Understanding intermittent explosive disorder (IED)

It’s uncomfortable (and even scary) to witness that one friend fly off the handle from a minor provocation or a stranger epically lose their cool in the grocery store. Big, aggressive behavior from our fellow humans can feel terrorizing, especially when they suggest physical violence. How can innocent bystanders wrap their heads around these kinds of angry outbursts?

If these explosions come out of nowhere and dissipate quickly, and they leave a number of scary consequences in their wake (like destroyed property or personal injury), there might be a psychiatric condition like intermittent explosive disorder underlying the outbursts.

What Is Intermittent Explosive Disorder? 

Intermittent explosive disorder (IED) is a mental health condition characterized by recurrent behavioral outbursts with high rates of anger and serious impulsive aggression toward others. People with intermittent explosive disorder cannot control their aggressive outbursts, which usually come on suddenly and target someone close to them. 

To witnesses, these outbursts might seem like irrational “freakouts.” They can involve physical aggression, threats of violence, or verbal aggression. They usually last about 30 minutes and are typically followed by remorse, embarrassment, and distress. 

Intermittent explosive disorder afflicts about 16 million people in the United States. It usually has an early onset, at a mean age of 12.

Is Intermittent Explosive Disorder a Serious Mental Illness?

The disorder can lead to grave outcomes for relationships and employment. But fortunately, it is highly treatable. And while someone with the condition is getting treatment, there are ways that the people closest to them can help de-escalate IED episodes (more on this later).  

What Type of Disorder Is Intermittent Explosive Disorder?

Intermittent explosive disorder is a distinct, taxonic behavioral disorder as opposed to a dimensional disorder. This means that someone with IED isn’t just on the far end of the aggressive continuum. It is a discrete condition. 

To be more specific, IED is considered one of the five impulse control disorders, a family which also includes oppositional defiant disorder (ODD), conduct disorder, kleptomania, and pyromania. 

Is Intermittent Explosive Disorder a Mood Disorder?

Intermittent explosive disorder is not a mood disorder — however, mood disorders like anxiety and depression do often co-occur (four times more prevalent in people with IED). In addition, substance abuse is common (three times more prevalent in people with IED). 

What Is the Difference Between Disruptive Mood Dysregulation and Intermittent Explosive Disorder?

Disruptive mood dysregulation is a mood disorder characterized by intense angry outbursts in children between the ages of 6 and 18 years, with symptoms typically starting before the age of 10. 

The biggest difference between disruptive mood dysregulation and intermittent explosive disorder is that the former involves an irritable or angry mood most of the day, nearly every day. Remember: Intermittent explosive disorder is characterized by sudden angry episodes. 

Signs and Symptoms of Intermittent Explosive Disorder DSM-5

According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), signs and symptoms of an intermittent explosive disorder episode include:

• Yelling
• Intense arguments
• Road rage
• Physical violence
• Damaging property

Those with IED might also experience headaches, muscle tension, heart palpitations, tremors, and an increase in energy before and during their episode. Once their outburst is over, they might feel relieved and/or tired. And later, regretful or embarrassed by their behavior.

How Do You Know If You Have Intermittent Explosive Disorder?

If you or your friend have angry outbursts that involve the above signs and symptoms, you might have intermittent explosive disorder. Some people with IED have these episodes regularly, while others go for weeks or months without having an outburst. 

The only way to know for sure if you have intermittent explosive disorder is to see a mental health professional. They can observe your symptoms, make a diagnosis, and then create a personalized treatment plan for you that’ll help you successfully manage your disorder. 

What Causes IED? Is Intermittent Explosive Disorder Genetic?

Like many psychiatric conditions, intermittent explosive disorder can be caused by a combination of neurological, genetic, and environmental factors. IED can first be diagnosed at age six and it usually peaks in mid-adolescence.

Most neurological research into the condition implicates serotonin abnormalities and difficulties in regulatory control of the prefrontal cortex. Psychological testing shows that people with IED have stronger amygdala reactions to angry faces. They also make more mistakes on the Stroop test, which measures cognitive interference. 

In addition, risk factors for intermittent explosive disorder include:

• Exposure to violence or explosive behavior as a kid
• Being male (intermittent explosive disorder is more common in men than women)
• Experiencing physical or emotional trauma (research has shown a strong link between childhood trauma and IED)
• Having a history of substance abuse
• Having other medical conditions

Is IED a Form of Bipolar? 

IED is frequently misdiagnosed, leading to inadequate treatment, so it’s helpful to understand what IED is not. First, it is not bipolar disorder: Some research suggests that IED and bipolar disorder can co-occur at high rates, but they are not the same thing. For example, someone with bipolar disorder exhibits far more mood symptoms than someone with IED. Both disorders, however, may involve brain regions that regulate top-down control of aggression and violent behavior. 

