Intermittent explosive disorder



Intermittent Explosive Disorder 785
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Definition

Intermittent explosive disorder (IED) is a disorder characterized by impulsive acts of aggression, as contrasted with planned violent or aggressive acts. The aggressive episodes may take the form of "spells" or "attacks," with symptoms beginning minutes to hours before the actual acting-out. The Diagnostic and Statistical Manual of Mental Disorders , fourth edition, text revision (also known as DSM-IV-TR ) is the basic reference work consulted by mental health professionals in determining the diagnosis of a mental disorder. DSM-IV-TR classifies IED under the general heading of "Impulse-Control Disorders Not Elsewhere Classified." Other names for IED include rage attacks, anger attacks, and episodic dyscontrol.

Description

Intermittent explosive disorder was originally described by the eminent French psychiatrist Esquirol as a "partial insanity" related to senseless impulsive acts. Esquirol termed this disorder monomanies instinctives , or instinctual monomanias . These apparently unmotivated acts were thought to result from instinctual or involuntary impulses, or from impulses related to ideological obsessions.

People with intermittent explosive disorder have a problem with controlling their temper. In addition, their violent behavior is out of proportion to the incident or event that triggered the outburst. Impulsive acts of aggression, however, are not unique to intermittent explosive disorder. Impulsive aggression can be present in many psychological and nonpsychological disorders. The diagnosis of intermittent explosive disorder (IED) is essentially a diagnosis of exclusion, which means that it is given only after other disorders have been ruled out as causes of impulsive aggression.

Patients diagnosed with IED usually feel a sense of arousal or tension before an outburst, and relief of tension after the aggressive act. Patients with IED believe that their aggressive behaviors are justified; however, they feel genuinely upset, regretful, remorseful, bewildered or embarrassed by their impulsive and aggressive behavior.

Causes and symptoms

Causes

Recent findings suggest that IED may result from abnormalities in the areas of the brain that regulate behavioral arousal and inhibition. Research indicates that impulsive aggression is related to abnormal brain mechanisms in a system that inhibits motor (muscular movement) activity, called the serotoninergic system. This system is directed by a neurotransmitter called serotonin, which regulates behavioral inhibition (control of behavior). Some studies have correlated IED with abnormalities on both sides of the front portion of the brain. These localized areas in the front of the brain appear to be involved in information processing and controlling movement, both of which are unbalanced in persons diagnosed with IED. Studies using positron emission tomography (PET) scanning have found lower levels of brain glucose (sugar) metabolism in patients who act in impulsively aggressive ways.

Another study based on data from electroencephalograms (EEGs) of 326 children and adolescents treated in a psychiatric clinic found that 46% of the youths who manifested explosive behavior had unusual high-amplitude brain wave forms. The researchers concluded that a significant subgroup of people with IED may be predisposed to explosive behavior by an inborn characteristic of their central nervous system. In sum, there is a substantial amount of convincing evidence that IED has biological causes, at least in some people diagnosed with the disorder.

Other clinicians attribute IED to cognitive distortions. According to cognitive therapists, persons with IED have a set of strongly negative beliefs about other people, often resulting from harsh punishments inflicted by the parents. The child grows up believing that others "have it in for him" and that violence is the best way to restore damaged self-esteem. He or she may also have observed one or both parents, older siblings, or other relatives acting out in explosively violent ways. In short, people who develop IED have learned, usually in their family of origin, to believe that certain acts or attitudes on the part of other people "justify" aggressive attacks on them.

Although gender roles are not a "cause" of IED to the same extent as biological and familial factors, they are regarded by some researchers as helping to explain why most people diagnosed with IED are males. According to this theory, men have greater permission from society to act violently and impulsively than women do. They therefore have less reason to control their aggressive impulses. Women who act explosively, on the other hand, would be considered unfeminine as well as unfriendly or dangerous.

Symptoms

IED is characterized by violent behaviors that are impulsive as well as assaultive. One example involved a man who felt insulted by another customer in a neighborhood bar during a conversation that had lasted for several minutes. Instead of finding out whether the other customer intended his remark to be insulting, or answering the "insult" verbally, the man impulsively punched the other customer in the mouth. Within a few minutes, however, he felt ashamed of his violent act. As this example indicates, the urge to commit the impulsive aggressive act may occur from minutes to hours before the "acting out" and is characterized by the buildup of tension. After the outburst, the IED patient experiences a sense of relief from the tension. While many patients with IED blame someone else for causing their violent outbursts, they also express remorse and guilt for their actions.

