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 for at least 3 months. 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.

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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: 2.7%
  • Mostly men

Pathophysiology

  • Neurobiological studies of aggression suggest the following causalities:
    • Disruption in serotonergic system in the brain resulting in abnormal muscular activity
    • Elevated levels of testosterone
    • Anatomical changes in prefrontal cortex and amygdala
  • Genetic factors: 
    • A genetic component has been confirmed (44%–72%).
    • More common in 1st-degree relatives of patients with IED
    • Studies show that genetic factors account for 50% of variance in aggression.
  • 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
  • Road rage
  • Getting involved in frequent fights
  • Increased energy during an aggressive outburst
  • Acts of self-harm and suicide attempts

Physical symptoms

  • Before an episode: tension or pressure build-up in the head or chest
  • Headaches
  • Muscle tension
  • Tingling sensation and tremors
  • Hearing an echo
  • Palpitations
  • After the episode ends: fatigue

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 for frustration
  • Mood changes or swings before an outburst
  • Extreme or intense anger
  • Brief period of emotional detachment
  • Blinding 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 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 or physical aggression without damage 2 times per week over 3 months
  • Verbal aggression or physical aggression with damage (minimum of 3 outbursts) over 12 months
  • Outburst directed at individuals, animals, 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:

  • Difficult for providers who may face problems with countertransference
  • CBT is recommended.
  • Goal is to have patients recognize and verbalize feelings prior to violent outbursts. 
  • Family therapy recommended for children/adolescents, and group therapy for older patients

Medication:

  • Antidepressants: 
    • 1st line: selective serotonin reuptake inhibitors (e.g., fluoxetine)
  • Mood stabilizers/anticonvulsants: 
    • 2nd-line treatment 
    • Anticonvulsant medications (e.g., valproate, phenytoin, carbamazepine)

Differential Diagnosis

  • Disruptive mood dysregulation disorder (DMDD): 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 is the presence of a normal mood period in IED, unlike the persistent irritability seen in DMDD. 
  • Conduct disorder: a behavioral disorder diagnosed in children. Patients 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 with conduct disorder do not commonly express regret after their offenses, unlike patients with IED.
  • Psychotic disorders: a group of serious mental health disorders characterized by the presence of psychotic symptoms such as delusions or hallucinations. Patients with psychotic disorders may appear to have violent behaviors similar to those with IED; however, patients with psychotic disorders have impairments in reality testing that become clinically apparent during mental status examination. 
Table: Features of intermittent explosive disorder compared with other important psychotic disorders
DisorderMain differentiating criteriaAge of onsetDuration
Intermittent explosive disorderRecurrent, severe, angry outbursts with normal mood between outburstsMay 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 disorderPatient 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
  • Angry or irritable mood, argumentative behavior, vindictiveness directed at adults or other authority figures
  • Does not involve aggressive behavior toward people/animals, destruction of property, or theft
Childhood or adolescence> 6 months
Attention deficit hyperactivity disorderLimited attention and/or hyperactivity symptoms in 2 different settings< age 12> 6 months
Conduct disorderInvolves aggressive behavior toward people/animals, destruction of property, or theftChildhood 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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