What Is Intermittent Explosive Disorder?
Intermittent explosive disorder, otherwise known as IED, is a psychiatric illness that is not well known. It doesn’t get the fame and attention that many more common disorders garner, like depression or anxiety. This can sometimes condition people into believing it’s not terribly common or that it’s not too troubling if it’s not being mentioned very often, but that couldn’t be further from the truth.
The disorder is behavioral in nature and generally marked by over-the-top reactions to stimuli. These reactions are often not aligned with what is actually going on. For example, someone may spill a drink and react so violently and be so upset that an onlooker would think something terrible and life-altering has just occurred. The person may lash out at others and even assault someone out of anger. Despite being so rarely talked about, the disorder affects as many as 16 million people in the United States over the course of their lifetimes, according to the National Institute of Mental Health.
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What It Looks Like
Only professionals should attempt to diagnose the disorder; however, the presence of symptoms can prompt a person to seek professional help. Mayo Clinic notes aggressive and verbal symptoms may present as:
- Irritable mood
- Racing thoughts
- Heart palpitations
- Tightness in the chest
- Violent arguments
- Physical altercations
- Damage to property
- Threatening behavior
- Tirades lasting a half-hour or so
While the official title it goes by now came along later on, the preceding diagnosis for IED-like symptoms was entered in the first edition of the Diagnostic and Statistical Manual of Mental Disorders in 1952 as passive-aggressive personality, aggressive type. By 1968’s second edition, it was upgraded to a full-blown personality disorder known as Epileptoid Personality Disorder and commonly referred to as explosive personality. The IED title came along with the third edition in 1980 and has stuck ever since. With this, it was categorized as a disorder of impulse control not otherwise classified. At this stage, the disorder was still considered to be rare. Diagnostic criteria included:
- Frequent events in which loss of control was exhibited over aggressive impulses that caused assault to others or damage to the environment around the individual
- Behavioral responses that are significantly misaligned with stimuli
- Lacking impulsive behavioral traits or aggressive moods between events
- Conduct disorder, schizophrenia, and antisocial personality disorder have all been ruled out
By 1994, the requirement that impulse control and aggressive behavior be non-existent between episodes was negated. In addition, it was added that the behavioral events could not be attributed to IED if they occurred under the influence of drugs or alcohol. The diagnosis cannot be rendered to individuals younger than 6 years old, and episodes cannot be premeditated. Today, assault and destruction of property still apply, as does a lack of control over aggressive impulses, but DSM-5 specifies this may present as verbal or behavioral acts.
Where Does It Come From?
IED may be caused by lesions in the prefrontal cortex of the brain in some cases. This may contribute to a genetic predisposition, too. Per Harvard Health Publications, first-degree relatives of those affected by IED have an increased likelihood of developing the disorder themselves. Most professionals in the treatment field believe it stems from both biological and environmental causes. Individuals who grew up in households where verbal or physical abuse was common appear to be more likely to develop IED. The Journal of Psychiatric Research reports physical abuse during childhood is significantly more common among individuals with IED than those without. A separate study published in the journal Psychiatry Research also notes low rates of parent-child bonding during childhood among individuals with IED. In addition, faulty processing of serotonin may be to blame in some individuals, too.
Substance abuse is not known to cause IED to develop. However, drug and alcohol use or abuse can cause very similar side effects that look like symptoms of IED. Hence, the reason that diagnostic criteria for the disorder requires that episodes of rage and behavioral misconduct aren’t carried out while under the influence of any such substance. On the flipside, having IED does make someone more likely to abuse drugs and alcohol. As a result, the need for this differentiation is real.
When IED Meets Substance Abuse
Substance abuse and addiction both work against mental illness, and IED is no exception.
The abuse of certain substances can worsen symptoms and the frequency of episodes in those who are affected by IED. Stimulants are more likely to exacerbate the symptoms of this disorder.
When it comes to brain chemistry, a lot is still unknown about IED. If serotonin processing or production are already issues in the brain of someone with IED, substance abuse may very well complicate things further. When stimulants like cocaine that impair the production of this neurotransmitter chemical are abused, serotonin may flood the brain, resulting in happiness and euphoria that makes the individual want to keep using. However, the crash that occurs when the effects of the drug wear off could be severely depressing. While often recognized as a relaxant and depressive substance, alcohol also tends to further irritate those with IED and can cause flare-ups that otherwise may not have happened.
Substance use disorders are three times more common among individuals affected by IED than the general population, per the American Journal of Psychiatry. It is thought that this increased propensity toward developing IED is rooted in self-medicating practices, as well as changes to brain chemistry. Self-medicating – using drugs or alcohol to cope with the symptoms of an illness or emotional upset – is common among individuals who suffer with mental illness. HelpGuide reports 53 percent of people who abuse drugs and 37 percent of those who abuse alcohol have at least one mental health disorder affecting their lives. People with IED may drink or get high to try and calm their irritation with others or to escape into such a relaxed state that they are less aware of what is going on around them. The overall goal would be to try and avoid outside stimuli that may make them lose control.
