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Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. The episodes must have been present 2 times weekly for at least 3 months without physical injury or damage to property (or at least 3 episodes over 12 months with injury and/or damage). These erratic and explosive outbursts can cause significant distress in the person and have a negative impact on their life. The disorder is usually diagnosed in young men. Treatment includes medications and behavioral modifications.

Last updated: 2 Nov, 2021

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

Overview

Definition

Intermittent explosive disorder (IED) is an impulse control disorder characterized by recurrent episodes of violent aggressive outbursts, either verbal or physical, out of proportion to the provoking events and immediately followed by a sense of regret.

Epidemiology

  • Prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: 2.7%
  • Mostly men

Pathophysiology

  • Neurobiological studies of aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder suggest the following causalities:
    • Disruption in serotonergic system in the brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification resulting in abnormal muscular activity
    • Elevated levels of testosterone Testosterone A potent androgenic steroid and major product secreted by the leydig cells of the testis. Its production is stimulated by luteinizing hormone from the pituitary gland. In turn, testosterone exerts feedback control of the pituitary LH and FSH secretion. Depending on the tissues, testosterone can be further converted to dihydrotestosterone or estradiol. Androgens and Antiandrogens
    • Anatomical changes in prefrontal cortex and amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy
  • Genetic factors: 
    • A genetic component has been confirmed (44%–72%).
    • More common in 1st-degree relatives of patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with IED
    • Studies show that genetic factors account for 50% of variance in aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder.
  • Environmental factors: Being subjected to harsh punishments during childhood increases the likelihood of developing IED.

Clinical Presentation

Behavioral symptoms

  • Breaking things and causing property damage
  • Verbal and physical aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder
  • Road rage
  • Getting involved in frequent fights
  • Increased energy during an aggressive outburst
  • Acts of self-harm Self-harm Psychiatric Assessment and suicide Suicide Suicide is one of the leading causes of death worldwide. Patients with chronic medical conditions or psychiatric disorders are at increased risk of suicidal ideation, attempt, and/or completion. The patient assessment of suicide risk is very important as it may help to prevent a serious suicide attempt, which may result in death. Suicide attempts

Physical symptoms

  • Before an episode: tension or pressure build-up in the head or chest
  • Headaches
  • Muscle tension
  • Tingling Tingling Posterior Cord Syndrome sensation and tremors
  • Hearing an echo
  • Palpitations Palpitations Ebstein’s Anomaly
  • After the episode ends: fatigue Fatigue The state of weariness following a period of exertion, mental or physical, characterized by a decreased capacity for work and reduced efficiency to respond to stimuli. Fibromyalgia

Cognitive symptoms

  • Racing thoughts
  • Poor concentration or inability to concentrate
  • Poor academic or occupational functioning

Psychosocial symptoms

  • Before and throughout an episode: feeling “out of control” 
  • Low tolerance Tolerance Pharmacokinetics and Pharmacodynamics for frustration
  • Mood changes or swings before an outburst
  • Extreme or intense anger
  • Brief period of emotional detachment
  • Blinding Blinding Epidemiological Studies rage
  • Depressed or frantic mood
  • During and between outbursts: irritability 
  • Following an episode: feelings of guilt, shame, or embarrassment

Diagnosis

Diagnosis is based on meeting specific clinical behavioral criteria in patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship who are > 6 years of age and excluding other mental disorders, medical conditions, or substance use.

Criteria are recurrent behavioral outbursts, manifested as:

  • Verbal aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder or physical aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder without damage 2 times per week over 3 months
  • Verbal aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder or physical aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder with damage (minimum of 3 outbursts) over 12 months
  • Outburst directed at individuals, animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, or property
  • Lasts < 30 minutes
  • Magnitude of aggressiveness is out of proportion to provocation.
  • Patient can’t resist having an outburst.
  • Causes distress in the individual or impairment in occupational or interpersonal functioning
  • Patient behaves normally between outbursts.

Management

Best results are achieved through a combination of medication and psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy.

Psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy:

  • Difficult for providers who may face problems with countertransference Countertransference Conscious or unconscious emotional reaction of the therapist to the patient which may interfere with treatment. Psychotherapy
  • CBT is recommended.
  • Goal is to have patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship recognize and verbalize feelings prior to violent outbursts. 
  • Family therapy Family therapy A form of group psychotherapy. It involves treatment of more than one member of the family simultaneously in the same session. Psychotherapy recommended for children/adolescents, and group therapy Group therapy A form of therapy in which two or more patients participate under the guidance of one or more psychotherapists for the purpose of treating emotional disturbances, social maladjustments, and psychotic states. Psychotherapy for older patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship

Medication:

  • Antidepressants: 
  • Mood stabilizers/anticonvulsants: 
    • 2nd-line treatment 
    • Anticonvulsant Anticonvulsant Anticonvulsant drugs are pharmacological agents used to achieve seizure control and/or prevent seizure episodes. Anticonvulsants encompass various drugs with different mechanisms of action including ion-channel (Na+ and Ca+2) blocking and GABA reuptake inhibition. First-Generation Anticonvulsant Drugs medications (e.g., valproate Valproate A fatty acid with anticonvulsant and anti-manic properties that is used in the treatment of epilepsy and bipolar disorder. The mechanisms of its therapeutic actions are not well understood. It may act by increasing gamma-aminobutyric acid levels in the brain or by altering the properties of voltage-gated sodium channels. First-Generation Anticonvulsant Drugs, phenytoin Phenytoin An anticonvulsant that is used to treat a wide variety of seizures. The mechanism of therapeutic action is not clear, although several cellular actions have been described including effects on ion channels, active transport, and general membrane stabilization. Phenytoin has been proposed for several other therapeutic uses, but its use has been limited by its many adverse effects and interactions with other drugs. First-Generation Anticonvulsant Drugs, carbamazepine Carbamazepine A dibenzazepine that acts as a sodium channel blocker. It is used as an anticonvulsant for the treatment of grand mal and psychomotor or focal seizures. It may also be used in the management of bipolar disorder, and has analgesic properties. First-Generation Anticonvulsant Drugs)

Differential Diagnosis

  • Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder ( DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder): a childhood psychological disorder involving chronic negative mood, irritability, and severe recurrent temperamental outbursts with onset before the age of 10. Affected children are always angry and irritable, even between outbursts. Disproportionate verbal or physical outbursts may be present. What distinguishes IED from DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder is the presence of a normal mood period in IED, unlike the persistent irritability Persistent irritability Disruptive Mood Dysregulation Disorder seen in DMDD DMDD Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder
  • Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder: a behavioral disorder diagnosed in children. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship do not recognize or respect the basic rights of others for a duration of more than 1 year. These violent behaviors are much more severe or damaging to others than those seen in IED. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder do not commonly express regret after their offenses, unlike patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with IED.
  • Psychotic disorders: a group of serious mental health disorders characterized by the presence of psychotic symptoms Psychotic symptoms Brief Psychotic Disorder such as delusions or hallucinations Hallucinations Subjectively experienced sensations in the absence of an appropriate stimulus, but which are regarded by the individual as real. They may be of organic origin or associated with mental disorders. Schizophrenia. Patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with psychotic disorders may appear to have violent behaviors similar to those with IED; however, patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship with psychotic disorders have impairments in reality testing that become clinically apparent during mental status examination Mental Status Examination Psychiatric Assessment
Table: Features of intermittent explosive disorder compared with other important psychiatric disorders
Disorder Main differentiating criteria Age of onset Duration
Intermittent explosive disorder Recurrent, severe, angry outbursts with normal mood between outbursts May be seen in late childhood or adolescence but usually diagnosed in young men (> 18 years)
  • > 3 months without symptoms
  • > 12 months with symptoms
Disruptive mood dysregulation disorder Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability. Disruptive Mood Dysregulation Disorder Patient is mainly angry all the time (most of the day and every day), with frequent outbursts.
  • Onset < age 10
  • Not diagnosed < age 6 or > age 18
> 12 months
Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder Childhood or adolescence > 6 months
Attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder Limited attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment and/or hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder symptoms in 2 different settings < age 12 > 6 months
Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder Involves aggressive behavior toward people/ animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, destruction of property, or theft Childhood or adolescence > 1 year

References

  1. Alpert JE, Spillmann MK. (1997). Psychotherapeutic approaches to aggressive and violent patients. Psychiatr Clin North Am. https://www.sciencedirect.com/science/article/abs/pii/S0193953X05703221
  2. Sadock BJ, Sadock VA, Ruiz P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.), Chapter 19, Disruptive, Impulse-control, and Conduct Disorders, pages 608-615. Philadelphia, PA: Lippincott Williams and Wilkins.

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