Understanding Intermittent Explosive Disorder

Key Takeaways:

  • Definition and Diagnosis: Intermittent Explosive Disorder (IED) is characterized by repeated, sudden episodes of impulsive, aggressive, or violent behaviour that are disproportionate to the situation.
  • Causes and Risk Factors: IEDs can be influenced by genetics, brain differences, childhood trauma, mental health issues, and environmental triggers.
  • Symptoms and Signs: Common signs of IED include verbal outbursts, physical violence, road rage, domestic abuse, and extreme irritability between outbursts.
  • Treatment Options: Effective treatments for IED include cognitive behavioural therapy, anger management classes, medication, and lifestyle changes.
  • Impact on Daily Life: Untreated IEDs can significantly affect relationships, work, legal standing, financial stability, physical health, and mental health.

Have you ever felt like you lost control in the heat of anger? Maybe you’ve had outbursts where you yell uncontrollably, say hurtful things, or even get physical with people or objects around you. If this sounds familiar, you’re not alone. 

Many people struggle to keep their anger in check at times. But when these rage episodes happen repeatedly, you may be dealing with intermittent explosive disorder (IED) despite your best efforts to control them.

What is Intermittent Explosive Disorder?

IED is a psychological disorder characterized by repeated, sudden episodes of impulsive, aggressive, or violent behaviour grossly disproportionate to the situation. According to the DSM-5, the standard reference for mental health disorders, a diagnosis of IED requires:

  • Three or more anger attacks over 12 months that involve damage or destruction of property or physical harm to animals or other people
  • The degree of aggressiveness expressed is severely out of proportion to any external stressors or provoking factors
  • The outbursts are not premeditated and reflect a failure to control impulses
  • The outbursts cause significant distress or impairment in relationships, jobs, or other areas of functioning

Some common symptoms of IED include:

  • Verbal outbursts like shouting, screaming, or heated arguments
  • Physical aggressiveness and physical violence, such as hitting, punching, and throwing objects
  • Impulsive aggression, even over minor incidents
  • Extreme irritability most of the time
  • Road rage or confrontations with strangers

IED affect up to 7% of the population at some point in their lives. It often begins in adolescence and is more common in younger adults under 40. Men seem to be affected more frequently than women.

So, what causes usual frustration to escalate into full-blown rage? There are likely multiple factors at play, both biological and environmental:

  • Genetics – IED can run in families, suggesting a hereditary component
  • Brain differences – People with IED may have less gray matter in areas that regulate emotions
  • Childhood trauma – Abuse, neglect, and exposure to violence increase IED risk
  • Mental health issues – Conditions like depression, anxiety, PTSD are linked to IED

While anyone can have an anger outburst now and then, consistent loss of control, like in IED, can wreak havoc on relationships, careers, and overall well-being. The good news is several treatments are available to help manage IED. But the first step is recognizing when anger has become a serious problem.

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Causes and Risk Factors

Experiencing the occasional burst of anger is part of being human. But why do some people struggle with rage and aggression they can’t control? There is still much to uncover about the origins of intermittent explosive disorder (IED). Still, research has shed light on critical factors contributing to this condition’s development contributing to this condition’s development.

Biological Factors

Our biology and brain makeup significantly affect emotional regulation and impulsive behaviour. Some insights into the biology underlying IED:

  • Genetics – IED tend to run in families, suggesting hereditary risks. Having a first-degree relative with IED increases your risk.
  • Brain differences – Imaging studies show structural and functional brain irregularities in people with IED:
    • Less gray matter – The volume of gray matter is lower in areas critical for emotional control, like the anterior cingulate cortex.
    • Overactive amygdala – This primal region related to fear and aggression shows heightened activity.
    • Low serotonin – This neurotransmitter influences mood and behaviour control.
  • Hormones – Fluctuating or abnormal testosterone levels, estrogen, and cortisol levels may contribute to irritability and poor anger control.

Environmental Triggers

In addition to biological vulnerabilities, situations and experiences in a person’s environment can set the stage for developing IED:

  • Childhood trauma – Physical, emotional, or sexual abuse as a child is strongly linked to later impulse control problems.
  • Exposure to violence – Growing up in a violent home or community normalizes aggression.
  • Parenting factors – Harsh punishment, neglect, poor supervision, and hostility model unhealthy behaviour.
  • Stress – High levels of chronic stress, especially early in life, affect the body’s stress response.
  • Substance abuse – Intoxication lowers inhibitions and makes aggressive outbursts more likely.

