Intermittent explosive disorder

Definition

Intermittent explosive disorder is characterized by repeated episodes of aggressive, violent behavior in which you react grossly out of proportion to the situation. Road rage, domestic abuse, and angry outbursts or temper tantrums that involve throwing or breaking objects may be signs of intermittent explosive disorder (IED).

People with intermittent explosive disorder may attack others and their possessions, causing bodily injury and property damage. Later, people with intermittent explosive disorder may feel remorse, regret or embarrassment.

If you have this anger disorder, treatment may involve medications and psychotherapy to help you control your aggressive impulses.

Symptoms

Explosive eruptions, usually lasting 10 to 20 minutes, often result in injuries and the deliberate destruction of property. These episodes may occur in clusters or be separated by weeks or months of nonaggression.

Aggressive episodes may be preceded or accompanied by:

• Irritability
• Increased energy
• Rage
• Tingling
• Tremors
• Palpitations
• Chest tightness
• Headache or a feeling of pressure in the head

Causes

The exact cause of intermittent explosive disorder is unknown, but the disorder is probably caused by a number of environmental and biological factors.

Most people with this disorder grew up in families where explosive behavior and verbal and physical abuse were common. Being exposed to this type of violence at an early age makes it more likely for these children to exhibit these same traits as they mature.

There may also be a genetic component, causing the disorder to be passed down from parents to children.

Additionally, there may be differences in the way serotonin, an important chemical messenger in the brain, works in people with intermittent explosive disorder. Higher levels of the hormone testosterone have been associated with intermittent explosive disorder.

Risk factors

A number of factors increase your risk of developing intermittent explosive disorder:

• Having another mental health problem. People with other mental illnesses — such as mood or anxiety disorders — may be more likely to also have intermittent explosive disorder.
• A history of substance abuse. People who abuse drugs or alcohol have an increased risk of intermittent explosive disorder.
• Age. Intermittent explosive disorder is most common in people in their teens and 20s.
• Being male. Men are far more likely to have intermittent explosive disorder than are women.
• A history of physical abuse. People who were abused as children have an increased risk of intermittent explosive disorder.

Complications

The violent behavior that's part of intermittent explosive disorder is not always directed at others. People with this condition are also at significantly increased risk of harming themselves, either with intentional injuries or suicide attempts.

Those who are also addicted to drugs or had another serious mental disorder, such as depression, are at the greatest risk of harming themselves.

People with intermittent explosive disorder are often perceived by others as always being angry. Other complications of intermittent explosive disorder may include job loss, school suspension, divorce, auto accidents or incarceration.

Preparing for your appointment

If you're concerned because you're having repeated emotional outbursts, you can talk with your primary care doctor, or you may want to make an appointment with someone who specializes in treating emotional disorders, such as a psychiatrist, psychologist or social worker.

Here's some information to help you get ready for your appointment, and what to expect from your doctor.

What you can do

• Write down any symptoms you're experiencing, including any that may seem unrelated to the reason for which you scheduled the appointment.
• Write down key personal information, including any major stresses or recent life changes.
• Make a list of all medications, as well as any vitamins or supplements, that you're taking.
• Write down questions to ask your doctor.

Preparing a list of questions can help you make sure you cover everything that's important to you. For intermittent explosive disorder, some basic questions to ask your doctor include:

• Why am I having these angry outbursts?
• Do I need any tests? Do these tests require any special preparation?
• Is this condition temporary or long lasting?
• What treatments are available, and which do you recommend?
• Are there any side effects from treatment?
• Are there any alternatives to the primary approach that you're suggesting?
• I have other health conditions. How can I best manage these conditions together?
• Is there a generic alternative to the medicine you're prescribing me?
• How long does therapy take to work?
• Are there any brochures or other printed material that I can take home with me? What Web sites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask questions during your appointment at any time that you don't understand something.

What to expect from your doctor
Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

• How often do you have explosive episodes?
• Does anything seem to makes these episodes occur more often?
• Is there anything that you've found that can help calm you down?
• Has anyone else in your family ever been diagnosed with a mental illness?
• Have you suffered from a head trauma?

Tests and diagnosis

To be diagnosed with intermittent explosive disorder, your doctor will ask you about your behavior to see if you meet the criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM) for intermittent explosive disorder. This manual is published by the American Psychiatric Association and is used by mental health providers to diagnose mental conditions and by insurance companies to reimburse for treatment.

