By Dr Raghuram Y.S. MD (Ay) & Dr Manasa, B.A.M.S
Intermittent Explosive Disorder is a type of mood disorder, abbreviated as IED. It involves sudden changes in mood and consists of sudden outbursts of aggression or violence. These reactions are usually out of proportion and magnified to a given situation or are irrational.
It is common for anyone to go through the above mentioned fluctuations of mood like aggression or temper once in a while. These are variants of anger. IED involves frequent, recurring outbursts. The people with IED might go on to do violent activities like destroying property, throwing tantrums or attacking others either physically or verbally.
Read – Anger: Relation With Body Types, Ways To Control Anger
Table of Contents
The characteristic feature of IED i.e. impulsive and aggressive episodes can take many forms. The below mentioned behaviours might be the signs and symptoms of IED –
- yelling at others
- indulging in intense arguments
- temper tantrums
- damaging / vandalising properties
- activities like breaking things, punching the walls
- indulgence in physical violence (slapping, beating, shoving etc) or domestic violence and assaults
- behaviours like road rage, indulging in fights or brawls
The above said symptoms do not occur all together or at a time. They may occur in spells or attacks which often occur without warning or may also surface with little warning. The attacks are short-lived. They rarely last longer than half an hour. They might occur along with the below mentioned physical symptoms –
- feeling of abnormally increased energy – also known as adrenaline rush
- palpitations – feeling of heartbeats
- tightness in the chest
- headache / increased pressure in head
- tension in muscles
- tingling sensation in muscles / body parts
What is common?
Before or after the IED episode one would commonly experience feelings of irritation, rage and loss of control. These people would also experience racing thoughts or feel emotionally detached.
One would experience one or more of the below mentioned immediately after the episodes of IED –
- relief from symptoms
- feeling of remorse
- feeling of guilt
Do episodes occur regularly or intermittently?
The episodes present in different ways to different people. IED episodes occur either regularly or after many weeks or months of nonaggressive behavior. They may indulge in acts of physical violence interposed by verbal outbursts in between.
Read – Should You Suppress Your Emotions? Do They Grow on You?
The present diagnostic criteria of DSM-5 distinguishes between the below mentioned in terms of diagnosing IED –
a. more frequent episodes of verbal aggression without harming people or property physically
b. less frequent acts of destructive (assaultive) behavior that causes serious type of harm to people or property
A study conducted in 2005 found that among 1,300 people who come seeking care for mental health issues about 6.3% of people met the criteria for DSM-5 IED at one or the other point of time in their lifetime. Apart from this about 3.1% met the criteria for a current diagnosis of IED.
Another study (2006) – about 7.3% among 9,282 people met with DSM-5 criteria for IED at some point of their lifetime. Among these about 3.9% people met the criteria in the past 12 months.
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The exact causes of IED are not known. A combination of genetic and environmental factors is believed to cause IED.
Apart from this the brain chemistry is also believed to have a role in causation of this condition. Low levels of serotonin in the brain are found to be associated with impulsive and aggressive behavior of IED.
One will be at increased risk of developing IED if the person is –
- under 40 years of age
- has been brought up in a physically / verbally abusive environment (household)
- has experienced many traumatic events during childhood
- has another mental illness that causes impulsive or problematic behavior such as ADHD, borderline personality disorder or antisocial personality disorder
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IED can cause the below mentioned complications –
- disturbance in relationships within close circle, difficulty in maintaining stable and supportive relationships
- disturbance in everyday activities
- frequent indulgence in arguments
- aggressive behavior significant harm within families may be caused by episodes of IED
- consequences for behaving aggressively like loss of job, expulsion from school, meeting with accidents, financial and legal issues
Other complications – IED patients have increased risk of having other mental and physical health issues. Below mentioned are some of those issues –
- alcohol / substance misuse / abuse
- risky and impulsive behaviors – problem gambling, unsafe sex etc
- high blood pressure
- chronic headaches
- eating disorders
- chronic pain
- heart disease
- self harm
Read – Ayurvedic Treatment For ADHD – Herbs, Therapies, Medicines, Remedies
Lifestyle and alternative treatments
Below mentioned methods form an important part of interventions which can be used in the treatment of IED since they do not have negative impact and also might help in easing the symptoms of IED.
- following and adopting ideal and balanced diet
- sleeping well
- regular exercise and being physically active
- avoiding drugs, alcohol, cigarettes
- avoid the causes and etiological factors which could cause stress
- learn methods of reducing and managing sources of stress
- make time for relaxing activities like listening to music, outing with family for a picnic etc
- practicing meditation and yoga, tai chi
- practicing mindfulness techniques
- alternative therapies – acupressure, acupuncture, massage etc.
- Treatment of IED consists of a combination of more than one strategy.
- Therapy – One can manage his or her symptoms of IED by meeting a counselor, a therapist, mental health professional / expert or psychologist either alone or in a group on a regular basis.
- CBT (Cognitive Behavioral Therapy) helps in identifying harmful patterns. It also involves using coping skills, relaxation techniques and relapse education to deal with aggressive impulses and symptoms of IED in an effective way.
- Study (2008) – 12 weeks of CBT either in the form of individual or group therapy was found to reduce IED symptoms including anger, aggression and hostility. This was possible both during treatment of IED and 3 months after the treatment.
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There are no specific medications for treating IED. No single medication works effectively. Research work on IED medication is limited. Medications do not help individually and need to be combined with therapy. Some medicines are known to reduce impulsive behavior or aggression. These include –
- antidepressants – mainly SSRIs
- mood stabilizers – lithium, carbamazepine etc.
