Psych · General adult psychiatry — impulse control
Intermittent explosive disorder
Also known as IED · Impulse-control disorder aggression · Explosive anger attacks · Impulsive aggression disorder · Rage attacks (clinical IED)
Exam-exhaustive fellowship reference on intermittent explosive disorder — DSM-5-TR A1/A2 frequency criteria, impulsive vs instrumental aggression, NCS-R and WMH epidemiology, serotonergic and SEIP mechanisms, differentials vs ASPD/BPD/bipolar/substance/organic, OAS-M assessment, CBT and fluoxetine RCT evidence, AED adjuncts, risk and forensic interface. FRANZCP-primary, globally tagged.
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Target exams
Red flags
- Imminent other-directed violence with weapon access, named victim, or escalating intimate-partner threat — same-day safety plan, multi-agency response as indicated
- Active suicidal ideation or recent self-harm — elevated in IED with PTSD/personality comorbidity; structured risk assessment
- Late-onset first explosive aggression (middle/late life) — organic red flag (TBI, FTD, seizure, delirium, substance) before idiopathic IED label
- Aggression only during mania, psychosis, or intoxication — do not diagnose primary IED without exclusion work-up
- Child/partner injury or household weapon use during attacks — safeguarding and information-sharing duties
- Rapid tranquillisation or restraint scenarios — medical clearance, least-restrictive pathway, staff safety
Meet the patient
A 34-year-old scaffolder is brought to ED by police after putting his fist through a plasterboard wall at home. The trigger was a comment about the dishwasher. It took ninety seconds from comment to wall, and about twenty minutes for him to be sitting on the kerb crying and apologising.[1][2]
His partner, quietly, in the corridor: this is the fourth wall. She has started taking the children to her mother's on Fridays. He has never hit her. She is not sure that sentence will still be true next year.[1][12]
He is not intoxicated, not manic, not psychotic, and genuinely appalled at himself. Two questions are live: does he meet criteria for a disorder, and is his family safe tonight? The second one is not answered by the first.[2][11][12]
References16ShowHide
- [1]Kessler RC, Coccaro EF, Fava M, et al. The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication Arch Gen Psychiatry, 2006.PMID 16754840
- [2]Coccaro EF Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5 Am J Psychiatry, 2012.PMID 22535310
- [3]Coccaro EF, Lee RJ, Kavoussi RJ A double-blind, randomized, placebo-controlled trial of fluoxetine in patients with intermittent explosive disorder J Clin Psychiatry, 2009.PMID 19389333
- [4]McCloskey MS, Noblett KL, Deffenbacher JL, et al. Cognitive-behavioral therapy for intermittent explosive disorder: a pilot randomized clinical trial J Consult Clin Psychol, 2008.PMID 18837604
- [5]Coccaro EF, Kavoussi RJ Fluoxetine and impulsive aggressive behavior in personality-disordered subjects Arch Gen Psychiatry, 1997.PMID 9400343
- [6]Mattes JA Oxcarbazepine in patients with impulsive aggression: a double-blind, placebo-controlled trial J Clin Psychopharmacol, 2005.PMID 16282841
- [7]Hollander E, Tracy KA, Swann AC, et al. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders Neuropsychopharmacology, 2003.PMID 12700713
- [8]McLaughlin KA, Green JG, Hwang I, et al. Intermittent explosive disorder in the National Comorbidity Survey Replication Adolescent Supplement Arch Gen Psychiatry, 2012.PMID 22752056
- [9]Scott KM, Lim CCW, Hwang I, et al. The cross-national epidemiology of DSM-IV intermittent explosive disorder Psychol Med, 2016.PMID 27572872
- [10]Fanning JR, Meyerhoff JJ, Lee R, Coccaro EF History of childhood maltreatment in intermittent explosive disorder and suicidal behavior J Psychiatr Res, 2014.PMID 24935900
- [11]Jenkins AL, McCloskey MS, Kulper D, et al. Self-harm behavior among individuals with intermittent explosive disorder and personality disorders J Psychiatr Res, 2015.PMID 25300440
- [12]Fanning JR, Lee R, Coccaro EF Comorbid intermittent explosive disorder and posttraumatic stress disorder: Clinical correlates and relationship to suicidal behavior Compr Psychiatry, 2016.PMID 27624432
- [13]Coccaro EF, Lee R, Coussons-Read M Elevated plasma inflammatory markers in individuals with intermittent explosive disorder and correlation with aggression in humans JAMA Psychiatry, 2014.PMID 24352431
- [14]Huband N, Ferriter M, Nathan R, Jones H Antiepileptics for aggression and associated impulsivity Cochrane Database Syst Rev, 2010.PMID 20166067
- [15]Jones RM, Arlidge J, Gillham R, et al. Efficacy of mood stabilisers in the treatment of impulsive or repetitive aggression: systematic review and meta-analysis Br J Psychiatry, 2011.PMID 21282779
- [16]Coccaro EF, Fanning JR, Keedy SK, Lee RJ Social cognition in Intermittent Explosive Disorder and aggression J Psychiatr Res, 2016.PMID 27621104