Intermittent Explosive Disorder

What is intermittent explosive disorder?

Intermittent explosive disorder (IED) is a mental health condition marked by frequent impulsive anger outbursts or aggression. The episodes are out of proportion to the situation that triggered them and cause significant distress.

People with intermittent explosive disorder have a low tolerance for frustration and adversity. Outside of the anger outbursts, they have normal, appropriate behavior. The episodes could be temper tantrums, verbal arguments or physical fights or aggression.

Intermittent explosive disorder is one of several impulse control disorders.

Approximately 80% of people with IED have another mental health condition, with anxiety disorders, externalizing disorder, intellectual disabilities, autism and bipolar disorder being the most common.

Who does intermittent explosive disorder affect?

Intermittent explosive disorder (IED) can affect children aged 6 years and older and adults. Adults diagnosed with IED are usually younger than 40 years old.

IED more commonly affects people assigned male at birth (AMAB) than people assigned female at birth (AFAB).

How common is intermittent explosive disorder?

Researchers estimate that approximately 1.4% to 7% of people have intermittent explosive disorder.

What are the signs and symptoms of intermittent explosive disorder?

The main sign of intermittent explosive disorder is a pattern of outbursts of anger that are out of proportion to the situation or event that caused them. People with IED are aware that their anger outbursts are inappropriate but feel like they can’t control their actions during the episodes.

The aggressive outbursts:

• Are impulsive (not planned).
• Happen rapidly after being provoked.
• Last no longer than 30 minutes.
• Cause significant distress.
• Cause problems at school, work and/or home.

Examples of how the anger manifests include:

• Temper tantrums.
• Verbal arguments, which may include shouting and/or threatening others.
• Physically assaulting people or animals, such as shoving, slapping, punching or using a weapon to cause harm.
• Property/object damage, such as throwing, kicking or breaking objects and slamming doors.
• Domestic violence.
• Road rage.

The anger episodes can be mild or severe. They may involve hurting someone badly enough to require medical attention or even cause death.

If you have IED, right before an anger outburst, you may experience:

• Rage.
• Irritability.
• An increasing sense of tension.
• Racing thoughts.
• Poor communication.
• Increased energy.
• Tremors.
• Heart palpitations.
• Chest tightness.

After an outburst, you may feel a sense of relief, followed by regret and embarrassment.

What causes intermittent explosive disorder?

Researchers are still trying to discover the exact cause of intermittent explosive disorder, but they think genetic, biological and environmental factors contribute to its development:

• Genetic factors: IED more commonly runs in biological families. Studies suggest that 44% to 72% of the likelihood of developing impulsive aggressive behavior is genetic.
• Biological factors: Studies show that brain structure and function are altered in IED. For example, brain magnetic resonance imaging (MRI) studies suggest that it affects the amygdala, which is the part of your brain involved in emotional functioning. In addition, studies show that the level of serotonin (a neurotransmitter and hormone) is lower than normal in people with IED.
• Environmental factors: Experiencing verbal and physical abuse in childhood and/or witnessing abuse during childhood appears to play a role in the development of IED. Having experienced one or more traumatic events in childhood also seems to play a role.

How is intermittent explosive disorder diagnosed?

If you think you or your child may have intermittent explosive disorder, it’s important to talk to your healthcare provider. They’ll likely refer you to a mental health professional who’s experienced in diagnosing IED.

A licensed mental health professional — such as a psychiatrist, psychologist or clinical social worker — can diagnose IED based on the diagnostic criteria for it in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders.

They do so by performing a thorough interview and having conversations about symptoms. They ask questions that’ll shed light on:

• Personal medical history and biological family medical history, especially histories of mental health conditions.
• Relationship history.
• School or work history.
• Impulse control.

Your mental health professional may also work with your family and friends to collect more insight into your behaviors and history.

To receive an intermittent explosive disorder diagnosis, you must display a failure to control aggressive impulses as defined by either of the following:

• High frequency/low intensity episodes: Verbal aggression (temper tantrums, verbal arguments or fights) or physical aggression toward property, animals or people, occurring twice weekly, on average, for three months. The aggression doesn’t result in physical harm to people or animals or the destruction of property.
• Low frequency/high intensity episodes: Three episodes involving damage or destruction of property and/or physical assault involving physical injury against animals or other people occurring within a 12-month period.

The degree of aggression displayed during the outbursts must be greatly out of proportion to the situation. In addition, the outbursts aren’t pre-planned. They’re impulse- and/or anger-based. Your mental health professional will also make sure that the outbursts aren’t better explained by another mental health condition, medical condition or substance use disorder.

People must be at least 6 years old to get an IED diagnosis, but it’s usually first observed in late childhood or adolescence.

How is intermittent explosive disorder treated?

Treatment for intermittent explosive disorder typically involves psychotherapy (talk therapy) focused on changing thoughts related to anger and aggression. Treatment may also include medication, depending on your age and symptoms.