Mental Health Comorbidities

IED rarely occurs in isolation. Many mental health conditions involve anger and emotional dysregulation and commonly co-exist with IED:

  • Depression – Irritability, negativity, and low frustration tolerance often accompany depression. Up to 43% of people with IED have depression.
  • Anxiety – Anxious distress and racing thoughts may precipitate anger episodes.
  • PTSD – Hyperarousal and flashbacks can trigger aggressive reactions. Around 38% of people with IEDs have PTSD.
  • Borderline personality disorder – Intense but unstable emotions are a hallmark of this disorder commonly linked to childhood trauma.
  • ADHD – Poor impulse control and hyperactivity increase susceptibility to anger problems.
  • Substance abuse disorders – Chronic alcoholism or drug addiction worsens and results from uncontrolled anger.

Other Risk Factors

  • Age – IED often first appears in adolescence. It’s most prevalent in younger adults under 30.
  • Gender – Men have nearly triple the risk of developing IED compared to women. The role of testosterone is being studied.
  • Traumatic brain injury – Injury to brain areas that govern impulse control is linked to aggression.
  • Cognitive disorders – Conditions like autism or intellectual disability that impair social skills can limit emotional regulation.

IEDs arise from a storm of biological vulnerabilities, life experiences, and mental health disorders. Multiple factors likely converge to create a tendency toward explosive anger that, untreated, can devastate lives.

Symptoms and Signs

Losing your temper from time to time is normal, but how can you tell if anger has become a more serious issue? People with intermittent explosive disorder (IED) display frequent, significant problems controlling their rage and aggression.

Some common signs and symptoms of IED include:

  • Repeated aggressive outbursts out of proportion to the situation (e.g. screaming over minor frustrations, threatening others over small disagreements)
  • Physical violence such as hitting, punching, kicking, throwing/breaking things
  • Verbal aggression like shouting, angry cursing, abusive language
  • Road rage – aggressive driving, making threats, hostile gestures
  • Domestic abuse – physically or emotionally abusive behavior toward family members
  • Angry tantrums or meltdowns
  • Extreme irritability between outbursts resulting in frequent confrontations
  • Impulsivity – taking rash actions when enraged without consideration of consequences

According to the DSM-5 diagnostic standards, three main criteria must be present to warrant an IED diagnosis:

  • Recurrent, impulsive aggression – Verbal or physical outbursts occurring twice weekly on average for 3 months or 3 severe episodes involving harm/destruction within a year.
  • Extreme reactions – Aggression expressed during outbursts is grossly disproportionate to any provocation.
  • Distress or impairment – The outbursts negatively impact relationships, work, or other areas of functioning.

Additionally, aggressive behaviour cannot be better accounted for by another mental or medical disorder, substance intoxication, or medication side effects.

People with IED often describe feeling unable to control their fury in the moment. Anger episodes tend to be short-lived, lasting less than 30 minutes, followed by feelings of remorse once the rage subsides.

Treatment Options

If you or someone you love suffers from intermittent explosive disorder (IED), know you don’t have to continue feeling powerless against uncontrollable rage. Various evidence-based treatment approaches are available that can help regain command of your emotions.

Psychotherapy

The cornerstone of treatment for IED is psychotherapy, particularly cognitive behavioural therapy (CBT). By exploring thought patterns and developing coping skills, CBT can help prevent aggressive outbursts. Common techniques include:

  • Cognitive restructuring – Identifying and reshaping anger-provoking thoughts
  • Relaxation training – Deep breathing, visualization, progressive muscle relaxation
  • Skills training – Improving communication, problem-solving, conflict resolution
  • Exposure therapy – Gradually facing anger-inducing situations while practicing new responses

Additional psychotherapies like dialectical behaviour therapy (DBT) and Acceptance and commitment therapy (ACT) that focus on mindfulness, distress tolerance, and emotion regulation can also be effective.

Anger management classes and support groups provide a structured environment to learn how to understand and better direct your anger. These are widely available across Canada.

Online therapy for individuals is an accessible option that allows you to meet regularly with a therapist via video. Our clinic offers online cognitive behavioural therapy for anger management and emotion regulation.