Demographics

IED is apparently a rare disorder. Most studies, however, indicate that it occurs more frequently in males. The most common age of onset is the period from late childhood through the early 20s. The onset of the disorder is frequently abrupt, with no warning period. Patients with IED are often diagnosed with at least one other disorder—particularly personality disorders , substance abuse (especially alcohol abuse) disorders, and neurological disorders.

Diagnosis

As mentioned, IED is essentially a diagnosis of exclusion. Patients who are eventually diagnosed with IED may come to the attention of a psychiatrist or other mental health professional by several different routes. Some patients with IED, often adult males who have assaulted their wives and are trying to save their marriages, are aware that their outbursts are not normal and seek treatment to control them. Younger males with IED are more likely to be referred for diagnosis and treatment by school authorities or the juvenile justice system, or brought to the doctor by concerned parents.

A psychiatrist who is evaluating a patient for IED would first take a complete medical and psychiatric history. Depending on the contents of the patient's history, the doctor would give the patient a physical examination to rule out head trauma, epilepsy, and other general medical conditions that may cause violent behavior. If the patient appears to be intoxicated by a drug of abuse or suffering symptoms of withdrawal, the doctor may order a toxicology screen of the patient's blood or urine. Specific substances that are known to be associated with violent outbursts include phencyclidine (PCP or "angel dust"), alcohol, and cocaine. The doctor will also give the patient a mental status examination and a test to screen for neurological damage. If necessary, a neurologist may be consulted and imaging studies performed of the patient's brain.

If the physical findings and laboratory test results are normal, the doctor may evaluate the patient for personality disorders, usually by administering diagnostic questionnaires. The patient may be given a diagnosis of antisocial or borderline personality disorder in addition to a diagnosis of IED.

In some cases the doctor may need to rule out malingering , particularly if the patient has been referred for evaluation by a court order and is trying to evade legal responsibility for his behavior.

Treatments

Some adult patients with IED appear to benefit from cognitive therapy. A team of researchers at the University of Pennsylvania found that cognitive approaches that challenged the patients' negative views of the world and of other people was effective in reducing the intensity as well as the frequency of violent episodes. With regard to gender roles, many of the men reported that they were helped by rethinking "manliness" in terms of self-control rather than as something to be "proved" by hitting someone else or damaging property.

Several medications have been used for treating IED. These include carbamazepine (Tegretol), an antiseizure medication; propranolol (Inderal), a heart medication that controls blood pressure and irregular heart rhythms; and lithium, a drug used to treat bipolar type II manic-depression disorder. The success of treatment with lithium and other mood-stabilizing medications is consistent with findings that patients with IED have a high lifetime rate of bipolar disorder .

Prognosis

Little research has been done on patients who meet DSM-IV-TR criteria for IED, although one study did find that such patients have a high lifetime rate of comorbid (co-occurring) bipolar disorder. In some people, IED decreases in severity or resolves completely as the person grows older. In others, the disorder appears to be chronic.

Prevention

As of 2002, preventive strategies include educating young people in parenting skills, and teaching children skills related to self-control. Recent studies summarized by an article in a professional journal of psychiatry indicate that self-control can be practiced like many other skills, and that people can improve their present level of self-control with appropriate coaching and practice.

See also Gender issues in mental health ; Self-control strategies

Resources

BOOKS

Baumeister, Roy F., PhD. Chapter 8, "Crossing the Line: How Evil Starts." In Evil: Inside Human Violence and Cruelty. New York: W. H. Freeman and Company, 1999.

Beck, Aaron T., M.D. Prisoners of Hate: The Cognitive Basis of Anger, Hostility, and Violence. New York: HarperCollins, 1999.

Tasman, Allan, and others, eds. Psychiatry. 1st edition. Philadelphia: W. B. Saunders Company. 1997: 1249-1258.

PERIODICALS

Bars, Donald R., and others. "Use of Visual Evoked-Potential Studies and EEG Data to Classify Aggressive, Explosive Behavior of Youths." Psychiatric Services 52 (January 2001): 81-86.

McElroy, Susan L. "Recognition and Treatment of DSM-IV Intermittent Explosive Disorder." Journal of Clinical Psychiatry 60 (1999) [suppl. 15]: 12-16.

Strayhorn, Joseph M., Jr. "Self-Control: Theory and Research." Journal of the American Academy of Child and Adolescent Psychiatry 41 (January 2002): 7-16.

