Understanding intermittent explosive disorder (IED) and how to defuse angry outbursts

• Intermittent explosive disorder (IED) is characterized by short, intense outbursts of anger that can leave destruction in their wake. 
• People with IED may have brain abnormalities that foster impulsivity. 
• IED can be misdiagnosed as bipolar disorder, borderline personality disorder (BPD), or post-traumatic stress disorder (PTSD).
• To calm someone during an IED episode, you can use empathetic statements, active listening, and emotional detachment. 
• IED can be treated successfully with cognitive behavioral therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs).

It can be hard to summon compassion for the friend who flies off the handle from a minor provocation, or for the stranger who epically loses their cool in the grocery store. Big, aggressive emotions from our fellow humans can feel terrorising, especially when they suggest physical violence. How can innocent bystanders wrap their heads around these kinds of angry outbursts? 

The mysterious explosions might come out of nowhere and dissipate quickly. They might leave a number of scary consequences in their wake: destroyed property, personal injury, lawsuits, trauma and confusion. And if you know the perpetrator, the explosions might seem completely out of character for the person you care about. In these cases, it’s worth asking if there’s a psychiatric condition underlying the outbursts. 

Read: Anger Management 101

What Is Intermittent Explosive Disorder (IED)? 

Intermittent explosive disorder (IED) is a mental health condition included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It’s considered one of the five impulse control disorders, a family which also includes oppositional defiant disorder (ODD), conduct disorder, kleptomania, and pyromania. People with intermittent explosive disorder (IED) cannot control their aggressive outbursts, which usually come on suddenly and target someone close to them. The disorder afflicts about 16 million people in the United States. It usually has an early onset, at a mean age of 12, and seems to be more common in men than women.

IED outbursts aren’t premeditated, they’re out of proportion to the situation, and they don’t fulfill any kind of purpose, such as the attainment of money or power. For example, a person with IED who blows up at their intimate partner isn’t trying to control their partner’s actions through intimidation. There’s no discernable purpose behind the angry episode. 

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. The disorder can lead to grave outcomes for relationships and employment. But fortunately, IED 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.  

What Causes IED?

IED 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. 

Like many psychiatric conditions, intermittent explosive disorder is 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. It tends to promote other comorbid disorders like depressive and anxiety disorders (four times more prevalent amongst people with IED), and substance use disorder (three times more prevalent). 

Some research has shown a strong link between childhood trauma and IED. 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. 

What IED Is Not

IED is frequently misdiagnosed, leading to inadequate treatment, so it’s helpful to understand what IED is not. To diagnose IED, mental health professionals need to rule out other possible causes of the behavior. For example:

• Disruptive mood dysregulation disorder (DMDD). 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.
• Bipolar disorder (manic depression). 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. 
• 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. 

How to Deal with IED Explosions

IED can be frightening. But when witnessing an active IED episode, showing your anxiety or fighting back can sometimes destabilize the person more. 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 anger, you may need to protect yourself by leaving the situation for good. 

Effective Treatment for IED

Mental health professionals treat IED with prescription medication, particularly SSRIs like fluoxetine, and cognitive behavioral therapy (CBT). A CBT psychotherapy package that includes coping skills training, relaxation training, and cognitive restructuring has been shown to reduce anger, automatic thoughts, and impulsive aggression. Some people with IED may even go into complete remission with professional treatment. 

If you’re concerned that someone you know might have symptoms of intermittent explosive disorder, they can complete a self-assessment 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. 

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