Overview
Aggression and impulsivity are the defining characteristics that make up Intermittent Explosive Disorder, manifesting as recurrent outbursts that may lead to physical and verbal abuse, injury to self and/or others, as well as damage and destruction of property. The outcomes of this outward aggression often lead to major distress and impairments across different areas of life.
The onset of the disorder is chronic and rapid, and usually begins in childhood and peaks in adolescence. Predominance in prevalence of Intermittent Explosive Disorder is seen among younger individuals, as well as those with higher levels of education.
Environmental factors as well as biological factors involving neurological imbalances and genetics have been linked as correlates of the disorder. Owing in part to the additional stress caused as an outcome of aggressive outbursts, there is a high possibility of comorbidities developing after the onset of Intermittent Explosive Disorder.
Common comorbidities include mood disorders, personality disorders, impulse control and substance use disorders.ย
The treatment of Intermittent Explosive Disorder involves both pharmacological and therapeutic intervention. Pharmacology generally depends on symptomatology and comorbidities, while therapy can be eclectic, often incorporating elements of behavioral intervention and social skill training.
Signs and Symptoms
The signs and symptoms of Intermittent Explosive Disorder include:
- Intense aggressive feelings or intense anger
- Recurrent, impulsive outbursts due to anger
- Physical or verbal abuse inflicted upon others
- Self-injury and/or attempts of suicide
- Destruction of property
- Aggressive reactions that are disproportionate (overreactions) to minor issues
Risk Factors
While clinical reports present a male predominance in the prevalence of Intermittent Explosive Disorder with a ratio of 2:1 against females, community survey samples have not pointed out a significant variation in terms of sex. Younger individuals are more affected by the disorder, and higher education has also been associated with the disorder.
Biological as well as environmental risks exist. Genetic factors pertaining to the vulnerability of first-degree relatives of those with Intermittent Explosive Disorder to the disorder as well as impulsive aggression have been outlined, as well as neurobiological abnormalities in the brain and limbic system.
Image scanning has shown evidence of a greater response of the amygdala to anger among those with the disorder. Maltreatment during childhood and/or adolescence is also a correlate.
The onset of the disorder is often seen in early stages of life, with some cases reportedly appearing as early as pre-pubescent childhood, with a peak in adolescence.
The course of Intermittent Explosive Disorder is chronic, with recurrent episodes occurring over a span of a minimum of 12 years.
Comorbid conditions are often present and include mood disorders (such as depressive, bipolar, and anxiety disorders), personality disorders (such as antisocial and borderline personality disorders), impulse control and substance use disorders.
The onset of comorbid disorders is typically seen after the onset of Intermittent Explosive Disorder as it can lead to the manifestation of adverse environmental conditions such as social and financial difficulties, relationship problems, and other stressful situations.ย
Diagnosis
The diagnosis of Intermittent Explosive Disorder is based upon DSM-5 criteria as well as thorough clinical assessment.
The diagnostic criteria for the disorder include the following conditions:
- There are recurrent behavioral outbursts due to an inability to control aggressive impulses which can be observed in the form of verbal or physical aggression that occurs twice weekly on an average for three months (physical aggression does not result in injury to animals or other individuals or damage or destruction of property). Alternatively, three outbursts resulting in property damage or physical injury to others may be recorded in a span of 12 months.
- The extent of the outburst is largely out of proportion with respect to the provocation or the environmental stressors that preceded it.
- The outbursts are not planned, but impulsive and anger based and are not performed to achieve any kind of objective.
- The outbursts lead to distress, occupational and/or interpersonal impairment, and financial or legal consequences.
- Minimum age is 6 years (or an equivalent level of development).
- The outbursts are not better explained as being caused by underlying mental disorders, medical conditions, or the effects of a substance. Aggressive behavior occurring as part of adjustment disorders in those aged 6-18 should not be considered for this diagnosis.
It is necessary to also complete medical tests, which may include physical or neurological assessments in order to rule out any physical causes of aggressive impulses and outburst. Diagnostic interviews are conducted to determine comorbid conditions, with informants such as family members and other acquaintances being involved as consults owing to the possible lack of objectivity and self-awareness among individuals with severe anger issues.
