Intermittent Explosive Disorder

Key Takeaways:

• Intermittent explosive disorder is an impulse control disorder that causes intense bouts of unpredictable aggression.

• Outbursts may involve violence directed toward people, animals, or objects, or threats toward people.

Understanding intermittent explosive disorder

Intermittent explosive disorder (IED) is a mental health condition that causes quick outbursts of unpredictable and intense aggression. These behaviors and the emotions that accompany them may have no source or stem from a minor problem. IED is classified as an impulse control disorder. Individuals of any age may be diagnosed with this condition. Intermittent explosive disorder can be difficult for individuals to live with, as impulsive aggression can impact someone’s relationships as well as their ability to work, attend school, and fulfill other responsibilities. Individuals with IED should seek treatment for their safety and that of their loved ones.

How common is it?

The prevalence of IED has risen due to the most recent revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5-TR). Across the globe, this condition affects between 4% and 6% of people.^[3] Of all those with IED, 73% of cases have a history of violence only directed toward other people.^[1] IED occurs more in males than in females.

Symptoms of intermittent explosive disorder

Individuals with IED experience the following symptoms:^[4][2]

• An inability to manage spontaneous bursts of anger.

• Frequent violent outbursts directed toward animals, property, or people.

• Physiological symptoms such as shortness of breath, increased heart rate, and excessive sweating.

There are several subtypes of IED based on where someone’s attacks are directed:^[1]

1. Injury to people only.

2. Damage to property only.

3. Damage to property and injury to people.

4. Damage to property and verbal or physical threats to people.

5. Verbal or physical threats to people only.

IED outbursts often lack an apparent cause, but they may be triggered by very minor problems. Incidents typically last 30 minutes or less. Outbursts may look different depending on where they take place. For example, if someone with IED has an outburst while they are in the car, they may engage in road rage. If someone is in a public place, such as a bar, they may break bottles and physically fight with people.

There also tends to be variation in the frequency and intensity of angry outbursts associated with IED. Some individuals experience lower intensity outbursts more often, some as frequently as several episodes per week. Others may experience much stronger outbursts as infrequently as two or three times each year.^[5]

Early Warning Signs

Someone can exhibit signs of intermittent explosive disorder as young as 6 years old.^[2] But symptoms more commonly arise between the ages of 13 and 15. It can be difficult for parents of young children and adolescents to tell the difference between age-appropriate temper tantrums and signs of intermittent explosive disorder. There are certain emotions and bodily signs someone may exhibit during an outburst that point toward IED. These include:^[2][3][4]

Intense emotions and changes in vital signs just before an outburst:

• Bodily tingling or shaking.

• Increased heart rate.

• Chest tension or shortness of breath.

• Racing thoughts.

• Feelings of rage or irritability.

• A sharp increase in nervous energy, which may look like jitteriness or pacing.

Outbursts involving:

• Slapping.

• Pushing.

• Angry, long, and often unprovoked rants.

• Intense arguments with other people that involve yelling or shouting.

• Shoving.

• Injury to animals or people.

• Property destruction.

Emotional and bodily signs after an outburst:

• Sudden fatigue.

• Remorse.

• Shame.

• Relief.

Is it preventable?

While IED itself is not preventable, treatment can help individuals prevent more frequent outbursts and related complications.

What causes it?

It is difficult to pinpoint the exact cause of intermittent explosive disorder. Experts do know that the amygdala and orbitofrontal cortex both play a large part in controlling impulses and regulating emotions. Therefore, it is suspected that dysfunction or underdevelopment in these parts of the brain may lead to IED.^[2]

Research also suggests that depression, personality disorders, anxiety disorders, and substance use disorders are more common in people who have IED.^[4][6] This evidence suggests a connection between addictive behaviors, low levels of neurotransmitters such as dopamine and serotonin, and difficulties with impulse control. Children diagnosed with this condition are more likely to experience suicidal thoughts or attempt suicide.^[4] Suicidal behaviors are more common among individuals who have IED along with other mental health concerns. Suicidality is also more common in people whose IED causes more violent assaults compared to those who direct their anger toward property.^[1]

Who is at risk?