DSM criteria include:

• Multiple incidents in which the person failed to resist aggressive impulses that resulted in deliberate destruction of property or assault of another person.
• The degree of aggressiveness expressed during the incidents is completely out of proportion with the precipitating event.
• The aggressive episodes aren't accounted for by another mental disorder and are not due to the effects of a drug or a general medical condition.

Other conditions that must be ruled out before making a diagnosis of intermittent explosive disorder include delirium, dementia, borderline personality disorder, antisocial personality disorder, schizophrenia, a manic episode, substance abuse or withdrawal, head trauma, seizures, or intoxication.

People with intermittent explosive disorder may also show some minor irregularities in neurological signs and electroencephalograms (EEGs). An EEG is a noninvasive test that measures the electrical activity in your brain.

Treatments and drugs

There's no one treatment that's best for everyone with intermittent explosive disorder. Treatment generally includes medication and individual or group therapy.

Many different types of drugs are used to help control intermittent explosive disorder, including:

• Antidepressants, such as fluoxetine (Prozac) and paroxetine (Paxil)
• Anticonvulsants, such as carbamazepine (Tegretol), phenytoin (Dilantin), gabapentin (Neurontin) and lamotrigine (Lamictal)
• Anti-anxiety agents in the benzodiazepine family, such as diazepam (Valium), lorazepam (Ativan) and alprazolam (Xanax)
• Mood regulators, such as propranolol (Inderal) and lithium

Individual or group therapy sessions also can be helpful. A commonly used type of therapy, cognitive behavioral therapy, helps people with intermittent explosive disorder identify which situations or behaviors may trigger an aggressive response. And, more importantly, this type of therapy teaches people with intermittent explosive disorder how to manage their anger and control their typically inappropriate response using relaxation exercises.

Coping and support

Controlling your anger
If you recognize your own behavior in the description of intermittent explosive disorder, talk with your doctor about what treatments are available to you, or ask for a referral to a mental health professional.

Coping well with anger is a learned behavior, just as behaving badly when you get frustrated is a behavior you have to unlearn. Cognitive behavioral therapy or anger management will help you recognize what pushes your buttons and how to respond in ways that work for you instead of against you.

In the meantime, work with your doctor on developing a plan of action for when you feel yourself getting angry. For example, if think you might lose control, try to remove yourself from that situation. Go for a walk or call a trusted friend to try to calm down. If you can't find a way to calm down on your own, you can go to your local emergency room and ask for help.

If your loved one won't get help
Unfortunately, many people with intermittent explosive disorder don't seek treatment. If you're involved in a relationship with someone who has intermittent explosive disorder, it's important that you take steps to protect yourself and your children. The abuse isn't your fault. No one deserves to be abused.

Create an escape plan
If you see that a situation is escalating, and suspect your loved one may be on the verge of an explosive episode, try to safely remove yourself and your children from the scene. However, leaving someone with an explosive temper can be dangerous. Consider taking these steps before an emergency arises:

• Call a domestic violence hot line or a women's shelter for advice, either when the abuser isn't home or from a friend's house.
• Keep all firearms locked. Don't give the abuser the key or combination to the lock.
• Pack an emergency bag that includes items you'll need when you leave, such as extra clothes, keys, personal papers, medications and money. Hide it or leave the bag with a friend or neighbor.
• Know where you'll go and how you'll get there if you feel threatened, even if it means you have to leave in the middle of the night.

Help is available
In an emergency, call 911 — or whatever your local emergency number is — or your local law enforcement agency. The following resources also can help:

• National Domestic Violence Hotline: 800-799-SAFE (800-799-7233). This hot line is available for crisis intervention and referrals to resources, such as women's shelters.
• Your doctor. Doctors and nurses can treat your injuries and let you know what local resources are available to keep you safe.
• A local women's shelter or crisis center. Shelters and crisis centers generally provide 24-hour emergency shelter, as well as advice on legal matters and advocacy and support services.
• A counseling or mental health center. Many communities offer counseling and support groups for people in abusive relationships. Be wary of advice to seek couples or marriage counseling. If violence has escalated to the point that you're afraid of your partner, this type of counseling won't be adequate.
• A local court. Your local court can help you obtain a restraining order that legally mandates the abuser has to stay away from you or face arrest. Local advocates may be available to help guide you through the process.