When Help Is Necessary
Substance abuse certainly presents with many risks aside from mental illness, such as:
- Deteriorating physical health
- Tearing families apart
- Loss of employment
- Financial trouble
- Legal repercussions
The worst thing someone with IED and/or a substance abuse problem can do is try to ignore either issue. These problems won’t go away or get better on their own. In fact, most of the time, leaving a mental illness untreated allows it to fester and get even worse. Symptoms will become more intense, and episodes of anger and rage may increase in frequency. Likewise, the disorder becomes harder to treat.
When an addiction is left untreated, the same results can ensue. The problem becomes more difficult to rehabilitate and may require a longer stint in rehab. In addition, the effects of substance abuse on IED continue to worsen, and the cycle continues, drawing the individual further into a lifestyle of self-medication.
Depending on the substances being abuse, the physical health effects vary from one person to the next, but there are no safe forms of substance abuse. All come with dangers, like respiratory depression, which is responsible for as many of the 46 deaths that occur as a result of prescription opioid pain reliever abuse every day, per the American Association of Retired Persons. Others, especially those who abuse alcohol, may suffer from gout, which can require surgery and even the amputation of limbs. Some people will abuse stimulants that cause them to have a stroke or heart attack, and others might fall asleep after using heroin and never wake up. It happens all the time and having a mental illness like IED only increases the chances of substance abuse and accompanying adverse events, especially death.
The Journal for the American Medical Association notes the results of one study in which adolescents afflicted with IED required treatment for medical injuries sustained as a result of an IED episode 52.5 out of every 100 times. The journal Psychiatry Research reports 12.5 percent of individuals with IED in a 2008 study had attempted suicide at some point in their lives, and 7.4 percent had harmed themselves in other ways that were not fatal.
Living with someone who has IED is tough. Generally, those who are closest to the afflicted will bear the brunt of their attacks and insults the most. Parents must deal with unruly adolescents affected by the disorder. A day in the life of these families may consist of physical, verbal, and emotional violence and abuse at the hands of the child. Many moms and dads end up feeling hopeless with nowhere to turn.
Parenting a child with IED takes patience and understanding that only a professional can assist with. Treatment is necessary to stop the behaviors and get the condition under control. Sadly, even as these children grow up to be adults, they will still have IED to deal with, and many of them turn against their families as a result.
Intimate relationships often end up being abusive when IED is involved. Friendships may also take a beating. Not many peers are willing to stick it out being friends with someone who routinely yells at them or physically attacks them, so they move on. Victim of IED are left to piece together what remains and wonder why they can’t manage to have normal relationships like everyone else.
Certainly, substance abuse also impacts families and other relationships. Many people who first start showing signs of addiction or mental illness will be aware of it on some level. They may not necessarily think they have a problem – the National Institute of Mental Health reports only 28.8 percent of IED-affected individuals in one study ever sought help for their anger issues — but they may recognize that their family and loved ones think something is amiss. The same goes for drug and alcohol abuse. For this reason, those struggling with addiction often try to hide their substance abuse habits.
While family members and friends may start out feeling concerned about their loved one, this can change over time. Many will turn if the person refuses to stop using drugs or alcohol. Loved ones may tire of the person’s lies or irresponsibility, and can’t take the stress of worrying about the person or cleaning up the messes left behind by substance abuse anymore. A lot of people who enter treatment for substance abuse report feelings of loneliness and having nowhere to turn. That is often a sign that family members and friends have stopped enabling them. Often, this is the place many must reach before they’re willing to accept help.
Having IED or substance abuse problems can seriously complicate one’s work life. Given how extremely violent episodes of IED can be, it may only take one event to get someone fired. Among individuals in one study who experienced at least three IED episodes in at least one year of life, only 8.2 percent were employed, per the Archives of General Psychiatry. Losing control and insulting a superior or coworker, or failing to show up at work one too many times due to the hangover from self-medicating with alcohol the night before, definitely presents just cause for termination. Finding another job while battling either of these issues is not easy either.
Of course, where there is a problem with work, there is often a problem with income. When people can’t pay their bills anymore due to spending all their money on drugs or losing their job because they couldn’t maintain control over their mood swings, they will often rely on others to pick up the slack. Eventually, those resources will run out, too.
While the idea of “rock bottom” is fictitious to many and not a requirement prior to entering treatment, many who do end up in rehab say legal ramifications were the last straw and what made them realize they needed to get help. According to the Centers for Disease Control and Prevention, more than 1.3 million American people were arrested for driving under the influence of alcohol or drugs in 2012.
Legal troubles only compound other issues. They put strain on family relationships and definitely come at a steep price when attorneys and lost wages are factored in. Likewise, some may have to spend time in jail and that could impose further repercussions, like losing custody of children.
