Intermittent explosive disorder is a condition characterized by repeated, impulsive episodes of marked by aggressive, violent behavior or verbal tirades and outbursts that are grossly out of proportion to the situation. The condition is more common among children. For adults, this might be exhibited in actions like road rage, or acts of overt violence. These sorts of outbursts by adults onerous, but we often allow such responses in our fellow adults, reasoning that they are justified in the situation.
When a person exhibits such elevated responses to stressors or frustrations, it can be quite confusing to both the person and their loved ones. It can become even more confounding when the person is a child. It is important to note that IED can appear in people that have not been exposed to a trauma nor is the victim of abuse. Intermittent Explosive Disorder, as the DSM 5 goes on to explain, can be diagnosed in children as young as six-years-old through to adults. What makes this pattern particularly frustrating for people that observe such outbursts in someone is that the episodes are relatively short-lived and the person may quickly return to an acceptable behavior pattern immediately after the episode.
Fortunately, mental health professionals have begun to recognize that IED is very real and can be controlled and treated with great success. By recognizing that a person’s episodes are more frequent than normal or more violent than a situation calls for, the disorder can be diagnosed and an appropriate course of treatment can be prescribed.
Intermittent Explosive-Disorder in Children
The development of a child’s mind is a complex process. We know that children learn from every experience they encounter. They learn how to appropriately respond to different stimuli and stressors through observation and trial and error. They see how the adults and their peers react to experiences and emulate. Then, through situational exposure, they use what they’ve learned.
When we see a child display a response that is well beyond a reasonable reaction to a situation, it is our natural behavior to scold the child or attempt to curb the episode. For example, in the case of a child having an episode in a classroom, a teacher or assistant will see the situation and knows they must react to maintain the safety of the other children and preserve the classroom environment for the other children. While this is obviously prudent for the benefit of the other children, it can actually be a detriment to the child engaged in an IED episode.
Until IED began gaining acceptance in the 1980’s as a diagnosis, many children were misdiagnosed as having Oppositional Defiant Syndrome. ODS also presented with outbursts, both verbal or physical in nature, that were in excess of the provocating stressor or stimuli. Where the two diagnoses diverge is in the child’s response to engagement during episodes. Whereas clinicians believed in the past that a child in an episode was acting aggressively in response to intervention, it is now understood that intervening during an episode does not expressly increase or accelerate the episode.
Symptoms of IED
The symptoms of IED include outbursts either in the form of verbal tirades or physical aggression. The outbursts occur without provocation or are situationally inappropriate.
There are no clear sources of the disorder, though there has been a higher incidence of it in people exposed to traumatic situations. For example, Harvard researchers tell us refugee populations seem to exhibit increased numbers of IED diagnoses than general populations.
According to one study, IED symptoms are notable on average at age 13 for boys and age 19 for girls.
The physical symptoms may include:
- Increased energy
- Racing thoughts
- Chest Tightness
The actual, violent episodes can manifest as follows:
- Temper tantrums
- Heated arguments
- Slapping, shoving or pushing
- Physical fights
- Property damage
- Threatening or assaulting people or animals
Oftentimes, a child may feel remorse or a sense of relief after an episode. There is often a physical sense of tiredness after an episode. Episodes typically do no last more than 30 minutes. In situations where physical violence occurs, the child is not cognitively aware of authority.
Untreated, they lack the ability to distinguish right and wrong and cannot control impulse reaction. A key point in differentiating IED from psychosis or other mental illness is post-episodic remorse. A child may later feel embarrassed or regretful for the episode.
It is important to note that the person experiencing the episode is not in control of their actions during the episode. Though this is a controversial position, Harvard University research indicates that there is measurable physiological brain chemistry changes that can be associated with Intermittent Explosive Disorder. In other words, a person experiencing an IED episode is no more in control of their mental situation than someone with another mental illness.
Children that suffer from IED do not exhibit planning or forethought related to episodes. Their episodes can be and often are independent of other mental illness. There are some indications that comorbidities do exist. Most common in these comorbidities is Post Traumatic Stress Disorder. Exposure to violence and/or domestic violence does appear to increase the instance of IED. There are also indications that anxiety disorders and depression can occur in children with IED.
It is important that clinicians rule out other factors for aggressive episodes before attributing them to IED. Contributing factors like head injuries, substance abuse and other mental illness can cause similar outbursts of rage, according to Childmind.org. In the absence of these conditions, IED may be the cause. Again, IED does carry with it a higher frequency of incidence, often two or more times a week for at least three months.
Most children that have been recommended for diagnosis and/or treatment are said to have come from family situations where explosive outbursts are the norm. This observation supports the likelihood that IED is a genetically predisposed disorder. Lack of earlier recognition of the disorder means that there is a lack of clinical evidence to support this, but anecdotally it seems reasonable, as many mental disorders can be hereditary.
