What are the criteria for Intermittent Explosive Disorder (IED)?

Intermittent Explosive Disorder (IED) Diagnostic Criteria

Intermittent Explosive Disorder is characterized by repeated brief episodes of verbal or physical aggression or destruction of property representing a failure to control aggressive impulses. 1

Core Diagnostic Features

• IED is characterized by discrete episodes of aggressive impulses that result in serious assaultive acts towards people or destruction of property 2
• These episodes represent a failure to control aggressive impulses 1
• The behavior causes severe impairments in daily functioning 2
• The episodes are recurrent and problematic, representing a pattern of impulsive aggressive behavior 3

DSM-5 Specific Criteria

• Recurrent behavioral outbursts representing a failure to control aggressive impulses 4
• The magnitude of aggressiveness expressed during the outbursts is grossly out of proportion to the provocation or precipitating psychosocial stressors 4
• The aggressive episodes are not premeditated but are impulsive in nature 3
• The episodes cause either marked distress, impairment in occupational or interpersonal functioning, or have legal/financial consequences 4

Exclusion Criteria

• The aggressive outbursts are not better explained by another mental disorder such as:
  • Antisocial personality disorder
  • Borderline personality disorder
  • Psychotic disorders
  • Manic episode
  • Conduct disorder
  • Attention-deficit/hyperactivity disorder 3, 4
• The behavior is not attributable to another medical condition or physiological effects of substances 2

Neurocognitive Findings

• Individuals with IED demonstrate poorer performance in cognitive inhibition compared to both psychiatric and healthy control groups 5
• Deficits in response inhibition, particularly in action cancellation, are significant 5
• Increased emotional interference is observed during cognitive tasks 5
• Self-control problems in IED involve deficiencies in cognitive, emotional, and behavioral inhibition mechanisms 5

Diagnostic Approach

• A thorough medical workup should be conducted before making the diagnosis 2
• Structured or semi-structured diagnostic interviews help ensure that comorbid and pre-existing conditions are considered 2
• The revised diagnostic criteria (IED-R) have shown high interrater reliability (kappa = .92) 6
• IED-R criteria are more sensitive than previous DSM criteria in identifying subjects with significant impulsive-aggressive behavior 6

Clinical Considerations

• IED causes significant impairment in social and occupational functioning 2
• The disorder may be underdiagnosed due to previous limitations in diagnostic criteria 4
• Behavioral outbursts typically last less than 30 minutes and often occur in response to a minor provocation 3
• The diagnosis should be made only after ruling out other potential causes of aggressive behavior 2

Differential Diagnosis

• Behavioral symptoms in Chronic Traumatic Encephalopathy (CTE) may include explosiveness, impulsivity, rage, and violent outbursts that can mimic IED 1
• Behavioral dysregulation in PTSD can present with irritable and angry outbursts, including extreme temper tantrums 1
• Mania can present with irritability and impulsive behavior that may be mistaken for IED 3

Treatment Considerations

• Treatment options include mood stabilizers, antipsychotics, beta-blockers, alpha-2 agonists, phenytoin, and antidepressants 2
• Behavioral interventions are valuable as part of the overall treatment approach 2
• Cognitive-behavioral therapy targeting self-control problems may be beneficial 5