Intermittent explosive
disorder (IED) is an impulse-control disorder characterized by a failure to
resist one’s aggressive impulses, which can lead to frequent
“explosions”—incidents of verbal aggression in the form of
temper tantrums, threats, or tirades, or physical attacks on other people and
their possessions, causing bodily injury and property damage.
The degree of
aggressiveness expressed during a typical IED episode is out of proportion to
any provocation or situational stress. An individual
may experience these episodes as "spells" or "attacks" in
which the explosive behavior is preceded by a sense of tension or arousal, and
followed by an immediate sense of relief and, often, sincere and genuine
regret. Later, the individual may feel upset, remorseful, or embarrassed about
their behavior.
Symptoms
Intermittent explosive
disorder is marked by frequent and distinct episodes in which an individual
fails to resist aggressive impulses or reactions grossly out of proportion to
any provocation. In general, these outbursts are brief and impulsive, not
premeditated, and last less than half an hour, but can result in serious acts
of assault or property destruction.
To be diagnosed with
IED, an individual must have displayed verbal or physical aggression toward
property, animals, or other people approximately twice weekly for a period of
at least three months. This aggression does not necessarily have to result in
damage to property or injury in animals or other people. A person can also be
diagnosed with IED if they have fewer but more destructive episodes; specifically,
three such episodes within a 12-month period that result in damage to property,
or physical assaults that lead to injury.
For an IED diagnosis to
be made, the aggressive episodes may not be better accounted for by another
disorder such as antisocial personality disorder, borderline
personality disorder, a psychotic disorder, a manic
episode, conduct disorder, or attention-deficit/hyperactivity disorder. They
also may not be due to the direct physiological effects of a substance, such as
a medication or a drug of abuse, or
a general medical condition, such as head trauma or Alzheimer's
disease.
Intermittent explosive
disorder tends to be persistent with episodes occurring for many years.
Therefore, the disorder can have serious consequences for an individual’s
everyday life, leading to job loss, school suspension, divorce and irreparable damage to other close
relationships, accidents (such as car accidents), hospitalization due to
injuries, financial problems, or incarceration or other serious legal problems.
People with IED may sometimes be prone to self-harm or suicidal ideation.
How common is intermittent explosive
disorder?
Previous estimates had
suggested that IED could be found in approximately 2.7 percent of the general
population, but many experts believe it may be much more common and that it may
be an underrecognized cause of much violent behavior. One study from the
National Institute of Mental Health (NIMH) suggested that, broadly defined, IED
may actually affect as many as 7.3 percent of adults, or as many as 16 million
Americans. Those with persistent and more destructive recurring episodes of IED
may have, on average, 43 such attacks over the course of a lifetime.
Causes
Intermittent
explosive disorder appears to emerge from a combination of biological and
environmental factors. There may be a genetic component through which
susceptibility to the disorder is passed from parents to children. There is
also some evidence that the neurotransmitter serotonin may play a role in the
development of IED. But many people with the disorder also grew up in families in
which explosive behavior and verbal and physical abuse were common. Being
exposed to such violence as a child, research finds, makes one more likely to
develop the same traits as they mature; in other words, at least in part, the
behavior may be learned.
How does intermittent explosive disorder
appear in the brain?
People with
intermittent explosive disorder may have differences in brain structure and
function that distinguish them from others. Some research suggests that IED is
linked to disruptions in serotonin pathways in the brain; other studies have
found that it is associated with lower white matter integrity and lower grey
matter volume in the connections between the frontal lobe and other brain
regions. This deficit may contribute to impaired social cognition and greater difficulty regulating
emotions.
Treatment
Treatment
of IED, while challenging, can also be highly effective, particularly if it's
started as early as possible, and eventually help individuals limit and control
their aggressive impulses. School-based violence prevention programs, for
example, may lead to early identification of IED cases, leading to treatment
that could prevent associated psychopathology.
Treatment
typically involves a combination of medication and psychotherapy; studies show that a
combination of both approaches offers the best prognosis. Cognitive behavioral therapy can help
individuals recognize their impulses and develop coping mechanisms such as
relaxation techniques for keeping rage at bay during an episode. Group
counseling and anger
management programs can also be helpful.
Studies
suggest that patients with intermittent explosive disorder can benefit from
treatment with antidepressants, anti-anxiety
agents in the benzodiazepine family, anticonvulsants, and mood stabilizers.
Since IED can be comorbid with conditions such as anxiety or depression,
clinicians need to factor that into their treatment plan, especially if
medication is used.