Laith Farid Gulli, M.D. Bilal Nasser, M.D.



User Contributions:

ashley
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Nov 25, 2007 @ 9:21 pm
my husband has alot of problems that are in these articles, it doesn't take much to set him off, one min. hes fine the next min. i ask him to do something and he doesn't like the way i word it and he hits me hes always telling me its my fault but then after words he feels horrible. i have been with him for 7 years and have 3 children, hes 28 years old i know this isn't him. i think he needs help
ASHLEY GET OUT OF THERE!
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Nov 30, 2007 @ 5:17 pm
Ashley, if your husband hits you, despite the fact that you have children together - GET OUT! Take the kids and get the heck out of there. My husband has this and has finally seeked help after busting down a door and me kicking him out. He finally saw the light. He has never, ever, laid a hand on me. Don't teach your children that it's okay to be with a man like that, or to be a man like that. If he hits you, he quite obviously needs help. Go to a shelter, seek help from family, friends, church. But do not under any circumstances...DO NOT let him hit you ever again. Feeling bad afterwards is the classic signs of an abuser. You are letting him think its okay to treat you that way by staying. I can't stress it enough - GET OUT!
shma
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Jan 6, 2008 @ 3:03 am
I didn't know that i was suffering from IED until today. I always used to wonder why i was getting so out of control for the tiniest arguement with my husband.But, after verbally insulting him I feel really relived as well as ashamed of myself.I have two kids and they have also started watching me. Now, i am scared whether i will pass on this kind of behaviour to my kids too...
Ashley T
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Mar 6, 2009 @ 12:00 am
My boyfriend has this
hes been diagnosed and i was wondering if anyone had found anyways of helping to calm them down and comfort them when the depression hits. I know for a fact that he doesnt like the way he acts and knows its not right he despretly wants to get rid of it and im just wondering if anyone has found anything i could do to help comfort him.
phoenix
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May 13, 2009 @ 10:10 am
i was just told that my 7 year old has IED. i have been reading so much about this disorder and after 2 years and many doctors i feel relieved to know what is wrong with my child. i always thought and still think that maybe it was something i did or didnt do enough of. after debating for a months and getting him counseling services and the whole 9 yards i finally decided to put him on medicine. as hard as it was to make that desicion i'm glad that i did because i see a HUGE difference with him and it makes me so happy to see my son smile.
Nicholas
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Aug 8, 2009 @ 1:01 am
I do not know if i have it but i get mad easily over stupid things
NEED HELP
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Aug 10, 2009 @ 6:18 pm
I think my husband has this problem. The tiniest thing will set him off, and usually its something totally out of our control. He gets soooo angry and he turns red and yells and shakes and hits things or pounds on them. He always regrets behaving that way, and he tries to control it and let it go but it builds up and he gets a lot of pressure in his head and eventually it happens all over again. It happens too often, at least once a month and sometimes more. I am at a loss, I have no idea what to do or how to help him. I do know it is tearing us apart. I try to have patience but I am slowly losing it..

I love him so very much and just want it to go away......
Alvin
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Aug 12, 2009 @ 2:02 am
I think i might have a slight case of IED cuz when someone says something that triggers me or even phsically touches me i blow up, can someone please tell me if the is a sign of I.E.D please, thank you!
Bobbie
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Aug 12, 2009 @ 11:11 am
My son has IED. He had a bad outburst a few days ago end is now in a hospital getting help he is only 9. He also is autistic and has been on meds.Dr just informed us that the prozac he has been on for 3yrs now was the cause of his outburst.The increase they had done just recently caused him to have a manic episode so they took him off of it.But their is a medication out there its called resperidone it helps my son controll himself most of the time.Dont give up or in go see a doctor they can help.
jazmin
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Aug 17, 2009 @ 11:11 am
Here is the info about ied its good info to look at
Roshnee
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Aug 19, 2009 @ 7:07 am
My 22 year old deaf daughter has been displaying these symptoms since her early teen. She was subsequently put on Nuzac and has now decided that she no longer needs the medication. Whilst the meds do not eliminate the outbursts completely it does give her a sense of reasoning and conscious which she does not normally have and the frequency and intensity of the outbursts are less. However, since being off the medication her outbursts have become more frequent and more violent with no sense of remorse or regret. In addition she is constantly threatening to kill herself. I am at my wits end and have actually put her out of the house as I cannot deal with it any longer! Can someone please help?
NANCY
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Aug 22, 2009 @ 8:20 pm
My Husband hoas how urbusts directed Torwads mor me any night to the chldren Usually they invold eyelling and name calling. as well s frusration. My lttest concern it is now be directed towrads my 12 year old.
There is little trust on my part no matter the false promise that he won'y reise him voice and emptry promies of calling me names.

