This survey of physicians found: - Around 5% of patients were estimated to have Intermittent Explosive Disorder (IED) - IED was most common in younger patients aged 16-45 - Physicians want legal immunity if reporting IED patients, but are wary of legal hassles - The majority want more patient/public education on IED from their Medical Association

1. Physician Survey on Intermittent
Explosive Disorder
Executive Overview
Prepared for the Medical Association of South Texas
(MAST) by Fred Arnstein, Ph.D. and Rebecca Lucy
This Report has been abridged and fictionalized
September 15, 2007

2. Introduction
Purpose of the Survey
This study was undertaken to explore how physicians currently deal with patients
they suspect of having Intermittent Explosive Disorder (IED) and how they would
like to deal with such patients in the future. In particular, the survey attempted to
learn what the role of legislation and regulation should be in the opinion of the
physician members.
Highlights of the Findings
• Intermittent Explosive Disorder, according to the respondents, occurs in
around 5% of the population – this percent would represent a large number of
individuals.
• The incidence of IED is most pronounced among younger people, between the
ages of 16 and 45. IED is most commonly reported by psychiatrists (46%),
followed by internal medicine (17%).
• South Texas physicians most often attribute IED to genetic predisposition
(cited by 70% of physicians) and abuse (cited by 67%), followed by
Substance/alcohol abuse (50%), Medication side effects (43%), and Seizure
disorders (41%).
• Patients are hesitant to communicate with physicians about rageful episodes.
Three quarters (73.3%) of physicians say their patients never or rarely
communicate about it. Instead, physicians most often learn about IED from
family members and from observation of personality in the office.
• Patients do not respond positively when anger management or other
treatments are suggested. 67% of patients were called resistant to the advice.
Relatively few physicians have encountered legal difficulties (1% of the
sample) but there were a number of comments about the legal and other
potential troubles involved in reporting (11% of all spontaneous comments).
• Physicians have a wide diversity of opinion about what should be expected of
them, legally and otherwise, on this issue. At one extreme, 26% are in favor
of aggressive mandatory action on many fronts. At the other extreme, 14%
are opposed to all the forms of involvement that were proposed. Between
these extremes, physicians believe that various combinations of actions should
be taken, but seem to be wary of the legal or other hassles associated with
their involvement. The large majority (78.4%) would like to see physicians
allowed to report IED, but with legal immunity.
• The majority (71.7%) of physicians would like the Medical Association to
explore the possibility of offering more patient and public education on the
issue. Over half of physicians would also like physician education explored.
And over half would like to explore how testing and enforcement might be
delegated to State agencies.

3. Methods
A committee of physicians and MAST staff developed the questionnaire for this
survey. A copy of the questionnaire appears in Appendix F.
The total sample consisted of 7358 questionnaires, which were mailed to
members’ preferred mailing addresses along with a cover letter and a postage-
paid return envelope. A total of 719 completed questionnaires (returned
sample) were returned in time for processing, for a response rate of 10%. The
results reported in this document can be considered accurate within plus-or-minus
four percentage points of opinions in the entire population of 7358 physicians.
Comparing the medical specialties of the respondents against the total sample
showed that, in terms of specialty, the sample was representative of the
population, with only 3% or less discrepancy between any returned specialty and
the population.
Other Characteristics of the Sample
Q18. Gender Predominantly male (72%), with 28% female. Three
percent did not report gender.
Q20. Primary The specialty most represented was Internal
specialty Medicine (28% of all reported specialties). 7% did not
indicate a specialty.
Q21. Type of practice 35%marked themselves as belonging to Independent
groups, followed by Solo practitioners (28%) and
Academic/teaching personnel (21%). 5% did not
respond.
Part 1—The Nature and Incidence of Impairment
This section explores the questions: What is the incidence of IED in the population
seen by physicians? And what is the nature of this Impairment?
Incidence of Intermittent Explosive Disorder
Most respondents (75% of them) judged that 5% or fewer of their patients have
IED.
Women physicians report more IED: 9.5% reported by women versus 6.8%
reported by men (sig=.015). Possible reasons for the difference: (a) people may
find it easier to communicate with women physicians, and/or (b) women
physicians may be more concerned about this issue and so look for it more often.
In addition, certain specialties differ greatly in the incidence of IED that they
report. Psychiatry is particularly high, reporting 47% of its patients with the
disorder.

