Intermittent Explosive Disorder

What is intermittent explosive disorder?

Intermittent explosive disorder (IED) is a disruptive disorder characterized by aggressive outbursts with rapid onset and little to no warning. Outbursts usually occur in response to a minor provocation and last for less than half an hour. IED yearly prevalence in the United States is 2.7%. This disorder is more common in men than in women.

What does IED look like?

Signs & Symptoms

DSM-5 Criteria

Criterion A. Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

Verbal aggression or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
3 behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period

Criterion B. The magnitude of aggressiveness expressed during the recurrent outbursts is grossly out of proportion to the provocation or to any precipitating social stressors.

Criterion C. The recurrent aggressive outbursts are not premeditated and are not committed to achieve some tangible objective.

Criterion D. The recurrent aggressive outbursts cause either marked distress in the individual or impairment in occupational or interpersonal functioning, or are associated with financial or legal consequences.

Criterion E. Chronological age is at least 6 years (or equivalent developmental level).

Criterion F. The recurrent aggressive outbursts are not better explained by another mental disorder and are not attributable to another medical condition or to the physiological effects of a substance. For children ages 6 to 18 years, aggressive behavior that occurs as part of an adjustment disorder should not be considered for this diagnosis.

Note:This diagnosis can be made in addition to the diagnosis of attention-deficit/hyper-activity disorder, conduct disorder, oppositional defiant disorder, or autism spectrum disorder when recurrent impulsive aggressive outbursts are in excess of those usually seen in these disorders and warrant independent clinical attention.

Risk Factors

Adverse childhood events
First-degree relatives with IED

Prognosis

Symptoms usually appear in late childhood or adolescence and are typically chronic and persistent
Individuals may struggle with loss of friends, employment, and finances, as well as have legal charges or lawsuits against them

Differential Diagnosis

Disruptive mood dysregulation disorder
Antisocial personality disorder
Borderline personality disorder
Delirium
Major neurocognitive disorder
Substance intoxication or substance withdrawal
Attention-deficit/hyperactivity disorder
Conduct disorder
Oppositional defiant disorder
Autism spectrum disorder

How is IED treated?

Behavioral interventions

Nursing Management

Risk for other-directed violence

Causes & Behaviors:

Characteristics of temperament
Peer rejection
Negative parental role models
Dysfunctional family dynamics

Interventions:

Observe client’s behavior frequently through routine activities and interactions; become aware of behaviors that indicate a rise in agitation and intervene accordingly
Redirect violent behavior with physical outlets for suppressed anger and frustration to promote relaxation
Encourage the client to express anger in appropriate ways, and offer discussion with the client on how to manage their emotions in effective ways

References

[1] American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

[2] Boyd, M. A. (2019). Psychiatric & mental health nursing for Canadian practice. Wolters Kluwer.

[3] Townsend, M. C. (2015). Psychiatric mental health nursing. F.A. Davis.