To diagnose IED, mental health professionals need to rule out other possible causes of the behavior, too. For example:

• Disruptive mood dysregulation disorder (DMDD). As discussed earlier, IED is characterized by brief, unprovoked episodes rather than pervasive and persistent emotions that might indicate a mood disorder like DMDD.  
• Post-traumatic stress disorder (PTSD). Aggressive behavior can also be a symptom of PTSD, but PTSD is dimensional, not taxonic in nature. The comorbidity of these two disorders may lead to worse outcomes.
• Rageaholism. Being a “rageaholic” is not a medical diagnosis.
• Personality disorder. Mental health disorders like antisocial personality disorder and borderline personality disorder are also dimensional, not taxonic. Someone with IED might also have a personality disorder, but the two diagnoses are distinct.
• Oppositional defiant disorder (ODD). Someone with ODD might lose their temper and suffer psychosocial consequences, but their hostility is typically more directed at authority figures. 
• Attention deficit/hyperactivity disorder (ADHD). Someone with ADHD might show affective intensity and lability, but ADHD doesn’t cause serious aggression.

How Do You Calm Someone with IED?

First, it’s important that you know you are not responsible for de-escalating an angry person. They must take responsibility for their own emotional and behavioral health. That said, if someone you care about has intermittent explosive disorder and you want to help during their outbursts, you can utilize specific de-escalation techniques. 

Effective de-escalation requires patience and calm. As much as you can, try to disengage from your personal feelings during the episode. It may be helpful to recognize the IED person’s behavior as out of their control. 

People with IED may have incredibly intense emotions, immature defense mechanisms (like projection and denial), and poor reality testing. This can all make it nearly impossible to deal with them rationally. So instead, you defuse. Here are some specific de-escalation techniques that might prove useful during IED outbursts:

• Use tactful language rather than belittling the person.
• Don’t invade the person’s personal space, but stay close enough to build rapport.
• Use shared problem-solving tactics to affirm the person’s feeling of autonomy. For example, say, “What can we do to fix this?”
• Don’t deliver ultimatums or engage in power struggles.
• Validate the person’s anger. They’re allowed to express their feelings as long as they’re not harming themselves or others.  
• Suggest face-saving alternatives to their aggression, like a cooling-off period.
• Use active listening skills, which show that you’re positively engaged.
• Offer empathetic statements, like, “It sounds like you’re really hurt.”
• Don’t relitigate what happened or who was at fault. Keep returning to potential solutions to the problem. 
• Use deliberately calm body language and a soothing tone of voice. Don’t feed the drama.
• Use positive reinforcement when the person regains control.

If you feel threatened, you’ll need to take a firmer approach. You may need to shift your supportive stance to a control stance and/or remove yourself to a safe area. 

An intimate partner of someone with IED may be familiar with the person’s emotional triggers and be able to recognize the signs that an outburst is coming. For example, the person with IED might shake, experience tightness in their chest, or start to become agitated. But this doesn’t mean that a partner has the luxury of avoiding the episode. In fact, they may be the first line of defense. 

For a loved one, acute IED outbursts might feel like emotional tyranny. The person may become verbally or physically abusive, which is never okay in an intimate relationship. To keep yourself safe, eliminate access to weapons or dangerous objects that the person might use to harm themselves or others. Devise an escape plan that you can enact if you feel threatened. 

Unfortunately, only a minority of people with IED receive treatment. They may never recognize the negative consequences of the explosive episodes they’re unable to control. If the person you love isn’t willing to admit they have a problem and work on mitigating their impulsive aggressive behavior, you may need to protect yourself by leaving the situation for good. 

Intermittent Explosive Disorder Treatment

Like many other mental disorders, intermittent explosive disorder treatment often involves prescription medication — particularly SSRIs like fluoxetine — and cognitive behavioral therapy (CBT). 

Intermittent explosive disorder medication: Antidepressants, anti-anxiety medications, and mood regulators are commonly prescribed for intermittent explosive disorder. Fluoxetine — a selective serotonin reuptake inhibitor (SSRI), which is an antidepressant — is the most studied and research-backed medication for treating IED. 

Therapy for intermittent explosive disorder: Cognitive behavioral therapy (CBT) includes coping skills training, relaxation training, and cognitive restructuring that has been shown to reduce anger, automatic thoughts, and impulsive behavior. 

Can Intermittent Explosive Disorder Be Cured?

No, intermittent explosive disorder cannot be cured. However, it can be successfully treated with medication and therapy, as outlined above. Treatment is focused on helping those with IED to better regulate or manage their angry outbursts.

Intermittent Explosive Disorder Test

If you’re concerned that someone you know might have symptoms of intermittent explosive disorder, they can complete an intermittent explosive disorder test here. 

If your concerns remain, a mental health professional can administer a full IED screening questionnaire (IED-SQ) and develop an individualized treatment plan. Remember: A diagnosis is not an identity. In most cases, it’s the first step toward recovery.