Intermittent Explosive Disorder and Its Impacts on Relationships

Intermittent explosive disorder (IED) causes sudden outbursts of anger entirely disproportionate to the situation. These outbursts can range from verbal abuse to physical violence and are not controllable or premeditated.

The DSM 5, or Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, describes IED as "a recurrent behavioral outburst representing a failure to control aggressive impulses as manifested by set criteria."

Paul Poulakos, D.O., a board-certified psychiatrist in Greenwich Village in New York City and an assistant professor at the Icahn School of Medicine at Mount Sinai, broke down the criteria for IED:

• You must display behavioral outbursts at least twice weekly over a period of three months.
• The intensity of the outburst/reaction is out of proportion to the situation. In other words, it is not considered a reasonable response given the circumstances.
• The recurrent aggressive outbursts are not better explained by another mental disorder and are not attributable to another medical condition.
• These outbursts are not premeditated; rather, they are in the moment and impulsive.

Although the outbursts typically last fewer than 30 minutes, this behavior causes significant distress to the individual experiencing it after the aggression subsides.

People with IED frequently have other mental health disorders alongside the condition. Research indicates 80.5 percent of people with IED have at least one comorbid disorder, the most common being anxiety disorder.

Alex Dimitriu, M.D., board-certified in psychiatry and sleep medicine, and founder of Menlo Park Psychiatry & Sleep Medicine in California and BrainfoodMD supplements, explained the main challenge in diagnosis is teasing apart IED from anxiety, stress, depression or sleep deprivation, as these conditions are far more common.

"People act explosively with temper tantrums and rage when they are at their wit's end, exhausted or overworked, and the smallest thing will make them snap," Dimitriu said. "Sleep deprivation is a common reason people can become more impulsive and short-tempered. Being overworked, stressed, depressed or anxious and reactive can also make people react suddenly and intensely."

Dimitriu also noted attention-deficit/hyperactivity disorder (ADHD) might also cause poor impulse control in some people.

"Indeed, people with both anxiety and ADHD perceive and respond to the world in an intense way," he explained.

Poulakos added that according to studies, IED affects anywhere from 2.7 to 7.3 percent of the general population. Per the National Institutes of Health, that range equates to an estimated 11.5 million to 16 million Americans affected by IED in their lifetime.

"IED is also twice as common in males than females," Poulakos said.

IED can significantly impact relationships and might predispose people to depression, anxiety, and alcohol and drug use disorders. It can also lead to serious consequences for an individual's everyday life, such as job loss or divorce.

How IED affects interpersonal and workplace relationships

Symptoms of IED typically appear in late childhood or early teenage years, with the majority of cases occurring in people younger than 35, and the highest-risk age group being 13 to 23 years old.

In these important years, you're discovering who you are as a person, finishing school and beginning to establish a career. But as Poulakos highlighted, the frequency and intensity of IED outbursts can significantly affect someone's interpersonal relationships, at work and at play.

"For the individual struggling with IED who is not in treatment, they may experience fear and/or anxiety in anticipation of a future outburst that feels out of their control," Poulakos explained. "This can lead to them isolating or responding in various maladaptive ways that could harm their relationships."

Poulakos added that the aggression accompanying an outburst might lead others to distance themselves, both socially and professionally.

"Being around someone with IED that is not undergoing treatment can feel like walking on eggshells, which can be uncomfortable and cause people to want to stay away," he said. "Left untreated, IED can lead to the loss of friendships, romantic or occupational relationships."

The treatments and support available

There is no gold-standard treatment for IED, but Poulakos advised that clinicians usually recommend a combination of psychotherapy and medication. He suggested a variety of proven psychotherapy treatment options:

• Cognitive behavioral therapy works by addressing potential cognitive distortions (beliefs, attitudes and thoughts) that may be maladaptive or destructive. By identifying cognitive distortions, it's possible to modify your thoughts. This can positively impact future behaviors and improve emotional regulation.
• Skill training may include incorporating relaxation exercises, communication techniques and/or anger management.
• Exposure therapy requires you to identify potential aversive scenarios that may prompt aggression. Once a trigger scenario has been identified, you are exposed to the scenario (under clinician supervision) repeatedly over time. The goal is for you to become desensitized, so the aggressive behavior no longer occurs when you're faced with that specific trigger scenario.
• Medications. Antidepressants—such as selective serotonin reuptake inhibitors (SSRIs) and serotonin and norepinephrine reuptake inhibitors (SNRIs)—are first-line options.

"Other treatments include addressing other existing psychiatric disorders and minimizing/avoiding alcohol or other drug intoxication, which can worsen the symptoms of IED," Poulakos added.

Living with, working alongside or supporting someone with IED

Nearly 40 percent of IED sufferers report a severe functional impairment in at least one area of their life, such as home management, their workplace, relationships or social life in general.

"An important point to raise to someone you know who might be struggling with these symptoms is that these outbursts are not extensions of themselves, but rather a symptom of a mental illness," Poulakos explained. "These outbursts are not premeditated. Hence, it is normal to feel like you can't control these impulses without treatment."

According to Poulakos, researchers believe there is a genetic component to the illness with an association with first-degree relatives. Fortunately, the behaviors often decrease and become less pronounced with age.

"If you know someone struggling with IED, remember to be compassionate," Poulakos said. "IED is associated with increased nonsuicidal, self-injury behavior and suicide risk."

Studies indicate approximately 17 percent of individuals with IED have attempted suicide and 38 percent have thought seriously about it.

"It is important to monitor these individuals closely and provide support," Poulakos added.

If you are concerned someone you know is having thoughts of suicide, don't hesitate to reach out for free and confidential support. The National Suicide Prevention Lifeline provides support for people in distress, as well as prevention and crisis resources, and is available 24 hours a day at 800-273-8255. In addition, starting July 16, 2022, the three-digit dialing code of 988 will automatically route callers to the lifeline.

It's easy to interpret the aggressive behaviors of individuals struggling with IED as inexcusable and intentional, which means you may be reluctant to offer compassion.

"Someone with IED has likely encountered this sort of negative response and may even be convinced that it is their fault," Poulakos explained. "It is important to remember that these behaviors are not planned nor intentional, and it is helpful to reassure the individual of this."