The goal of treatment for IED is remission, which means that your symptoms (anger outbursts) go away or you experience improvement to the point that only one or two symptoms of mild intensity persist. For people who don’t achieve remission, a reasonable goal is stabilizing the safety of the person and others, as well as a substantial improvement in the number, intensity and frequency of anger outbursts.

Psychotherapy for IED

Psychotherapy (talk therapy) is usually the main treatment for intermittent explosive disorder, especially cognitive behavioral therapy (CBT).

CBT is a structured, goal-oriented type of therapy. A therapist or psychologist helps you take a close look at your thoughts and emotions. You’ll come to understand how your thoughts affect your actions. Through CBT, you can unlearn negative thoughts and behaviors and learn to adopt healthier thinking patterns and habits.

CBT teaches people with IED how to manage negative situations in day-to-day life and may thus prevent aggressive impulses that can trigger explosive outbursts.

Specific techniques mental health professionals use in CBT for intermittent explosive disorder include:

• Cognitive restructuring: This involves changing faulty assumptions and unhelpful thoughts about frustrating situations and perceived threats.
• Relaxation training: Relaxing techniques like deep breathing and progressive muscle relaxation (tensing and relaxing different muscle groups while imagining situations that provoke anger) can help minimize your response to triggering situations.
• Coping skills training: This involves role-playing situations that may cause an explosive episode and practicing healthy responses like walking away.
• Relapse prevention: This involves educating people with IED that recurrence of impulsive aggressive behavior is common and should be viewed as a lapse or “slip” rather than a failure.

Medications for IED

Certain medications may increase the threshold (level) at which a situation triggers an angry outburst for people with intermittent explosive disorder.

Fluoxetine (a selective serotonin reuptake inhibitor, or SSRI) is the most studied medication for treating intermittent explosive disorder. Other medications that have been studied for IED include phenytoin, lithium, oxcarbazepine and carbamazepine.

In general, healthcare providers typically prescribe the following classes of medications for IED:

• Antidepressants.
• Antipsychotics.
• Anticonvulsants.
• Antianxiety medications.
• Mood regulators.

What are the risk factors for developing intermittent explosive disorder?

Risk factors for intermittent explosive disorder include:

• Being a young person AMAB.
• Being unemployed.
• Being single (unmarried).
• Having lower levels of education.
• Experiencing physical or sexual violence, especially as a child.
• Having biological family members with intermittent explosive disorder.

If you’re concerned about your child’s risk of developing intermittent explosive disorder, talk to your healthcare provider.

What is the prognosis (outlook) for intermittent explosive disorder?

People with intermittent explosive disorder tend to have poor life satisfaction and lower quality of life. It can have a very negative impact on your health and can lead to severe personal and relationship problems.

Cognitive therapy and medication can successfully manage IED. However, according to studies, IED appears to be a long-term condition, lasting from 12 to 20 years or even a lifetime.

Having intermittent explosive disorder makes it more likely that you’ll develop the following conditions:

• Depression.
• Anxiety.
• Alcohol use disorder.
• Substance use disorder.

In addition, people with IED are at an increased risk for self-harm (self-injury) and suicide. Because of this, it’s essential to seek medical help as soon as possible if you feel you or a family member has intermittent explosive disorder.

How do I take care of myself if I have intermittent explosive disorder?

If you have intermittent explosive disorder, it’s essential to seek professional, medical treatment. You’ll learn a variety of coping techniques in therapy. These can help prevent anger episodes. They include:

• Relaxation techniques.
• Changing the ways you think (cognitive restructuring).
• Communication skills.
• Learning to change your environment and leaving stressful situations when possible.

It’s also very important to avoid alcohol and recreational drugs. These substances can increase the risk of violent behavior.

When should I see my healthcare provider for intermittent explosive disorder?

If you or your child has been diagnosed with intermittent explosive disorder, you’ll need to see your healthcare team regularly to make sure your treatment (talk therapy and/or medication) is working.

If you or your child displays behavior that harms or endangers others, such as other people or animals, it’s important to find immediate care.

People with intermittent explosive disorder who are thinking of harming themselves or attempting suicide need help right away.

If you or someone you know is in immediate distress or is thinking about hurting themselves, call the Suicide and Crisis Lifeline toll-free at 988.

A note from Cleveland Clinic

It’s important to remember that intermittent explosive disorder (IED) is a mental health condition. As with all mental health conditions, seeking help as soon as symptoms appear can help decrease the disruptions to your life. Mental health professionals can offer treatment plans to help you manage your thoughts and behaviors.

The family members and loved ones of people with IED often experience stress, depression and isolation. It’s important to take care of your mental health and seek help if you’re experiencing these symptoms. If you’re in a relationship with someone with intermittent explosive disorder, take steps to protect yourself and your children.