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Treatment choices definitely aren’t lacking in the IED or substance abuse departments. Both problems can benefit from a combination of medication and intensive therapy. Getting to that point is generally the hardest part. Many people do not easily accept that they have an addiction, and the same is true with mental illness. Both problems are highly stigmatized in American culture, and oftentimes, people are resistant to accepting that they are affected. Despite this, there are ways of countering this resistance.
Typically, sufferers have frequent but milder episodes on a monthly basis or only a few a year, which are far more intense. Oddly enough, the more frequent form seems easier to manage, per the American Journal of Psychiatry.
First and foremost, don’t walk into a confrontational situation with a loved one who is affected by IED and substance abuse without serious preparation. The truth is that individuals suffering from IED and substance abuse have likely already thought that a family member or friend may confront them and they’ve prepared what they would say, whether it’s true or not. Addressing these issues requires staying a few steps ahead. If attempts have already been made to discuss their problems and they aren’t open to it, then it may be time for more serious measures.
An intervention is one step families can take to get their loved one into treatment. In fact, interventions tend to help everyone involved. Relatives can breathe a sigh of relief as a professional interventionist takes the reigns and leads them to a solution. The margin for error is much smaller when working with someone who does this day in and day out. There are several types of interventions, and a professional can assist the family in deciding what method of approach is best for their loved one. When the right steps are taken to make sure the intervention is carried out appropriately, it’s reported that as many as 85 percent of targeted clients end up accepting help, per AARP.
When it comes to IED, tricyclic selective serotonin reuptake inhibitors – SRRIs – are the most common form of treatment. Mood stabilizers like lithium may also be used. These medications treat the symptoms of the disorder by acting on receptors in the brain to exercise better impulse control and inhibit the telltale reactive personality features that affect people with IED.
Substance abuse is a different story. Not everyone with a drug or alcohol abuse habit needs medication, but certain cases warrant it. Those who have been abusing heroin or opioid painkillers will likely require a long-term treatment plan in which they are placed on either buprenorphine or methadone to slowly wean themselves off the illicit substances. People who abuse stimulants don’t have this sort of substituiary protocol, but they can be treated with sedatives and benzodiazepines during medical detox to calm the side effects of withdrawal, like tremors and paranoia. Those who have a drinking problem might require the use of antidepressants to combat feelings of sadness and despair that often come in tow with detox. Many will continue to need medications after detox, too. Psych Central notes 30 percent of people who battle alcoholism live with prolonged depression after detoxing.
Treating the side effects of withdrawal isn’t necessarily just about making the detox process more comfortable. It’s about the big picture. The less difficult it is for people to complete detox, the more likely they are to do so. Likewise, the more comfortable those with IED are during withdrawal, the more likely it is that they’ll get through the process safely, without experiencing IED symptoms that could lead them to make irrational decisions out of frustration, like relapsing.
The use of any medications should be closely monitored by a medical professional. Their use is always determined on a case-by-case basis.
Therapy is a necessary component to treat both substance abuse and IED. In both cases, the therapist is dealing with behavioral disorders that are often influenced by dysfunction in the brain. Likewise, IED complicates substance abuse and vice versa, so both need to be treated at the same time for the best chance at optimal results.
Cognitive Behavioral Therapy is the most widely prescribed form of therapy for IED clients. It works by retraining the brain in how to react to certain stimuli. This type of therapy can take time to show results in IED sufferers, but it’s the most effective form of treatment for the disorder. A Journal of Consulting and Clinical Psychology study reported significant improvements in impulse control among individuals with IED treated with group or individual CBT methods.
Therapy can also be of assistance to others besides the person suffering from IED and addiction. Family therapy can be helpful in mending relationships with those who may have been betrayed, harmed, or wronged in some way before the person sought treatment.
Sometimes, the affected individual may harbor a lot of guilt over behaviors that were influenced by substance abuse and IED. Support groups can strengthen resolve and help affected persons to come to terms with the events that have occurred and accept responsibility for them. They’ll learn that there is a silver lining in every situation, and they won’t feel guilty or ashamed forever. In fact, talking with peers who have been in their shoes before often helps individuals to get through tough times in recovery.
In addition, diet and exercise regimens, meditation, and skills groups are all beneficial supplements to any treatment plan. Many people who suffer with IED find that certain health activities, such as kickboxing or increased cardio activity, can help to alleviate the stress they once kept inside and thereby reduce the frequency with which they experience IED episodes.
Completing treatment and entering recovery can be intimidating. A quality treatment facility will offer many conveniences to clients to assist them during this process. Those who are out of work can find career counselors on staff at many facilities. These professionals can assist clients in preparing for interviews and writing resumes for job submissions. For younger clients, certain rehab centers offer supplementary educational programs so they can attend treatment and continue their education at the same time. Other programs offer outpatient care to accommodate clients’ work and personal schedules. All quality programs will cater treatment plans to each individual client, ensuring the plan works for the client’s current situation and amend it according to the individual’s progress in recovery.