Medication

While there are no medications specifically approved for IED, particular drugs may be used as an adjunct treatment to help control aggression and stabilize mood:

  • Antidepressants – SSRIs like Prozac are commonly prescribed for irritability and impulse control.
  • Mood stabilizers – Lithium anticonvulsants (Depakote, Tegretol) can reduce angry outbursts.
  • Antipsychotics – Risperdal Abilify may be used for severe aggression.
  • Anti-anxiety drugs – Benzodiazepines like Klonopin quickly relieve agitation but carry risks.
  • Beta-blockers – Propranolol blocks adrenaline’s effects and can dampen rage reactions.

A doctor should carefully monitor medication since efficacy for IED is limited, and side effects can occur.

Lifestyle Changes

Adjunctive lifestyle adjustments to support IED treatment include:

  • Stress management – Yoga, exercise, meditation, nature time
  • No drug/alcohol use – These lower inhibitions and worsen symptoms
  • Sufficient sleep – Lack of sleep impacts mood and decision-making
  • Healthy diet – Limit sugar, caffeine, processed foods that exacerbate symptoms
  • Support system – Surround yourself with understanding people you can count on

With professional help and commitment to treatment, people with IED can overcome their explosive anger and regain emotional equilibrium. 

Living with IED

Coping with intermittent explosive disorder (IED) is an ongoing challenge, but various strategies can help you manage your symptoms and minimize their impact on your life.

Coping Techniques

With professional treatment, many people with IED find the following techniques helpful for keeping their anger under control day-to-day:

  • Take a timeout – Walk away from anger-inducing situations until you cool down.
  • Deep breathing – Slow, centred breathing can defuse tension rapidly.
  • Progressive muscle relaxation – Alternately tensing and relaxing muscle groups reduce stress hormones.
  • Cognitive restructuring – Reframing thoughts in a calmer, more rational way.
  • Communication skills – Expressing anger assertively, not aggressively, staying calm and listening.
  • Self-care – Regular exercise, healthy eating, sufficient sleep, stress management. Reduce alcohol.
  • Support network – Surround yourself with positive people you can count on to help in difficult moments.
  • Change your environment – Avoid or limit time in situations or with people who regularly trigger rage episodes.
  • Stick with treatment – Keep up with medications, therapy, and support groups. Healing takes time.

Impact on Daily Life

Living with untreated IED can overshadow all areas of life:

  • Relationships – IED causes conflict with family, friends, and partners. Loved ones often feel hurt, resentful, afraid, or detached. Social isolation is standard.
  • Work or school – Frequent anger issues result in disciplinary action, job loss, and dropout. Colleagues and classmates tend to keep their distance.
  • Legal problems – Aggressive behaviour commonly leads to lawsuits, arrests for domestic violence, destruction of property, and traffic violations.
  • Financial hardship – Impulsive behaviour, unstable employment, and damages from rage incidents take a monetary toll.
  • Physical health – Chronic stress and anger negatively impact heart health, weaken the immune system, and increase inflammation.
  • Mental health – IED is linked to higher rates of depression, anxiety, PTSD, and substance abuse—the risk of self-harm and suicide increases.

However, effective treatment allows people with IED to heal relationships, succeed at work, avoid legal troubles, protect their health, and lead happier lives.

Caregiver and Family Considerations

For loved ones of someone with IED:

  • Learn about IED and encourage treatment, but don’t enable poor behaviour. Set boundaries.
  • Make a safety plan. Know your local emergency resources. Remove objects that could be used as weapons.
  • Don’t take anger personally. Understand episodes are a symptom of their condition.
  • Offer loving support, but don’t try to fix or control them.
  • Prioritize your self-care. Seek counselling if needed.
  • Help them adhere to treatment plans and lifestyle changes. Provide accountability.
  • Be patient. Celebrate small improvements. Change takes time. Focus on positive qualities.

Caring for someone with IED is challenging. With compassion, education, and support, families play a pivotal role in recovery.

Stories and Examples

Beyond the facts and figures, real stories from people affected by intermittent explosive disorder (IED) provide a human perspective on living with this condition.

Tom's Story

Tom first realized he might have a problem with anger when his wife threatened to leave after he put his fist through a wall during an argument.

“It scared me how quickly I lost control over something so minor. But looking back, I see now I’ve always had a short fuse.”

