Intermittent explosive disorder — structured clinical viva

Diagnosis first. Operationalise DSM-5-TR IED: A1 and/or A2 frequency, disproportionate impulsive aggression, age ≥6, impairment, exclusions. Take collateral and map childhood conduct carefully — absence of CD argues against ASPD as the sole label, but comorbidity is possible.^[1][5]

Just ASPD? Not automatically. ASPD requires pervasive rights violation since 15 plus CD onset before 15 and other criteria. IED is about discrete impulsive attacks; remorse after attacks is common in IED narratives and does not prove safety. Instrumental, remorseless exploitation points more to ASPD/psychopathy constructs. Formulate both if both thresholds are met.^[1]

Does medication work? No disease-modifying drug is labelled solely for IED, but evidence is not empty. Fluoxetine has a dedicated IED RCT showing reduced OAS-M aggression/irritability; practical start 20 mg oral daily, titrate in the 20–60 mg range with monitoring.^[2] Oxcarbazepine has RCT support in impulsive aggression; divalproex has signal especially in Cluster B impulsive aggression — use with lab and pregnancy safeguards, not as knee-jerk first drug for all.^[4][6] Always treat alcohol/stimulant comorbidity.

Psychological care. Multicomponent CBT for IED has pilot RCT support — teach skills, not cathartic venting.^[3]

Risk formulation. Static: prior assault, early short fuse, male sex, legal involvement. Dynamic: recent public assault, alcohol, acute interpersonal triggers, weapon access (ask), partner fear, non-adherence. Protective: remorse/motivation, probation structure, employment if present. Tools aid structured judgement; they do not perfectly predict. Safety plan for others and self; multi-agency with probation.^[1][5]