“Although the DSM-5 includes IED under impulse control disorders, it does not neatly fit into that category or any broader category,” commented Rene Olvera, MD, MPH, associate professor in the Department of Psychiatry and Research Imaging Institute at University of Texas Health Science Center at San Antonio.

“IED may appear to be a mood disorder,” Olvera told Psychiatry Advisor.  But mood is “something pervasive and emotions are more dynamic, while IED is unprovoked and episodic and does not fit either of these.”

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Olvera noted that at some point in their lives, “individuals with IED might meet the criteria for mood disorders. Or there are other disorders with anger as a component, such as antisocial personality disorder or oppositional defiant disorder in children. So the best way to categorize IED is through exclusion factors—what they are not.”

Perhaps because there is so much overlap between IED and other conditions, it is underdiagnosed, misdiagnosed as other conditions.

“Most people who come to our clinic do not come independently seeking treatment for anger,” Olvera said. “They may be seeking treatment for another psychiatric condition such as depression, or because their wife wants to leave, or because they are having trouble with the law.”

“Disentangling” the issues and teasing out the presence of IED is challenging and often depends on assessing whether there is secondary gain from the explosive behavior, said Olvera. This will emerge from taking a careful history of patterns of the outbursts. When did the person become upset? What was the precipitating incident, if any? Was there something the person hoped to achieve through the anger? “Sometimes, explosive behavior takes place because the person gains something from it. A man might threaten his wife so she will not leave him. A child might throw a tantrum so his parents will allow him to go out with friends.”

But if questioning reveals that there was no history of a precipitating event or purpose for the outburst, a diagnosis of IED would be reasonable.

Treating IED

Treating IED begins with helping the patient recognize that the behavior is not accomplishing anything positive and, in fact, has serious negative consequences, said Olvera. “Some patients can see that the explosiveness causes problems and nothing was gained from the behavior — in fact, much was lost. We want to get them to the point where they seek treatment because they are motivated to change.”