For him things go long well then something minor will set hi off. He has mmade prmise that have lasted weeky However, like an alcohiml it will return again. I am concinced after all these years that these are empty romsies.

After all, how does one deal with this while keeping my mariage intact. I eon't watn to divorce becuae he is wonderful father....please help. I need help and can't be going on like this

Thank you ,

Nancy









These explions don't involve hittine nbu justyelling and verbla abuse on his partl I live in contasnt warines that it will happen again. God knos wha sets him off but it happends ghough I trip to givehim teh doubt it wmon't happen again. It will. I liken it tot a allcohic falling offthe wagon. This certainy is not hearly for me nor my famil

I do recgnize he needs contrat reacssucne and is always asking me to say how well he doin with work but even that doesn't wrok. He harbors a lot of anger and I don't know how much I can stand this

Thanks you,


Nancy
Joanna
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Sep 1, 2009 @ 8:08 am
My husband was just diagnosed with IED, and subsequently placed on medication. We have been married 10 years, and his anger at times is out of control. He has a propensity to smash things, although he has not struck me in 9 years. I told him the first time was the last time. Yesterday was hell, he ranted and raved for over 2 hours, I did not think he would ever shut up. He says my lack of ability to properly manage our money is what set him off. I have managed our money for the entire marriage, because he himself asked that I take that responsibilyity as he is not good with money. Anyhow my question is what help is there for family that has to deal with this disorder in a family member? He tells me I am crazy, and need to go to the same mental health clinic he does. Who knows, after all these years I may very well be
Thanks,
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Aug 3, 2010 @ 10:10 am
anything can trigger him to become very up set. I am taking LEXAPRO and I have found that it works for me I have been taking it for about 2 to 3 months now and I am so happy me and my boyfriend have not faught since I started taking LEXAPRO. There is all diffiernt meds. for IED I chose LEXAPRO cause it startes working in 3 days.
Regina
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Aug 12, 2010 @ 5:17 pm
My husband was diagnosed with this disorder after a huge outburst in an airport, then subsequently ending up in jail, a hospital, and finally a mental hospital for the criminally insane. At first, I believed everything he was saying (after he has already been abusive both physically and verbally to me.) We know have a daughter almost 2, but I can not tolerate it anymore. We will be leaving him with no plan on returning unless he gets the help he needs. A major problem is that he still feels that all his problems are the cause of others. This disorder can reck a marriage, a family, and ultimately, the world of the person who has it.
FairyAngel
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Feb 13, 2011 @ 8:20 pm
GIRLS, do you have such a low self-esteem that makes you stay in these relationships? I left my husband because I did not want my kids to think it was okay for the behavior which was being acted out by husband. Since then, my son has acquired this behavior and has resulted in a couple of minor arrests not putting up with it. I get a lot of name calling from my son and it is not okay but I do not know what to do. He has a probation hearing coming up which I will voice my concern still on his verbal abuse towards me and how he does not refrain from doing it. He has tried counseling but not three to five times a day as might others do. I am suffering inside all the time due to his behavior and it is so hurtful. I cry all the time inside and keep it inside which is not good for me, either but I can't afford a counselor for myself.
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Mar 31, 2011 @ 10:22 pm
I believe my step-father might have this disorder. Ever since I can remember any little thing that is out of his hands or if something does not go his way, he will get mentally and verbaly abusive. My husband, my father-n-law and I have had to put restraining orders on him for his threats and violent outbursts. I am afraid that if my kids go around him they may think it is o-kay to act like this. My mother puts up with it for some odd reason but I believe that he needs to be checked out but a speclist. Even though we have cut ties in being with each other, I honestly believe with each day his condition grows worse. If anyone has any more information on this disease, could someone let me know.
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Jun 8, 2011 @ 9:09 am
My husband was recently diagonosied with this disorder. It has been a tough thing to deal with cause he is no longer the man I married. The littlest things will set him off such as buring a pan of biscuts and once he is set off sometimes it takes hours for him to calm down and return to a fuctioning state. Its really difficult to deal with too cause as of right now their doesnt seem to a medicine that can cure this disorder or at least help with the symptoms of it.

