Introduction

Intermittent Explosive Disorder (IED) is a mental health condition where you have recurrent, sudden outbursts of anger or aggression that are way out of proportion to the triggering event.¹ These episodes are intense, unpredictable, and sometimes even frightening for both the individual experiencing them and those around them.¹ 

Imagine feeling like you're constantly walking on eggshells, never knowing when a minor annoyance might escalate into a full-blown explosion. These outbursts can have many effects. For example, they can make relationships harder, make work life or school life more difficult, making you feel guilty or shameful.¹ 

Understanding the complexities of IEDs is very important. It is to increase empathy and support individuals struggling with this condition. Here, we present you with the journey from symptoms to its diagnosis. 

Diagnosing intermittent explosive disorder

General symptoms of intermittent explosive disorder

Intermittent Explosive Disorder (IED) is a condition that can be frightening for those involved. These symptoms include:

• Recurrent outbursts of anger or aggression
• Heightened irritability or tension
• Impulsive behaviour
• Feelings of remorse or shame following outbursts

These hallmark features often lead to disruptive and distressing episodes, impacting various aspects of daily life.¹

DSM-V and ICD-11 criteria for diagnosis

When understanding mental health conditions, clinicians and psychologists rely on two tools. These are the Diagnostic and Statistical Manual of Mental Disorders (DSM) and the International Classification of Diseases (ICD). These resources help to diagnose and treat conditions, ensuring people receive the support they need. The latest edition of the DSM is five (V), and the current edition of the ICD is eleven (11). We will describe how each is diagnosed by each tool below.²

DSM-V criteria

Let's delve into the detailed DSM-5 criteria for IED: ²

• Recurrent outbursts demonstrating an inability to control impulses, including either:
  • Verbal aggression, such as tantrums, verbal arguments, or fights, occurs at least twice weekly over a week-long period for at least three months without resulting in physical injury or property damage
  • Three outbursts occur with injury or destruction within a year-long period
• Aggressive behaviour is grossly disproportionate to the magnitude of psychosocial stressors
• Outbursts that are not premeditated and serve no purpose
• Outbursts causing distress, impair function or result in financial or legal consequences
• The individual must be at least six years old
• The recurrent outbursts are not a result of other medical disorders or substance use

Also, the DSM-5 distinguishes between two types of aggressive outbursts:

• Episodes of verbal or non-damaging, non-destructive, or non-injurious physical assault occurring at least twice weekly for three months
• More severe destructive or assaultive episodes occur, on average, three times within a year, including acts like destroying objects or assaulting individuals or animals

ICD-11 criteria

Let's delve into the ICD-11 criteria for this condition. For the ICD-11, IED involves sudden, intense episodes of verbal or physical aggression or damage to property. It is part of the group of impulse control disorders.³ The outbursts happen repeatedly. They are hard to control, often happening out of proportion to what triggered them. 

It's crucial to note that these symptoms can't be explained by other mental or behavioural issues.³ They also are not part of a long-term pattern of anger and defiance, like in oppositional defiant disorder.⁴ These outbursts can seriously affect different areas of life, like personal relationships, work, or school. 

Differential diagnosis

Many conditions resemble an IED. Differential diagnosis means looking at all the facts about a person's behaviour, history, and feelings. By understanding what's causing problems, clinicians can find the best ways to help them. Here are a few:

1. Conduct disorder (CD): Conduct disorder means a person keeps disregarding rules or doing things that upset others.⁵ While both CD and IED involve being aggressive, CD usually includes more bad behaviours than just getting angry sometimes⁵
2. Bipolar disorder: Bipolar disorder is when someone's mood swings a lot, like feeling super happy and energetic one moment and then down the next.⁶ Even though people with bipolar disorder can get irritable and angry during high times, their mood swings happen in a pattern, unlike the explosions of anger seen in IED^1,6
3. Borderline personality disorder (BPD): Borderline personality disorder is when someone's feelings and relationships are all over the place, and they often do things without thinking.⁷ While both BPD and IED might involve acting without thinking, BPD is more about struggling with emotions and relationships, not just sudden bursts of anger⁷
4. Oppositional defiant disorder (ODD): Oppositional defiant disorder is when someone's arguing or being difficult, especially with authority figures.⁴ While both ODD and IED involve being angry and defiant, ODD is more of a constant pattern of behaviour, while IED is about explosive outbursts that happen out of the blue^1,4
5. Substance use disorders: Substance abuse or dependence can make someone act without thinking and become aggressive.⁸ Clinicians need to figure out if someone's aggression is because of using substances or because of a different mental health problem like IED⁸
6. Disruptive mood dysregulation disorder (DMDD): DMDD is when someone has extreme tantrums that don't fit the situation.⁹ Even though these tantrums might seem like the ones in IED, DMDD mostly happens in kids and is about being grumpy all the time, not just having sudden angry explosions^1,9

How would one be assessed? 

Here is a step-by-step outline of how it may look if you are going to get diagnosed with Intermittent explosive disorder.

1. Initial screening: The first step involves talking with a healthcare professional, like a GP, psychiatrist, or psychologist. They'll ask for recent experiences, history, and treatment.¹⁰ You might also be asked to complete a questionnaire to assess how you are feeling and if it's causing problems in your life such as the IED screening questionnaire.¹¹ This isn't a direct diagnostic test for IED, but this questionnaire could give guidance
2. Comprehensive evaluation: If the initial screening suggests that there might be Intermittent explosive disorder (IED), they'll look into it further. It means they'll ask many questions to understand how often you get angry, how bad it is, and what might be making it happen¹⁰
3. Questionnaire and questions: They'll have a longer conversation with you to learn more about you and your life. They'll ask about your family and friends, and how you're feeling. They'll want to know when this began. If, anything else is bothering you, and how it's affecting your life¹⁰
4. Checking the rules: They'll use tools called the DSM-5 or the ICD to check if what's been happening matches up with the IED description.¹¹ This means they'll look to see if you're having lots of angry outbursts which are causing problems, and if there's nothing else going on that could explain it
5. Tests: Sometimes, they might ask you to do tests to check what you think or feel. These tests help them understand why you might be getting so angry and how they can help. These could be screening tests for other conditions like bipolar disorder or scans of the brain to see what could be going on, like an EEG for potential seizures¹⁰
6. Asking others: They might talk to people close to you, like family and friends, to get a better idea of what's been happening. They'll ask about how often you are angry. If anything seems to initiate it, how does it affect everyone around you? It is called a collateral history¹⁰
7. Doctor's check: They might send you for a check-up with a doctor to ensure there's nothing else going on in your body to cause the anger. This might mean doing some tests or scans to be sure¹⁰
8. Planning next steps: Once they understand what's happening, they'll work with you to figure out what to do next. It could mean taking some medication, going to therapy, or learning new ways to deal with your anger.¹⁰ The idea is to help you feel better and get on with your life without so much anger getting in the way

Summary

In summary, the journey of understanding and dealing with Intermittent explosive disorder (IED) is like finding a path through a confusing maze. You start by talking with doctors who help you make sense of your experiences using guidelines like the DSM-5 and ICD. Along the way, you learn about other conditions that might be similar, like bipolar disorder or conduct disorders, but not quite the same, and this may help you understand your situation better.

As you move forward, treatment becomes a journey of its own, with medication, therapy, and learning new ways to cope. It's not always easy; there are bumps in the road and moments of frustration. But with the support of your loved ones and healthcare team, you may start to see progress and reclaim control over your life.

In the end, it's about more than just managing anger. It's about rediscovering happiness, building stronger relationships, and looking forward to a brighter future. With each step forward, you demonstrate your strength and resilience, paving the way for a better tomorrow. We hope this guide helped you find some clarity.