Growing up, Tom’s father had frequent violent outbursts.

“I grew up thinking that yelling, throwing things, even hitting was normal when you got angry. I never saw my dad get help for it, so I didn’t realize there was anything wrong with me either.”

The temper flare-ups created problems for Tom at school and jobs over the years. He found himself getting into fights and arguments regularly. Still, it wasn’t until his wife gave him an ultimatum that he sought help. Tom has seen significant improvements after an IED diagnosis and several months of therapy.

“Just knowing this is a recognized condition, not just me being an angry person, has made a big difference. The tools I’ve learned in therapy like walking away from situations and countering my negative thoughts have really changed my life. I feel in control now.”

Sarah's Story

As a child, Sarah’s single mother struggled with alcoholism and often lashed out at Sarah verbally and physically. In her twenties, Sarah would go from calm to enrage over minor annoyances like getting stuck in traffic or having a waitress bring the wrong food order. These explosive episodes caused problems at work and in her relationships.

“I feel so much shame after I blow up at people. I apologize but they never seem to want to be around me anymore. I don’t want to be this way but it’s like I’m a bottle of soda that’s been shaken up and I just burst.”

Sarah’s concerned roommate suggested she might have intermittent explosive disorder and urged her to see a counsellor.

“I’m learning how my childhood shaped these patterns and that my brain adapted in ways that don’t serve me anymore. When I start to get worked up, I take some deep breaths, walk away, and visualize calm ocean waves like my therapist taught me. It really helps defuse the rage.”

Sarah continues to work on understanding her triggers and finding healthy outlets for her emotions.

Therapist Perspective

“Many people think someone with aggression issues is just a violent hothead. But when you understand the underlying neurological and psychological mechanisms, you gain empathy.”

We help clients identify distorted thought patterns, communicate assertively, employ de-escalation strategies, and gain perspective through mindfulness techniques.

“With consistency, these skills start to ‘rewire’ the brain’s response to triggers. Rage begins to lose its power over their choices. Many begin to heal wounded relationships. It’s very rewarding.”

Improving one’s environment is also key. “Limiting exposure to provoking situations reduces the need to tap into the new coping skills.”

Co-Occurring Disorders

The signs of intermittent explosive disorder (IED) sometimes resemble those of other mental health conditions. It’s important to note that IED often occurs alongside other mental disorders, including:

  • Conduct disorder
  • Oppositional defiant disorder (ODD)
  • Bipolar disorder
  • Anxiety disorders
  • Depressive disorders
  • Post-traumatic stress disorder (PTSD)

Frequently Asked Questions (FAQs)

Everyone gets angry sometimes. But with IED, rage reactions are frequent, intense, and disproportionate, resulting in behavioural or verbal aggression that causes distress and impairment. It's a chronic problem controlling impulsive anger, not just occasional frustration.

Yes, IED often emerge in adolescence, though a definitive diagnosis isn't made until adulthood. Around 10-15% of teens may experience IED symptoms. Early treatment can prevent worsening in adulthood.

Those with certain cluster B personality disorder traits like emotional volatility, and hostility have increased IED susceptibility. But no single personality type inevitably leads to IED if other risk factors aren't present.

Triggers vary but include minor inconveniences, perceived insults, arguments with family, work problems, driving frustrations, etc. The same minor annoyances that bother but don't enrage most people can provoke an outburst in someone with an IED.

Frequent temper tantrums or lashing out violently in childhood, punching walls, regular relationship conflict due to excessive anger, self-harm threats during rage episodes, and a family history of aggression or mental illness are red flags that something more profound is amiss.

Cognitive behavioural therapy focused on emotional regulation, communication training, and skills building has the most substantial evidence. Supportive psychotherapy and medication are also often included in a comprehensive treatment plan.

Pareen Sehat MC, RCC

Pareen Sehat MC, RCC

Pareen’s career began in Behaviour Therapy, this is where she developed a passion for Cognitive Behavioural Therapy approaches. Following a Bachelor of Arts with a major in Psychology she pursued a Master of Counselling. Pareen is a Registered Clinical Counsellor (RCC) with the BC Association of Clinical Counsellors. She specializes in CBT and Lifespan Integrations approaches to anxiety and trauma. She has been published on major online publications such as - Yahoo, MSN, AskMen, PsychCentral, Best Life Online, and more.

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