Intermittent explosive disorder (IED) is an impulse-control disorder, characterized mostly by abrupt episodes of unnecessary fury or impatience. The disorder is signified by violence, impulsiveness and persistent aggressive outbreaks. These erratic and explosive outbursts can cause significant distress in the person, have a negative impact on their relationships, work and school, and they can also have legal and financial penalties. There are many symptoms and these are mostly based on individual genetics, presence of co-occurring complaints and habit or addiction to drugs or alcohol.

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Definition of Intermittent Explosive Disorder

Intermittent explosive disorder is defined as recurrent incidents of violent aggressive behavior in an otherwise normal individual, which are out of proportion to the provoking events.

Individuals typically describe the occurrence of episodes as “spells” or “attacks” in which the fiery behavior is controlled by a sense of tension or urging. This is immediately followed by a sense of reprieve. Frequently, a genuine regret or concern is communicated after the outburst. Once the action is over, individuals may feel upset, regretful or ashamed of their behavior.

Epidemiology of Intermittent Explosive Disorder

Intermittent explosive disorder usually begins in late childhood or adolescence. The disorder then mostly proceeds, and may predispose for later hopelessness, apprehension and substance abuse conditions. Conventional assessments suggest that intermittent explosive disorder occurs in 2.7 % of the common population.

The majority of patients suffering from intermittent explosive disorder are young men with a history of frequent traffic accidents, moving abuses and probable sexual impulsiveness. These patients can display perilous sensitivity to alcohol.

Pathophysiology of Intermittent Explosive Disorder

This disorder is commonly characterized by distinct episodes of aggressive impulses, which are mostly out of proportion to the aggravation or any triggering psychosocial stressors. This results in severe assaulting actions towards people or damage of possessions or property.

This disorder is currently placed under “Disruptive, Impulse-Control and Conduct Disorders” categorized in the eminent Diagnostic and Statistical Manual of Mental Disorders (DSM-5).

Generally, the neurobiological studies of aggression suggest that numerous neurotransmitters are involved in this disorder. The common factors include:

  • Serotonergic system: The most reliable findings that suggest disruption in the serotonergic system of the affected person.
  • Testosterone levels: Elevated levels of testosterone have been associated with aggression in adults.
  • Anatomical evidence: These suggest that the prefrontal cortex and amygdala can also be associated with impulsive aggression.

Causes of Intermittent Explosive Disorder

The foremost cause of intermittent explosive disorder is alleged to be an amalgamation of several constituents which mostly include genetic physical factors and environmental factors.

Genetic Factors

This disorder is composed of characteristics that are mostly passed from the parents to their children.

Physical Factors

It has been argued that intermittent explosive disorder might occur as the outcome of certain abnormalities present in the parts of the brain that control awakening and inhibition.

Impulsive aggressions are mostly linked to an abnormal mechanism in certain parts of the brain that regulate the muscular activity via serotonin. Serotonin, whose main work is to send chemical signals throughout the brain, may be composed differently in people with intermittent explosive disorder.

Environmental Factors

The environment in which an individual grows up can also have an impact on the overall development of IED. It has been theorized that people who are raised in homes in which they have been subjected to harsh punishments are more likely to develop IED.

Risk Factors of Intermittent Explosive Disorder

The most common risk factors include:

  • Male sex
  • Exposure to violence at a very early age
  • Exposure to explosive behavior at home (e.g., angry or annoyed outbursts from parents or relatives)
  • Having experienced physical trauma
  • Experiencing emotional trauma
  • History of substance abuse
  • Certain medical circumstances

Signs & Symptoms of Intermittent Explosive Disorder

The explosive or fiery episodes of IED often last less than thirty minutes and may lead to verbal assaults, injuries and deliberate, willful destruction of property. These eruptions mostly occur in clusters or may be parted by weeks or even months of non-aggressive actions. In-between these explosive upsurges, the person suffering from IED may be bad-tempered, impulsive, destructive or fuming.

People suffering from intermittent explosive disorder present with diversified symptoms. These are mostly based on the individual’s genetic temperament, development of social skills, managing strategies or addiction to alcohol or drugs.