Individuals who have experienced trauma related to physical or sexual violence are at a higher risk of IED than those without a trauma history. Since individuals with a low socioeconomic status are more likely to experience trauma, poverty is another risk factor for IED.^[2] In terms of demographic factors, unemployed young males who have a low education level and are separated or divorced are at the highest lifetime risk of this condition.^[1]

Diagnosing intermittent explosive disorder

Mental health professionals begin the diagnostic process for intermittent explosive disorder by checking for any other mental health concerns that may explain someone’s outbursts. They may have to perform interviews and tests to determine whether or not someone misuses drugs or alcohol, has recently sustained a traumatic brain injury or other physical injury, or has other mental health conditions (such as bipolar disorder with active mania or depression). Each of these can be a potential root cause of violent or angry outbursts.

The next step is to determine if someone’s outbursts meet the following criteria:

1. The person cannot control their anger.

2. They frequently engage in fights or experience tantrums.

3. They respond with violence and/or destructive rage that is not appropriate for a given situation.

These criteria typically warrant a diagnosis of intermittent explosive disorder. ^[4]

What tests and assessments are there?

Mental health professionals may use several tests to identify impulsive or aggressive traits that may point toward IED. These may include the Life History of Aggression (LHA), Buss-Perry Aggression Questionnaire (BPAQ), Barratt Impulsiveness Scale (BIS-11), and Life History of Impulsive Behavior (LHIB).^[7] Some professionals may also use the Childhood Trauma Questionnaire, which can potentially identify individuals at risk of IED as well as other mental health concerns associated with trauma.^[5]

The IED Screening Questionnaire (IED-SQ) is a validated screening tool that combines items related to the life history of aggression with DSM-5 diagnostic criteria.^[2]

The IED-SQ demonstrated:

• Strong concordance with best estimate diagnoses (Kappa = 0.80).

• Good test-retest reliability (Kappa = 0.71).

• Ability to identify 4.3% of community samples as meeting DSM-5 criteria for lifetime IED, consistent with epidemiological prevalence rates.

Treatment options

Treatment is essential to help individuals with IED maintain their quality of life. There are no medications designed specifically for the treatment of IED. However, pharmaceuticals can still help with symptom management and are especially beneficial when paired with psychotherapy. Multiple studies have shown that a type of antidepressant called selective serotonin reuptake inhibitors (SSRIs) work well when combined with Cognitive Behavioral Therapy (CBT).^[5][8]

When provided to individuals with IED, CBT lowered physical aggression and led to full symptom remission, while SSRIs decreased irritability.^[8] When combined, these two modalities are considered even more effective. Individuals should be aware that less intense outbursts occurring several times each month are considered easier to treat, specifically with the combination of medication and CBT.^[5]

Cognitive Behavioral Therapy is helpful for this condition as it teaches someone to recognize signs of anger and respond to them more healthily. If someone is diagnosed with IED as a child, they may go through CBT as part of family therapy. This helps their loved ones understand their condition and allows the family unit to work together toward recovery.

Deep brain stimulation is another treatment method that has proven effective for those with IED. This modality has fewer side effects when compared to medication, so it may be desirable for individuals who take other psychiatric medications in an effort to avoid negative drug interactions. Follow-up time is considered especially important for the effectiveness of IED treatment, so individuals should be sure to maintain regular contact with a mental health professional during the treatment process.

Living with intermittent explosive disorder

Due to the challenges associated with intermittent explosive disorder, individuals should follow recommendations from their mental health professional. This will help them avoid complications such as difficulty at work, poor academic performance, relationship problems, and legal concerns.

Psychotherapy is a large part of managing this condition, especially in the early stages. Individuals should also be prepared to use the skills they build in therapy to avoid triggers, develop coping skills, and rely on social support. Family therapy can be helpful for individuals of any age with IED. This will help parents learn about the condition and enable their children to better avoid triggers. Family therapy also allows someone’s significant other, relatives, and other loved ones to support them in managing the condition.

Living with someone who has intermittent explosive disorder

Education about this condition will be helpful for loved ones of those with IED. Family therapy and couples therapy can also strengthen relationships by allowing for improved communication and a greater understanding of one another. Loved ones of those who have IED may also find solace in support groups. These forums can help individuals find a sense of community with others who have similar experiences.