4. Age of IED Patients
The survey data shows a U-shaped relationship of age with the reported incidence
of IED. Younger people are most at risk, decreasing in the middle years, and
trending upward in the oder years.
Q7b: Of patients who have IED, approximately what percent
are in each of the following age groups?
Age Group (in years) Percent of IED
(average)
16-25 43%
26-45 34%
46-60 20%
61-70 10%
71-80 18%
81+ years 24%
Part 2—How Physicians Currently Deal with Impairment
This section explores the question: How do physicians currently deal with IED
patients? The answers to this question include not only technical issues (such as
what tests are used to assess the disorder) but also the relationships and
communications between physicians and patients, particularly around driving.
How Often Patients Communicate Concern
Patients typically do not communicate concern about their own IED to their
physicians. Asked how often patients communicate, 53% said Rarely and another
20% said Never. This leaves about one quarter of physicians who said that their
patients do report such concerns Sometimes (21%) or Regularly (3%).
Driver Impairment: A marker for IED
When physicians do learn that their patients may have IED, it is most often from
family members (marked by 65% of physicians) rather than from the patients
themselves. The second most common tip-off is from the behavior of the patient
while seeing the physician (40%).
In third position is the self-reports of patients themselves (16%). This finding
reinforces the finding that only 24% of physicians said their patients communicate
concerns about this issue sometimes or regularly.
What Tools Physicians Use to Assess IED
Of those physicians who reported using specific tools to assess driver impairment,
the tool mentioned most frequently was The Mini Mental State Exam (MMSE), used
by 25% of the physicians. This were followed by the Minnisota Multiphasic
Personality Inventory (MMPI) used by 15%.

5. Advising Patients to Seek Help
Question 9b asked, “How typically, when you encounter a patient who appears to
have IED, do you advise the patient to seek help?” Seven percent of the
respondents said ‘Never’ and another 31% said ‘Rarely’ – a total of 39% for these
categories. The largest group (41%) said ‘Sometimes’ while a relatively small
group (16%) said ‘Regularly.’
It is interesting that the mean score on this question (2.68) is considerably higher
than the mean for Q9a (2.07), which asked how often patients communicate their
concern. In other words, patients “Rarely” communicate their concerns, but
Physicians approach the “Sometimes” level of giving advice. This suggests that
physicians tend to be rather concerned about the issue and, one would assume,
wish that their patients would communicate more about it.
When asked (Q9d) “Approximately how patients many did you report to the
Registry of Motor Vehicles in the past five years for IED?” only 24 respondents out
of the entire sample (3%) respond to the question in a way that makes it clear
that they actually did report anyone.
How Patients Respond When Advised To Get Help
A majority (56%) of all patients were resistant to physician advice to take anger
management classes or use other methods to reduce their proneness to IED.
Twenty-seven percent were described as compliant or receptive.
Legal Complications From Reporting IED-related Driver Impairment
Only a very small proportion of respondents report ever having had legal
complications from
• Reporting IED (4 physicians) or
• Not reporting IED (3 physicians)
Still, the fact that any legal complications have arisen over these matters (a total
of 7 instances reported) means that there is potential for trouble as more attention
is paid to the condition.
Among the 65 spontaneous comments made by respondents in the survey, 11%
(7 comments) concerned liability or other problems in dealing with impairment.
These comments convey the sense of difficulty, and perhaps frustration, that
sometimes occur. Here are some of these comments.
“I have never reported an IED case to the Registry of Vehicles for fear of
violation of confidentiality.”
“I believe that it is illegal in this state to report a patien.t”
“Patients response is ‘angry’ when I advise them not to seek help.”
“I’m not stupid. It’s a legal minefield and you will lose the patient if you push.”

6. Part 3—How Physicians Can and Should Deal with IED Patients
This section explores the question: How can and should physicians be involved
with IED issues in their patients, particularly with regard to driving vehicles and
‘road rage.’ Attitudes of the physician respondents toward potential changes in
their roles are examined.
How Physicians Want to Deal with Driver Impairment as Part of IED
A fundamental question explored in this survey was: How much, and in what
ways, should physicians be involved in dealing with IED among their patients? We
explored this issue through six different questions, presented here in order of
percent who said “Yes.”
Yes No Not sure
Q3. Should physicians be allowed, by law, to 76% 12% 12%
report IED patients
15b. Given immunity, should reporting be 67% 14% 19%
permitted without requiring patient consent
Q1. Should physicians evaluate danger to others in 56% 26% 18%
their patients
Q14. Should evaluation be made a part of 45% 25% 29%
preventative care
Q2. Should physicians certify medical fitness to 44% 35% 21%
drive
15a. Given immunity, should reporting be made 33% 40% 27%
mandatory
There is a good deal of uncertainty in these responses. Particularly when it comes
to preventive care (Q14) and mandatory reporting (Q15a) over one quarter of
physicians were “Not sure.” This suggests that many physicians simply have not
thought through the possible ramifications of these scenarios.
Clustering of Like-Minded Physicians
To explore the issue more closely, we used cluster analysis to group individual
respondents based on their answers to the six questions. A 5-cluster solution
yielded the most clearly defined groupings. Statistically speaking, the clusters are
almost perfectly distinct: using Discriminant Analysis, 97.3% of the cases could be
correctly classified.
The chart below summarizes the Cluster findings. Note that each question could be
answered in three ways: Yes, No, or Not Sure. Most of the clusters had a clear
“Yes” or “No” pattern of responses to most of the questions. We also used cross-
tabulations to see whether the clusters varied significantly in their demographics
or in their answers to other questions from the survey. These cross-tabulations are
detailed in the technical report.

