Sarah: “Hey Tim, would you mind taking out the trash on your way to the car?”

Tim could feel his anger rising. Yes, it was a simple request, but he knew he was about to have another attack. He could feel the aggressive impulse building. “I am so tired of being told what to do. I will take out the trash when I feel like it. Stop being so demanding!” Then he hit the table and walked away.

Sarah had not been demanding. She asked nicely. Then, suddenly Tim was very angry. He flew into a rage for no apparent reason. Sarah was stunned at the intensity of his response. She told me his reaction seemed way out of proportion to the request. This has happened three to four times before. She was worried.

Tim struggles with a psychiatric disorder called Intermittent Explosive Disorder (IED). Like an Improvised Explosive Device, Tim has an explosive anger. His reactions are more than the occasional outburst under stress. Much like improvised explosive device, Sarah doesn’t see it coming.

Between 1 to 7% of people will develop this disorder during their lifetime. Usually it develops in the teen years, but can also be seen earlier or later in a person. While we don’t know exactly why this occurs in some people, we do know there are contributing factors.

Looking at Tim’s life as a child, we see some contributing factors; Tim was exposed to verbal and physical abuse, and had a history of trauma as a child. This disorder also appears to run in families. Tim’s father was often described as someone with a very bad temper. Other contributing factors include depression, anxiety and substance use/abuse.

Basically, IED presents like an adult temper tantrum. Think of the Incredible Hulk. The person goes into a rage over something that doesn’t seem like that big of a deal. They become irritable, shout, argue, damage things, get into fights, threaten other people, have racing thoughts, chest tightness, tremors and palpitations. The person has trouble resisting those aggressive impulses no matter the cause.

This disorder falls into a category of psychiatric disorders related to impulse control and disruptive behavior. People with IED don’t usually seek treatment until there are major problems at work or in their relationships. The key feature is the difficulty controlling aggressive impulses. There is also verbal aggression that does not result in physical harm to people, property or animals. But the person can also have at least 3 episodes of damaging or destroying property or physical assault. Basically, the aggression shown is out of proportion to the situation. However, unlike someone who has conduct disorder, the person usually feels bad after the explosive outburst and can express genuine regret. Some, like Tim, feel embarrassed by their behavior after the fact.

People with IED need treatment to learn better coping for the intense aggressive impulses they feel. They have to learn relaxation techniques and work on changing the way they think, recognizing what triggers their anger. A type of therapy called Cognitive Behavior Therapy (CBT) helps the person reappraise his thoughts that lead to aggression. In addition, using an adult time-out to calm down can be extremely helpful. Sometimes medications are used to reduce aggressive impulses. Finally, avoiding alcohol and drugs, which make a person disinhibited, is recommended.

When people do not get help, it obviously affects their relationships. Sarah became frightened of Tim and lost all trust in his ability to control himself. This led Tim to feel depressed and use alcohol to calm himself down. Alcohol use didn’t help when his low frustration tolerance was activated. In the end, Tim agreed to work with a therapist. During therapy, he realized his explosive episodes had been a problem for a long time. He didn’t want to scare his wife, be out of control, or have outbursts at his workplace. Thankfully, Tim, got help and is doing much better today.

Handling an explosive person

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