According to Theravive.com, people that have been exposed to highly traumatic situations, such as gun violence, war zones and refugees are more susceptible to episodes of IED. Even when their current situation is one of relative safety and socially mainstream activity, stressors can trigger IED episodes.
Fortunately, Intermittent Explosive-Disorder is treatable. Like much of mental health, correcting IED takes time and can require both behavioral remedies and pharmacological treatments. There is no one way, no magic bullet that works for everyone.
Families and loved ones must be enlisted in the treatment program. Failing to recognize the degree of influence a person’s homelife has on their mental well-being can be a grave underestimation with dire consequences.
It is possible to reach remission through a number of psychotherapeutic treatments. Treatment protocols that focus on cognitive restructuring have been found to be very effective. The person with IED has a tendency to externalize the causation of their episodes. An appropriate treatment plan will take this into consideration and work to help the patient recognize that the disorder, not the situation is the cause of their aggression.
Cognitive Behavior Training (CBT), is a behavior modification program that teaches patients how to refocus thought processes before and during mental health episodes. There are several CBT programs that have proven to be successful in managing symptomology. It is important that patients maintain program involvement to obtain success.
While the Cognitive Behavior Training is being administered to the patient, it has proven beneficial for family members, and partners in particular, participate in behavior-modifying training, as well. Recognizing and treating the contributing factors that may exist in the home has a profound effect on the overall success of any patient’s course of treatment.
In addition to learning how to improve the overall condition of the family unit, it is very important for partners and families to learn how to best handle a person in the midst of an IED episode. By learning how to properly engage someone in an agitated, aggressive state, family members can help prevent injuries and damage to property. Understanding the causes and the nature of cogitation for the patient helps other family members respond during and after an episode.
CBT can be particularly successful in children with IED because of their ability to feel remorse after an episode. The thought is that because they truly do not wish to have the episode and can sense that their episode was a negative experience afterwards, they have the intellectual capacity to change the behavior.
According to a small study conducted by the University of Chicago, after a program of 12 weekly sessions, study participants exhibited significantly lower numbers of episodes and lower levels of depression.
Relaxation therapy is another successful treatment program. By teaching patients relaxation techniques and self-soothing practices, therapists have been able to decrease the impact external stressors have on patients.
There are many options in relaxation therapy programs and no one is better than others—what works for some may not work for others. Work with psychology professionals when choosing a relaxation program to ensure there is no contradictory methodology.
Harvard University suggests relaxation programs like:
- Breath Focus
- Guided Imagery
- Tai Chi
- Mindful Meditation
Group counseling can be beneficial for many patients. Being able to communicate issues in a safe, controlled environment with peers has proven a successful method in treating mental illnesses. Programs that address specific symptomology are available through local hospitals and medical centers. For assistance in finding local programs, your psychologist or your local chapter of NAMI can help. Group counseling should be limited to age-appropriate groups and should always be led by trained mental health counselors and social workers.
Communication skills training is very helpful for younger patients. Knowing that children are still developing their communications skills, a psychotherapist that specializes in helping develop communications skill can help a small child learn how to express their needs. Developing the ability to better communicate can lower the frustrations that may lead to IED episodes. Through play-therapy and other age-appropriate therapies, communication skills can be improved, even nonverbal communication skills that may help defuse a stressor.
Again, family members are encouraged to participate in this skill training program. Being better able to read the signals of a child before an episode starts can go a long way in preventing a full-blown IED episode.
Medication can help. When other methods fail to produce enough results, it may be necessary to investigate pharmacological options. While there are no medications that are specifically created for IED, there are several kinds of prescription medications that may help control the physiological causes of IED. Studies are indicating that there may be issues with serotonin levels, particularly in the prefrontal cortex, where aggression control is based. There have been good results using a number of different classes of psychotherapeutic medications in treating IED.
Selective serotonin reuptake inhibitors (SSRI), a class of antidepressants have been known to help maintain better serotonin levels in IED patients.
Aggressive patients on fluoxetine have shown good response to the medication and less incidents of aggression.
Mood stabilizers, like lithium, have also been helpful in establishing better impulse control.
Anticonvulsants, typically in the Benzodiazepine class of medications have been prescribed at low doses to help keep impulse control balanced.
Intermittent Explosive Disorder can be a troubling issue for anyone. With seemingly little warning and no clear cause, it can be a trying time for both children and adults, alike. Episodes can negatively affect all facets of life, from home to school or work and from family to friends. But once recognized, IED can be successfully treated and remission is possible.
Working with mental health professionals, a patient can find relief from the aggressive outbursts and troubling behaviors that make a seemingly normal person act aggressively, impulsively and out of character. And though treatment may take time and might require several adjustments before finding an effective program, it can be successful and the IED can be managed.