7. Cluster Analysis Results Based on Level-of-Involvement Questions
CLUSTER DESCRIPTION Aggressive Voluntary Certify and Report but Keep Out of
(Roughly from most “Activist” Mandatory Evaluation Be Allowed Don’t It
Action and to Report Evaluate or
to “Least Activist”) Reporting Certify
Abbreviation Mandatory Voluntary Allowed Only Keep Out
Report
n=185 n=161 n=143 n=123 n=102
Q3. Should physicians be allowed, Yes Yes Yes Yes No
by law, to report IED patients (95%) (81%) (79%) (87%) (69%)
15b. Given immunity, should Yes Yes Yes Yes No
reporting be permitted (85%) (80%) (60%) (78%) (74%)
without requiring patient
consent
Q1. Should physicians evaluate Yes Yes Mixed No No
danger to others in their (89%) (86%) (75%) (61%)
patients
Q14. Should evaluation be made a Yes Yes Mixed/ Mixed No
part of preventative care (85%) (66%) No (59%)
Q2. Should physicians certify Yes Mixed Yes No No
medical fitness to drive (82%) (86%) (79%) (82%)
15a. Given immunity, should Yes No Mixed/ Mixed No
reporting be made mandatory (86%) (61%) No (81%)
Summary Description of Each Cluster
Here is a brief discussion of each cluster. They are listed in order of
aggressiveness, and coincidentally the sizes of the clusters fall as we go down the
list.
26%: “Aggressive Mandatory Action” (Mandatory) answered strongly Yes to
every one of the six basic questions. Most striking, they were the only cluster
clearly in favor of mandatory reporting. They want to do everything possible to
deal with impaired IED drivers. One has the impression that their priority is to
reduce the danger that such individuals pose to the public, and they do not mind if
they and their medical colleagues are required by law to do this.
23%: “Voluntary Evaluation and Reporting” (Voluntary) is in favor of an
activist approach for most of the questions, and so is quite similar to Mandatory.
However, Voluntary largely opposes mandatory constraints on reporting (61%
against). In this way only, they are close to the least activist cluster, Keep Out.
20%: “Certify and Be Allowed To Report” (Allowed) favors reporting, on a
voluntary basis, and also favors certification. However, responses to the other
three questions tend more in a negative direction. Allowed seems to be focused on
the physician’s role as informer and certifier, but wants to avoid the problems and
paperwork that come with more mandatory or extensive involvement.
17%: “Report but Don’t Evaluate or Certify” (Only Report) strongly favors
reporting, but does not want to get involved in evaluation or certification to drive.
Only Report is perhaps even more hassle-avoidant than its neighbor, Allowed.

8. 14%: “Keep Out of It” (Keep Out) is at the opposite extreme from Mandatory.
In Keep Out are physicians who predominantly say No (69%) to the idea of even
being allowed to report patients. And most of them answer No to all the other
questions as well. One has the impression here of physicians who feel that the
topic is too difficult or threatening to be worth pursuing and simply want to be left
out of it.
Interpreting and Dealing With the Clusters
The picture that emerges is clear: two extremes and several groups in the middle.
Furthermore, these middle groups differ in some important ways among
themselves (described above).
It is clear from our data that physicians who encounter more IED have a greater
tendency to adopt an activist stance. There may be some implication in this for
what the Medical Association should do. But there is not sufficient
overrepresentation of one demographic group over another in each cluster to
justify the Association using, say, different educational content or strategy for
particular demographic segments.
Instead, the clusters serve to highlight the diversity of opinion within the physician
community about what their role should be, running the gamut from passionate
activism to fierce isolationism. It is very likely that at present there is a good deal
of ignorance about present legislation and about the implications of future
legislation. An appropriate strategy, then, would include a heavy emphasis on
education and consensus building, hopefully before further legislation is seriously
considered, let alone passed.
Part 4—Role of the Association Regarding IED
What actions do physicians believe the Medical Association of South Texas (MAST)
should take with regard to IED?
Approaches Desired from MAST
Q16 asks: “Which of the following approaches do you think the MAST should
explore, regarding IED drivers in South Texas? (please check all that apply).
Percent of cases
(physicians)
Patient/Public education 71.7%
Physician education 56.8%
Delegate standardized testing, enforcement, 54.5%
compliance, monitoring, reevaluation, etc., to
the state Registry of Motor Vehicles (RMV)
Legislative action (other) 1.4%

9. Legislative Initiatives that MAST Should Explore
Q17 asked: “Please indicate below any policy/legislative initiatives, relative to IED
patients, that you think the MAST should explore on behalf of physicians and
patients in South Texas (please check all that apply):
Percent of cases
(physicians)
Policy or legislation to allow physicians to 78.4%
report , with immunity from legal action for
such reporting or failure to report.
Policy or legislation to require physicians to 21.8%
report IED, with immunity from legal action
for such reporting or failure to report.
Evaluation (other) 2.2%
Legislation (other) 2.1%
Education (other) 1.1%
The most popular initiative was to allow physicians to report, but with immunity
(78.4%). Considerably less popular was the initiative to require physicians to
report, albeit with immunity (21.8%). This last result is quite close to the 25.6%
of respondents who fell into the cluster labeled Aggressive Mandatory Action.