Intermittent Explosive Disorder

Intermittent explosive disorder is listed under the section “disruptive, impulse-control, and conduct disorders” in the fifth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V). These disorders are characterized by aggressiveness, violent behavior, and a limited capacity for self-control. 

A person with IED understands that their outbursts are inappropriate or out of proportion to the situation but may struggle to control their actions during these episodes. These outbursts, which typically last less than 30 minutes, may be frequent or occur with days or weeks of peaceful behavior. In between more significant episodes of anger, the person may experience verbal outbursts and become irritable, angry, and impulsive. According to the Diagnostic and Statistical Manual of Mental Disorders, to be diagnosed with IED, these outbursts must:

• Cause distress² or create problems in daily life, such as at school, work, or home
• Be impulsive (not planned or intended to accomplish a specific goal)

Some physical and psychological symptoms may occur right before an episode of aggression. These include:

• Racing thoughts
• Rapid heartbeat
• Tingling
• Shaking, trembling
• Increasing irritability
• Tightness in the chest

Some examples of how aggression or anger may manifest in someone with IED include:

• Destruction of property (punching walls, throwing and breaking objects, slamming doors)
• Loud verbal arguments, which can include shouting and threats
• Road rage incidents (aggressing with the car itself, use of firearms, or getting out of the car to fight)
• Temper tantrums
• Domestic violence
• Physical assault toward people or animals

According to the Diagnostic and Statistical Manual of Mental Disorders, a diagnosis of IED may be given if an individual struggles to control aggressive behavior and falls into one of the following two categories:

• Low frequency and high-intensity episodes: Within 12 months, the individual has been involved in three episodes involving physical attack that results in injury toward an animal or human or destruction of property.
• High-frequency and low-intensity episodes: Within three months, the individual has been involved in an average of two weekly episodes of verbal or physical aggression toward animals or humans that have not resulted in injury. 

The Diagnostic and Statistical Manual of Mental Disorders also states that an individual’s outbursts must not be caused by certain mental health or medical conditions (e.g., depression, bipolar disorder, Alzheimer’s disease, borderline personality disorder).

The cause of IED is currently unknown, but researchers believe that there are biological, genetic, and environmental factors that may contribute to this disorder. For example, the following factors may be present: 

• Certain studies have found in people with IED, there are structures and functions in the brain that are altered. MRIs show changes to the amygdala (the emotional center of the brain), reduction in grey matter, and lower levels of serotonin in those with IED. 
• IED runs in families, with studies suggesting that from 44% to 72% of cases are likely genetic.

IED occurs more frequently in people who have experienced childhood trauma. Trauma can include cases of physical, sexual, or verbal abuse or witnessing a traumatic event during developmental years.

Researchers are still studying the details of this condition, and no approved FDA treatment for IED has been identified yet. However, some therapeutic modalities and strategies may help individuals manage symptoms healthily.  

Medications

While there is no specific medication approved for the treatment of IED, there are a few medications that may be prescribed for an individual with this disorder to manage their symptoms. These include:

• Anti-anxiety medications
• Anti-depressants
• Mood stabilizers
• Anticonvulsants
• Anti-psychotic medications
• Alpha-2-Agonists
• Beta Blockers

Other treatment options

Deep brain stimulation (DBS) is being explored as a possible treatment for IED. However, only one study has been completed so far. According to the study, this procedure may show promise and further research is recommended. 

DBS is a process by which a device is surgically implanted and sends electric signals to specific brain areas. It is currently used to treat Parkinson’s disease and other movement disorders and is being tested as a treatment for other mental health conditions like depression, OCD, and Tourette’s.  

Self-care 

While not yet robustly researched in conjunction with IED, there are some evidence-based lifestyle habits that a mental health professional may recommend to manage emotions. These lifestyle changes include:

• Avoiding substances like drugs or alcohol, as these can exacerbate anger reactions and further lower inhibitions
• Getting moderate physical activity regularly
• Practicing sleep hygiene and getting the recommended seven to nine hours of sleep every night
• Eating nutritious and balanced foods 
• Engaging in relaxation techniques like breathing exercises or meditation

For those with IED, psychotherapy³ is the first-line treatment. A mental health professional can help a participant identify the sources of their symptoms, develop anger management strategies, and address symptoms of potential comorbid mental health conditions.

CBT and DBT are both evidence-based, effective forms of therapy to manage the symptoms of IED. A licensed therapist can help individuals develop new ways of viewing and reacting to situations, improve communication skills, encourage healthy lifestyle changes, and teach problem-solving techniques. 

Not all geographical areas offer specialized therapy or a variety of choices in therapists. Online therapy is an option that brings support to those who wouldn’t otherwise be able to attend therapy sessions. With online therapy platforms like BetterHelp, clients can be matched with a licensed therapist that meets their needs. Sessions can take place via phone, video, or live chat.  

Below are other resources to find out more about IED or find support: 

• The United Brain Association: Intermittent Explosive Disorder
• The National Alliance on Mental Illness (NAMI)
• Mental Health America (MHA)
• National Suicide and Crisis Hotline (988)

For help with substance use, contact the Substance Abuse and Mental Health Services Administration's National Helpline at 1-800-662-HELP (4357).

For those experiencing abuse, contact the Domestic Violence Hotline at 1-800-799-SAFE (7233). Support is available 24/7. Please also see our Get Help Now page for more immediate resources.

For those with thoughts of suicide, contact 988 Suicide & Crisis Lifeline at 988. Please also see our Get Help Now page for more immediate resources.

A 2022 study on IED and comorbidity, suicidality, and impairment found that those with the most common behavioral subtype of IED were strongly associated with a high rate of externalizing disorders (also known as disruptive disorders), including oppositional defiant disorder and conduct disorder. A higher risk for suicidality was observed in individuals who had comorbid disorders. 

Researchers found that these findings contrasted with earlier clinical studies of IED, which showed that this disorder was strongly associated with internalizing disorders (anxiety, OCD, mood disorders), and believe more research is needed on IED. 

A study from 2017 found that when IED is comorbid with PTSD, individuals with these diagnoses show significantly higher levels of both aggressive behavior and suicide attempts when compared to individuals with PTSD alone. The takeaway for researchers was that this study added support that an IED diagnosis may help identify people who are at high risk for both aggression and suicidal behavior. 

Below are several key statistics on intermittent explosive disorder:

• IED may affect up to 7.3% of the adult population in the United States (approximately 16 million Americans).
• Approximately 82% of people with IED also present with substance use disorders, anxiety, or depression, and only 28% received treatment specifically for anger.
• People with IED who attack people and property (around 4% of the US population) are estimated to be involved in 43 attacks over a lifetime.
• Cognitive-behavioral therapy has been proven to be one of the most effective methods of treatment for IED, associated with symptom remission, especially in individuals with lower levels of anger.