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Single Case Study: Neuropsychological Functioning in a Patient Diagnosed with Intermittent Explosive Disorder Pre and Post Neurosurgery

  • María José Alvarez-Alonso (a1), Isabel Morales-Muñoz (a2), Ana María Castaño-León (a1), Alfonso Lagares (a1), Gabriel Rubio (a1) and Rosa Jurado-Barba (a1)...


Intermittent explosive disorder (IED) is characterized by a difficulty to resist the urge to carry out a recognized harmful behavior. The central symptom is aggressiveness, expressed in isolated episodes. Executive function impairments are habitually found in impulse control disorders. Neuropsychology of impulsivity is related to dysfunctions in the orbito-frontal cortex, dorsolateral cortex and anterior-cingulated regions, being consequently involved in cognitive mechanisms of inhibition. Lesions in those areas are common in IED. In the most severe cases of IED, surgical procedures are required for treatment. In this study, we examined JML; a patient suffering from a severe case of IED. He experienced frequent episodes of auto and heteroaggression and multiple psychiatric admissions, and thus stereotactic surgery was the recommended treatment. The procedure consisted of an electrode situated lateral to the lateral ventricle, targeting the projections between frontal and subcortical affected regions. We aimed to study the neuropsychological functioning of JML, before and after electrode implantation. Our results suggested that surgery in IED improves cognitive performance at some levels. JML significantly improved his cognitive flexibility, measured with WCST, and alternate attention assessed with CPT and TMT-B tests, after electrode implantation. Cognitive flexibility deficits may be also related to increased aggressiveness. Therefore, improvements at this level may involve a reduction of impulsivity and aggressive behavior.


Corresponding author

*Correspondence concerning this article should be addressed to María José Alvarez-Alonso. Hospital 12 de Octubre. Madrid (Spain). E-mail:


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Alcazar-Corcoles, M. A., Verdejo-Garcia, A., Bouso-Saiz, J. C., & Bezos-Saldana, L. (2010). Neuropsychology of impulsive aggression. Revista de Neurología, 50, 291299.
Amara, G., Richa, S., & Bayle, F. J. (2007). Intermittent explosive disorder: Current status. Encephale, 33, 339345.
American Psychiatric Association (1980). Diagnostical and statistical manual of mental disorders, III (DSM-III). Washington, DC: Author.
American Psychiatric Association (2000). Manual diagnóstico y estadístico de los trastornos mentales. [Diagnostic and statistical manual of mental disorders]. (4th Ed. Revised Text). Barcelona, Spain: Masson.
Coccaro, E. F. (2000). Intermittent explosive disorder. Current Psychiatry Reports, 2(1), 6771.
Coccaro, E. F. (2011). Intermittent explosive disorder: Development of integrated research criteria for Diagnostic and Statistical Manual of Mental Disorders, 5th Ed. Comprehensive Psychiatry, 52, 119125.
Coccaro, E. F. (2012). Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. The American Journal of Psychiatry, 169, 577588.
Coccaro, E. F., McCloskey, M. S., Fitzgerald, D. A., & Phan, K. L. (2007). Amygdala and orbitofrontal reactivity to social threat in individuals with impulsive aggression. Biological Psychiatry, 62, 168178.
Conners, C. (2004). Conner's Continous Performance Test II (CPT II V.5). Toronto, Canada: Multy-Health Systems Inc.
Eddy, C. M., Rizzo, R., & Cavanna, A. E. (2009). Neuropsychological aspects of Tourette Syndrome: A review. Journal of Psychosomatic Research. 67, 503513.
Faria, M. A. (2013). Violence, mental illness, and the brain - A brief history of psychosurgery: Part 3 - From deep brain stimulation to amygdalotomy for violent behavior, seizures, and pathological aggression in humans. Surgical Neurology International, 4, 91.
Golden, C. J. (2010). STROOP: Test de Colores y Palabras. [The STROOP Color and World Test] (5th Ed.). Madrid, Spain: TEA Ediciones.
Hassan, N., & Cavanna, A. E. (2012). The prognosis of Tourette Syndrome: Implications for clinical practice. Functional Neurology, 27(1), 2327.
Heaton, R., Chelune, G. J., Talley, J. L., Kay, G. G., & Curtiss, G. (2009). Test de Clasificación de Tarjetas de Wisconsin. [Wisconsin Card Sorting Test WCST]. Madrid, Spain: TEA Ediciones.
Hollander, E., & Rosen, J. (2000). Impulsivity. Journal of Psychopharmacology, 14, 3944.
Kertzman, S., Grinspan, H., Birger, M., & Kotler, M. (2006). Computerized neuropsychological examination of impulsiveness: A selective review. Israel Journal of Psychiatry & Related Sciences, 43, 7480.
Kessler, R. C., Coccaro, E. F., Fava, M., Jaeger, S., Jin, R., & Walters, E. (2006). The prevalence and correlates of DSM-IV intermittent explosive disorder in the national comorbidity survey replication. Archives of General Psychiatry, 63, 669678.
Kim, M. C., & Lee, T. K. (2008). Stereotactic lesioning for mental illness. Acta Neurochirurgica Supplement, 101, 3943.
Maley, J. H., Alvernia, J. E., Valle, E. P., & Richardson, D. (2010). Deep brain stimulation of the orbitofrontal projections for the treatment of intermittent explosive disorder. Neurosurgical Focus, 29, E11.
McCloskey, M. S., Lee, R., Berman, M. E., Noblett, K. L., & Coccaro, E. F. (2008). The relationship between impulsive verbal aggression and intermittent explosive disorder. Aggressive Behavior, 34(1), 5160.
McElroy, S. L. (1999). Recognition and treatment of DSM-IV intermittent explosive disorder. Journal of Clinical Psychiatry, 60, 1216.
Mpakopoulou, M., Gatos, H., Brotis, A., Paterakis, K. N., & Fountas, K. N. (2008). Stereotactic amygdalotomy in the management of severe aggressive behavioral disorders. Neurosurgical Focus, 25(1), E6.
New, A. S., Hazlett, E. A., Newmark, R. E., Zhang, J., Triebwasser, J., Meyerson, D., … Buchsbaum, M. S. (2009). Laboratory induced aggression: A positron emission tomography study of aggressive individuals with borderline personality disorder. Biological Psychiatry, 66, 11071114.
Nuttin, B., Gabriels, L., Cosyns, P., & Gybels, J. (2000). Electrical stimulation of the brain for psychiatric disorders. CNS Spectrums, 5, 3539.
Patel, S. R., Aronson, J. P., Sheth, S. A., & Eskandar, E. N. (2013). Lesion procedures in psychiatric neurosurgery. World Neurosurgery, 80, e9e16
Porta, M., Cavanna, A. E., Zekaj, E., D’Adda, F., & Servello, D. (2013). Selection of patients with Tourette syndrome for deep brain stimulation surgery. Behavioural Neurology, 27(1), 125131.
Potenza, M. N., Koran, L. M., & Pallanti, S. (2009). The relationship between impulse control disorders and obsessive-compulsive disorder: A current understanding and future research directions. Psychiatry Research, 170(1), 2231.
Rey, A. (1994). Test de Copia y de Reproduccion de Memoria de Figuras Geométricas Complejas. [Rey–Osterrieth Complex Figure]. (6th Ed.). Madrid, Spain: TEA Ediciones.
Rosell, D. R., & Siever, L. J. (2015). The neurobiology of aggression and violence. CNS Spectrums, 20, 254279.
Siever, L. J. (2008). Neurobiology of aggression and violence. The American Journal of Psychiatry, 165, 429442.
Spreen, O., & Strauss, E. (Eds.). (1998). A compendium of neuropsychological tests: Administration, norms and commentary. New York, NY: Oxford University Press.
van de Giessen, E., Rosell, D. R., Thompson, J. L., Xu, X., Girgis, R. R., Ehrlich, Y., … Siever, L. J. (2014). Serotonin transporter availability in impulsive aggressive personality disordered patients: A PET study with [11C]DASB. Journal of Psychiatry Research, 58, 147154.
Wechsler, D. (2012). WAIS-IV Escala de Inteligencia de Wechsler para adultos – IV (4th Ed.) [Wechsler Adult Intelligence Scale WAIS-IV]. Madrid, Spain: NCS Pearson, Inc.
Wilson, B., Alderman, N., Burgess, P. W., Emslie, H., & Evans, J. J. (1996). Behavioral Assessment of Dysexecutive Syndrome (BADS). London, UK: Pearson.
Wright, A., Rickards, H., & Cavanna, A. E. (2012). Impulse-control disorders in Gilles de la Tourette Syndrome. The Journal of Neuropsychiatry & Clinical Neurosciences , 24(1), 1627.



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