- anti-anxiety drugs
- anti-psychotic drugs
Study – In 2009 it was found that fluoxetine (SSRI) reduced impulsive aggressive behaviors in IED patients. SSRIs should be taken for at least 3 months time for it to provide good effects. Symptoms of IED also tend to recur once medications are stopped. It is also important to know that everyone does not respond to medications.
How you can help in suicide prevention in IED patients?
If you find out that someone is harming himself or hurting another person, call your local emergency number. Also stay with the person until you get help from the concerned authorities. Try to remove any harmful equipment in and around the surroundings – like guns, knives, harmful medications etc. try to listen to those people but do not try to judge, yell or threaten them. Get help from a crisis or suicide prevention hotline if you or someone near and dear to you is considering suicide.
See a health / mental health professional
Many people who have IED hesitate to ask for help or to seek treatment. But one needs to know that without professional help it is not possible to prevent episodes of IED.
If you think or know that you have IED you need to take an appointment with your doctor or mental health professional without delay. If you are sure of harming yourself or someone else, call for help immediately. You can educate people about the signs and symptoms of the disease and ways of coping with them. You can alert your loved ones to seek help if they happen to have symptoms of IED.
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A study has shown that IED is a highly prevalent, persistent and seriously impairing adolescent mental disorder that is both understudied and undertreated. It says that research is needed to uncover risk and protective factors for the disorder, develop strategies for screening and early detection and identify effective treatments. (Read more)
A study in China tells that the relationships between IED, anger and aggression reflect the need to develop and implement specific and individually tailored intervention approaches to correct behavior of IED juvenile offenders. This is to prevent new crime. (Read more)
People with IED are at greater risk for substance abuse. (Read more)
People with IED have smaller emotional brains. (Read more)
People with IED elevate levels of markers of systemic inflammation in blood. (Read more)
IED is more common than previously thought. A little known mental disorder marked by episodes of unwarranted anger is more common than previously thought, a study funded by the National Institutes of Health’s (NIH) National Institute of Mental Health (NIMH) has found. (Read more)
The below mentioned conditions shall be considered for understanding IED from Ayurveda perspective.
Krodha – IED is a mood disorder and involves sudden changes in mood, sudden outbursts of aggression, rage, temper or violence. All these terms can be considered as various presentations of Krodha. Krodha means anger, rage, temper or tendency to be violent. This is one of the conditions which is manifested due to imbalance of mental doshas i.e. rajas and tamas. To be precise these qualities develop due to abnormal increase of rajas / rajo guna quality of the mind. Herein the person will tend to be hyperactive, aggressive and angry.
But anger is a normal human reaction and emotion and depends on how one reacts to a situation or person. It may be by nature too. In such a condition it will not be considered as a disease. But when krodha becomes persistent, repetitive and consistent it will become a mano roga i.e. a mental disorder.
Predominance of Rajo Guna – As already said the predominance of rajo guna quality of mind for a longer duration might expose one to becoming a victim of IED.
Predominance of Pitta / Pitta constitution / Pitta disorders / Pitta afflicting the mind – High pitta in the body may also cause mental symptoms apart from physical disorders / symptoms. When pitta afflicts the mind it may make a person angry and aggressive. When pitta constantly afflicts the mind / brain / nervous system – it will cause anger and temper which will stay for long and will become a mental disorder in the long run. On the other hand severe anger and IED which becomes chronic will also afflict pitta and cause severe aggravation of pitta. This is because Ayurveda believes that pitta aggravation takes place due to longstanding anger and aggression. So, anger causing an increase in pitta and high pitta causing anger are biphasic reactions. High pitta may also disturb the balance of mind doshas and might increase rajo guna quality which in turn causes IED in the long term.
Unmada / Pittaja Unmada / Vataja Unmada – when we look at the symptoms of IED they look like a combination of symptoms found in pittaja and vataja type of unmada – psychoses and some symptoms relate to the clinical picture of other type of psychoses called as bhutonmada.
Read – Unmada-Insanity: Ayurvedic Understanding And Management
- Nidana Parivarjana – keep away the causes and triggers which might cause IED / anger.
- Manasika Roga Chikitsa – The principles of treating the mind and contamination of mind channels should be followed in treating IED. They include intellectual trimming and training, seeding thoughts of courage and counseling. All measures, foods, and activities which bring about the balance of mind and mind doshas should be included in the treatment. The Rajo guna imbalance should be corrected and methods of increasing sattvika guna should be adapted.
- Balancing Pitta – Pitta balancing foods and activities should be included. Therapeutic purgation will be one of the ideal approaches.
- Balancing Vata – Though pitta increase might cause IED it is the association of Vata with pitta or motivation / trigger from vata which makes the condition worse, just like the fire getting the company of a breeze. Therefore vata calming measures including therapies, food changes and lifestyle changes should also be included. The association of vata with pitta should be analyzed wisely by the physician. Oil therapies done on the head and medicated enemas will help in this direction.
- Unmada / atatvabhinivesha treatment – Treatment principles of psychosis, epilepsy / memory disorder and disturbances of intellectual application should be considered in treating IED. Mainly treatment lines of Vataja, Pittaja and Bhuta Unmada shall be considered. Daivavyapashraya – non medicinal remedies like meditation, prayers, penance, sacrificial and fire sacrifices, etc shall also be considered as supportive treatments.
- Sattvavajaya – mind strengthening therapies and strategies shall be implemented.
- Medhya Rasayanas – Brain tonics which calm the brain and nerves shall be used in the treatment of IED.
- Ghrta Preparations – medicated ghee preparations used in the treatment of psychosis and memory disorders / epilepsy shall be used. Example – Brahmi Ghrta, Kalyanaka Ghrta, Saraswata Ghrta etc.