mystery to us.
There are three requirements (DSM-IV, 312.34, Intermittent Explosive Disorder) listed to qualify for this diagnosis. First, you must have “several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.” Second, “the degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.” (This means the reason cited for the explosion doesn’t merit the size or intensity of the explosion.’ Third, “The aggressive episodes are not better accounted for by another mental disorder….” Another way of looking at this is: You have blowout fits of anger in early adolescence (onward) that nobody can contain or help you to stop. You become increasingly destructive. You begin to do this even when the situation doesn’t merit that much of a reaction. And you’re not, otherwise, crazy. Now you have IED. Let’s see the hands of all males who can tell me they didn’t do some of this during their adolescence! And now, let’s see the female hands, too! As a graduate student at U.C. Berkeley, Dr. Judith Wallerstein was my professor as we studied adolescent behavior. Early in the course, she read us a description of some pretty bizarre behavior, asking us to determine who she was describing. We had many psychiatric diagnoses, all of which were incorrect. “That, Ladies and Gentlemen,” she eventually announced, “is a description of normal adolescent behavior!” ANY behavior is “normal” until is occurs past the time in life when it is no longer appropriate. Please do not take Dr. Coccaro’s study and allow people to remain perpetual adolescents, screaming and throwing things and destroying, with our permission, because we think they are “sick.” The behavioral syndrome is real. The chemicals are real. The need for us to accept that we have a “problem” that can only be controlled through medication and psychotherapy is not real. Primarily, we need to change how we parent our children.
I can raise Dr.Coccaro’s statistics right now. Put my name in the hat as one of the “normal people” who has experienced IED. I suffered from IED for many years, starting in adolescence. After all, I grew up in a verbally, physically and sexually abusive household (my father was present, all but the first three years of my life–due to World War II). I moved 14 times and attended 17 different schools by age 17. I lived in a boarding school for two years, and with my grandparents for another year, all by the age of 6. My father set limits on me, the firm kind that a military officer (which he was) knew how to assert. He, however, was also my primary “perp” for the abuse. I got very, very angry and learned how to scream, be hysterical, throw things, slam doors and be verbally and, at times, physically abusive.
Here, however, is the part I am most excited to share! What I have learned in my life and in my work as a psychotherapist shows me that those patterns and those serotonin levels can be restored! Even with a strong abusive background, years of living with IED, and long-held-onto anger, the problem can be reversed, without medication! I, and hundreds of others with whom I have worked in the past 34 years as a psychotherapist, am living proof. Despite what we encounter early in our lives (I’d say because of it), we as human beings are designed to learn and overcome those early lessons and deficits. They are just part of what we came to the earth to learn about.
What we will have to do, however, is to resume a clear and present parental role, wherein parents provide love, and logical consequences to children as they help guide them to a balanced adult life. (Go to www.loveandlogic.com for some fantastic resources for how to do this, with thanks to Jim Fay and Dr. Foster Kline) We need to stop this insane slide in the direction of believing “fathers aren’t necessary” in families, and make certain that both parents are as fully available in parenting their children as we can devise. And, as a woman who raised a son (now 28) and a daughter (now 35) for 18 1/2 years as a single parent, I can safely tell you that single mothers need to take their job more seriously. If they accept the “single parent” status, and don’t work to bring their children’s father into their lives, they will at the very least have to learn to develop some cajones and set firm limits with their sons and daughters, in particular being powerful enough to contain the testosterone-rich early adolescent power (and sadism) of their sons. No more excuses. If I can learn how to master my rages as an IED parent, how not to slap and hit (as I was slapped and hit), and learn to love with strength and power without undue force, so can any other mother–or father.
I’m working hard to prepare a 12-CD in-depth course called “The Tao of Anger,” which will enable psychotherapists AND the general public to gain mastery over anger, even if it has been with them for decades. Over 250 pages of “Born to Learn” are now written, in which I describe the way our earth is set up as a “giant school” to which we all come in order to learn. Be ready, when these are released, to read and study them and to share them with those you love. Please send your support, your reactions, and start to learn to Master your own emotions, parent children with “Love and Logic,” and not accept IED as “normal” in adults. It’s not, never has been, and won’t become “normal” unless we accept the media’s way of looking at this so-called “new disease”!