He's a great father but their are times I do worry about leaving our kids with him cause this is something that he cant control and something that happens so quickly. Dont get me wrong never do I believe that in any state would harm our children, but as I am sure anyone with kids would, I worry for them and him while i have to be away.

Someone please find something for this situation. I want the man I married back not this one I see everyday.
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Jul 26, 2011 @ 12:12 pm
my 9 year old shows signs of this. she hits me and leaves bruises on me. she is fine at school but she acts up at home and hurts me or her sister. then in the morning she doesn't remember what happend. some think it's signs of ADD and ADHD
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Sep 6, 2011 @ 8:08 am
I am reading this and crying. I believe my husband of 15 years has this as well. I agree I want my husband back.. This monster takes him over with no warning. I am starting counseling and i hope he will be a part of it. Praying...just praying
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Nov 5, 2011 @ 5:17 pm
Aprille,
I am also crying while reading this. Today, my 9 year old went into a rage because he was sent to his room. He would not stop screaming and yelling and I had to sit on him and put a sheet over his mouth to mute out the horrible screams,. It was like he was demonic. He eventually got a nose-bleed from thrashing around so much and the blood just kept dripping onto the floor I wanted to throw up and all I could do was cry. Finally, after yelling for my boyfriend (his guardian of 3 yrs) to come and help all he saw was the blood and gave me a look. I just wanted to curl up and die. My son ran out of the room and I lay on his floor crying alone.
God, I need help. He is taking 25 mg of Zoloft which is not doing anything at all I think. Can I ask what meds your son is on and what kind of doctor you took your son to see? I am so beside myself I cannot write anymore. Please advise,Susan
cch
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Nov 8, 2011 @ 9:21 pm
Wow - I just got home from my son's therapist appointment. I went by myself because we were discussing plans for him at school. That is where his episodes take place. At him we have rarely seen any of these behaviors and when we did, it was at least 5 years ago. He is not 12 and his behaviors at school continue to be the symptoms of IED. His Psychiatrist has not confirmed this diagnosis yet but we have already been through the ODD, ADHD, Bipolar diagnosis' but he doesn't match any of them fully. What sets him apart is that he will get himself so angered he has actually defacated in the school's quiet area for bahavioral issues. When he does this, he is sent home which is what he wants so he is comfortable again. Please let me know if anyone else has experienced their child defecating and urinating during one of these rages. He does display other symptoms but again only at school. Hitting, kicking, cursing, swearing and property distruction but this is not every day. It happens every few weeks. He is on zoloft, depakote and intuniv and this mix seems to work best for him. We have tried many others. This is such a stressful disorder to deal with but I can't imagine how these kids and grownups must feel knowing they have it.
LadyCheshire
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Jun 12, 2012 @ 11:23 pm
First of all, I owe the authors of this article a huge thank you. Recently, I have actually been attempting research as to why I act so overzealous when angry. Now I know. I have had and dealt with this problem since I was a young child. Something would set me off, and I would "blow up". I would scream, throw things, curse violently, act aggressively towards people or animals, and kick holes in the wall. Afterward, I would always feel heavy guilt & remorse for acting out that way. It still happens to this day, though I have managed to control a small section. Everyone, please hear me out when I say this IS debilitating. It ruins relationships, friendships, and even business to a degree. I find myself angry all the time with customers at work that is not even worth sweating over. Am attempting to go in for a psychological evaluation soon, but if anyone has any words of wisdom, or a light dose medication (very sensitive) that they would recommend inquiring about, please let me know. Anger drains the life & energy out of you, and as human beings, we need both of those.
Cecil Nixxon
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Oct 13, 2014 @ 9:09 am
I have recently dealt with several random outbursts of intermittent explosive disorder by strangers. In each case these individuals attemtped to assault me and draw me into a physical altercation for no reason other than their illness. While I have compassion for those afflicted by serious disorders, it is a good thing that I was not armed... I successfully de-fused the situations but only through level-headed effort on my part. Had I been armed, I would have reacted with the threat of deadly retaliation. But of course, when one is in the mindless rage of intermittent explosive disorder, this action would have resulted predictably in escalation, forcing me to put the assailant down.

If you or a loved one has this problem, you had better get them some treatment or pay up their burial insurance. They will ultimately tangle with someone less benevolent than I and the disease will not be recognized as anything more than criminal behavior warranting deadly force.

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