Confirming an Intermittent Explosive Disorder diagnosis can be challenging, as aggression is a commonly observed symptom in multiple diagnoses including Bipolar Disorders, Dissociative Disorders and the Autism Spectrum.
The use of a graphic timeline demonstrating the onset of aggression and the onset of other psychiatric comorbidities may be beneficial in determining an accurate diagnosis.
Treatment
Treatment for Intermittent Explosive Disorder often focuses on controlling symptoms, and thus can also work by using comorbid disorders as guides to determine management. Both pharmacological as well as psychotherapeutic approaches to treatment of Intermittent Explosive Disorder are available.
Mood stabilizers, anticonvulsants, antipsychotics, or SSRIs (Selective Serotonin Reuptake Inhibitors) are potential pharmacological interventions. The decision to use a particular pharmacological agent is dependent on the symptoms observed as well the underlying comorbidities that need to be treated effectively.
Therapeutic mediation often takes form of behavioral therapies, commonly Cognitive Behavioral Therapy and social skills training. Group therapy and family therapy are also effective in regulating aggression.
Different forms of therapies can be combined in a multidimensional approach to treatment, such as using Cognitive Behavior Therapy in order to work through social skills in a group setting.
Creating self-awareness about anger and physical arousal and using it in order to solve problems is often the focal point of sessions, and emphasis is also put on preventing impulsivity, promotion of thinking about consequences, and coming up with possible alternative behaviors to substitute aggressive outbursts.
Differential Diagnosis
1. Disruptive mood dysregulation disorder: In contrast to intermittent explosive disorder, disruptive mood dysregulation disorder consists of a persistently negative mood state most of the day, nearly every day, between impulsive aggressive outbursts. A diagnosis of disruptive mood dysregulation disorder can only be given when the onset of recurrent, problematic, impulsive aggressive outbursts is before age 10 years.
2. Antisocial personality disorder or borderline personality disorder: Individuals with antisocial personality disorder or borderline personality disorder often display recurrent problematic impulsive aggressive outbursts. However, the level of impulsive aggression in individuals with antisocial personality disorder or borderline personality disorder is lower than that in individuals with intermittent explosive disorder.
3. Delirium, major neurocognitive disorder, and personality change due to another medical condition, aggressive type: A diagnosis of intermittent explosive disorder should not be made when aggressive outbursts are judged to result from the physiological effects of another diagnosable medical condition.
4. Substance intoxication or substance withdrawal: A diagnosis of intermittent explosive disorder should not be made when impulsive aggressive outbursts are nearly always associated with intoxication with or withdrawal from substances. However, when a sufficient number of impulsive aggressive outbursts also occur in the absence of substance intoxication or withdrawal, and they require independent clinical attention, a diagnosis of intermittent explosive disorder may be given.
5. Attention-deficit/hyperactivity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder: Individuals with any of these childhood-onset disorders may exhibit impulsive aggressive outbursts.
Comorbidity
Depressive disorders, anxiety disorders, substance use disorder, antisocial personality disorder and borderline personality disorder are most commonly comorbid with intermittent explosive disorder. Individuals with ADHD, conduct disorder and oppositional defiant disorder are at a risk of having intermittent explosive disorder as a comorbidity
Specialists
The treatment for Intermittent Explosive Disorder is primarily carried out by psychiatrists, clinical psychologists, and/or counselling psychologists. Since there is a high chance of a comorbid psychiatric disorder being present, it is likely that a psychiatrist or clinical psychologist would be involved in the treatment, especially when prescription of medication is involved.
Since a vital part of the diagnostic procedure includes the sufficient exclusion of neurological causative factors, it is helpful to involve a neurologist or neuropsychologist early in the diagnostic process as well.ย
In Conclusion
The intermittent explosive disorder is characterized by recurrent, abrupt periods of irrational, violent action or irate outbursts of anger verbally out of proportion to the circumstances.
If you suffer from the intermittent explosive disorder, prevention is probably out of your hands until you seek medical attention. These recommendations may assist you in preventing some episodes from spiraling out of control when combined with or as part of treatment. To prevent explosive episodes from happening again, your doctor might recommend maintenance medication.
Develop your relaxing skills. You may find it helpful to regularly practice deep breathing, calming images, or yoga.
Consult our professionals and begin your healing therapies.
