Temper, temper
>> Hotheaded? Coccaro studies the biology behind explosive anger.

Sing, goddess, the anger of Peleus' son Achilleus and its devastation, which put pains thousandfold upon the Achaians…." So begins Richmond Lattimore's translation of Homer's Iliad, a text famously centered around the ire of Achilleus (or Achilles) at being dishonored by his leaders. Achilles's anger is translated by other writers as wrath and even mania. Emil Coccaro, the director of the clinical neuroscience and psychopharmacology research unit in the Department of Psychiatry might more accurately-if less poetically-diagnose the Greek warrior with IED: Intermittent Explosive Disorder.

IED is not simply anger, but aggression, the inability to properly deal with anger and the tendency to be set off by the smallest provocation. "Anger is an emotion," says Coccaro, who has been studying aggression for 18 years, ever since he was an assistant professor of psychiatry at the Mount Sinai School of Medicine. "The normal person gets angry and sits there with it a bit and decides what, if anything, they're going to do about it. They have 'reflective delay,' which means they take time to think about how to respond. Someone with IED will also be angry, but they get angry very fast and respond to provocation immediately. Normal people do not express their anger so overtly."

Bobby Knight, the former Indiana University men's basketball coach who was as famous for throwing chairs and choking players as for his coaching skills, may be a more recent example of the behavior associated with IED. While Coccaro cautions that he has never met or examined Knight, he notes that a person "who exhibits those kinds of behaviors-screaming, shouting, throwing things around, pushing people, breaking things-that get them into trouble is what IED is about. Explosivity is the key to this disorder.

"You probably know people who are calm, cool, and collected, and nothing bothers them-that's the opposite of IED. Then there are people who are very touchy, and you have to walk on eggshells when you're around them." When Coccaro lectures on IED to medical students, he refers to a character in Martin Scorsese's film Goodfellas. Joe Pesci plays Tommy, a quick-witted-and quick-tempered-wiseguy.

"He's got antisocial personality disorder, but not everyone with antisocial personality disorder explodes like that," observes Coccaro. "The DeNiro character in that movie was antisocial, but he didn't generally blow up; he was controlled. Pesci's character, on the other hand, was blowing up all over the place." When Tommy kills another wiseguy who insults him, "He overkills him; he keeps beating him after he's dead. That's something that someone with IED might do. Going above and beyond what's required to express their anger. When other characters in the movie committed violent acts, on the other hand, these were clearly premeditated."

The difference between impulsive aggression and premeditated aggression is important for treating IED, which may affect between 8 million and 16 million people in the U.S. Until the mid-1990s, when Coccaro and his colleagues began focusing on IED as a discrete disorder, that distinction wasn't as clear. While no biological clues have been found as to what causes premeditated aggression, IED has been linked to low levels of serotonin in the brain and is suspected to have a genetic element. Although diagnostic criteria are vague and have undergone significant changes in the past decade, patients seem to respond to drugs such as fluoxetine (Prozac) and the anticonvulsants phenylhydantoin and divalproex.

Achilles didn't have medication to control his temper, and if Pesci's character in Goodfellas was waiting for the goddess Athena to descend and stay his murderous hand, he would have discovered it was not in the script. At Chicago, Coccaro continues his research on IED patients and hopes that increased awareness of IED will encourage people with "bad tempers" to seek treatment. "The thing about being able to have a diagnosis is that you can educate people that it's a disorder rather than just bad behavior," he says. "There's a biology to it and a science behind it, so people can think, 'Maybe I have this chemical imbalance that can be treated,' which is different than thinking, 'This is just me and I can't do anything about it.'" -C.S.