Intermittent explosive disorder — ED assault and dual diagnosis (MEQ)

(i) Working diagnosis. Intermittent explosive disorder (DSM-5-TR) with comorbid alcohol use disorder and acute intimate-partner violence risk. Operational fit: recurrent failure to control aggressive impulses; A1 path supported by several verbal/physical outbursts per week for 4 months without requiring injury, and A2-level property damage episodes also described in the past year; magnitude out of proportion to minor domestic triggers; impulsive/anger-based rather than instrumental; age ≥6; distress/impairment and relational/legal risk; not better explained by mania, psychosis, or ASPD (no CD history). Alcohol is a comorbidity/modifier, not the sole explanation if sober attacks occur.^[1][4]

(ii) Differentials with discriminators. (1) ASPD — pervasive rights violation and CD before 15; here no CD and remorse after attacks. (2) Bipolar mania/mixed — syndromal elevated/irritable mood lasting days–weeks with decreased need for sleep and other manic features; absent here. (3) Alcohol-induced aggression alone — attacks only when intoxicated; he reports sober attacks too, so dual formulation. (4) BPD — abandonment fear, identity disturbance, self-harm for regulation as core; not described as primary pattern. Also keep organic/TBI on the list if history emerges.^[1]

(iii) Acute risk management. Medical clearance; UDS/breath alcohol as indicated; de-escalate; staff safety. Partner safety first: private enquiry about fear, injuries, weapons, children in home; offer support services; involve police/multi-agency pathways if imminent serious harm; document information-sharing reasoning per jurisdiction without inventing statutes. Disposition based on residual acute risk (crisis admission if uncontainable imminent violence). Safety plan for early-warning signs; no collusion with minimisation. Assess his self-harm/suicide risk as well given elevated self-harm associations in IED samples with comorbidity.^[1][5]

(iv) Medium-term plan. Psychological: multicomponent CBT for anger/aggression (arousal reduction, cognitive restructuring of hostile appraisals, problem-solving, relapse prevention) — pilot RCT support in IED for group and individual formats.^[3] Integrated alcohol treatment (motivational work, withdrawal management if needed, relapse prevention). Couples work only if safe and desired by partner. Pharmacological: fluoxetine 20 mg orally daily, review at 2–4 weeks, titrate toward 20–60 mg daily as tolerated based on IED RCT practice, adequate trial often ≥8–12 weeks; monitor activation, sexual side-effects, early suicidality if mood symptoms, adherence, and alcohol interaction counselling (avoid reckless mixing).^[2] Track outcomes with aggression logs/OAS-M style measures. Avoid chronic benzodiazepines as anti-aggression strategy. Multi-agency review dates; step up if risk escalates.^[2][3]