The signs and symptoms of IED commonly vary from patient to patient, and are mostly based upon individual personality, severity of IED, presence of co-occurring mental health ailments, and usage of alcohol or drugs.

Following are some of the common examples of different signs and symptoms that a person suffering from IED may reveal:

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
  • Suicide attempts

Physical Symptoms

  • Before an episode, there is a tension or pressure build-up in the head or chest
  • Headaches
  • Muscle tension
  • Fatigue after the episode ends
  • Tingling sensation
  • Tremors
  • Hearing an echo
  • Palpitations

Cognitive Symptoms

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

Psychosocial Symptoms

  • Low tolerance for frustration
  • Mood changes or swings before an outburst
  • Extreme or intense anger
  • Brief period of emotional detachment
  • Irritability during and between outbursts
  • Blinding rage
  • Feeling “out of control” before and throughout an episode
  • Depressed or frantic mood
  • Feeling of guilt following episode
  • Feeling of shame or embarrassment after the episode

Diagnosis of Intermittent Explosive Disorder

Diagnosis starts with taking a comprehensive personal history of the patient and occasionally from the family members and friends. A medical and psychological examination is performed, along with noting down of the educational records. This is done to perform a complete mental status examination and apply these criteria from the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) (a clinical reference guide for mental health professionals).

Diagnostic criteria for IED include:

  • Failure to resist the aggressive impulses that commonly result in serious assault or devastation of property during a number of episodes.
  • Revealing a degree of aggressiveness, which is exceptionally out of proportion to the circumstances.
  • Incapability to attribute these aggressive episodes to another mental disorder, medical disorder or even the direct effects of a substance such as alcohol or a drug.

Treatment of Intermittent Explosive Disorder

Treatment of intermittent explosive disorder mostly includes remission, which is demarcated as the persistence of symptoms or improvement to the extent that just one or two symptoms of slight intensity might persist. For patients who do not achieve remission, the aim is to get reaction, i.e., calming down or soothing the patient and others, along with a significant development in the number, intensity and the frequency of symptoms.

Medication

There are many different types of drugs that may possibly benefit in the treatment of intermittent explosive disorder. These medications might include certain

  • Antidepressants (precisely certain selective serotonin re-uptake inhibitors or SSRIs)
  • Anti-convulsant mood stabilizers like lithium carbonate (Lithonate)
  • Anti-convulsant medications
  • Tranquilizers like Clozapine (Chlozaril) and Haloperidol (Haldol)
  • Beta blockers might also help to control explosive rage
  • Other drugs, if required

Behavioral Modifications

Behavioral modifications or psychotherapy can help the people understand and have a control in their thoughts and behavior. This therapy mostly involves:

  • Focus on underlying feelings or motivations, including both the conscious and unconscious thought process.
  • Uncover underlying feelings and reasons behind an anger or rage.
  • Help the individual in developing a better way to think about and also to control their behavior.

Cognitive behavior therapy: This therapy mostly focuses on the conscious thoughts and patterns overt behavior.

  • This will help the person to recognize the onset of their urge or impulse to explode.
  • To identify the triggers or circumstances associated with the onset.
  • To develop ways to prevent the explosive behavior from occurring.

Prevention of Intermittent Explosive Disorder

For people suffering from IED, prevention is most likely beyond control unless the treatment is performed by a professional. Common things that should be followed are:

  • Stick with the treatment plan
  • Practice relaxation techniques
  • Develop new ways of thinking
  • Use problem-solving
  • Improving or working on communication skills
  • Change the environment
  • Avoiding mood-alternating substances

Effects of Intermittent Explosive Disorder

If left untreated, the consequences of Intermittent Explosive Disorder can be severe. The common effects or consequences of intermittent explosive disorder include:

  • Academic impairment
  • Suspension from school
  • Poor social skills
  • Low self-esteem and self-loathing
  • Dropping from school
  • Injuries
  • Incarceration
  • Alcohol abuse
  • Domestic violence
  • Child abuse
  • Self-harm
  • Suicidal feelings
  • Substance abuse and addiction

Co-occurring Disorders

There are many other disorders which can have similar symptoms like IED. Hence, before the diagnosis of IED, these disorders need to be ruled out:

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