Intermittent Explosive Disorder - an overview (2022)

Intermittent explosive disorder is a diagnosis that characterizes individuals who have episodes of dyscontrol, assaultive acts, and extreme aggression that is out of proportion to the precipitating event and is not explained by another Axis I or an Axis II disorder.

From: Massachusetts General Hospital Handbook of General Hospital Psychiatry (Sixth Edition), 2010

Intermittent Explosive Disorder (IED)

Fred F. Ferri MD, FACP, in Ferri's Clinical Advisor 2022, 2022

Treatment (Table E1)

TABLE E1. Medications for Intermittent Explosive Disorder

MedicationStarting DoseBlood LevelAdverse OutcomesCautionary Notes
Fluoxetine10 mg PO dailyN/AMania, sexual dysfunction, SIADHCaution in patients with bipolar disorder
Phenytoin100 mg PO tid10-20 mcg/mlHepatotoxicity, gingival hyperplasiaCaution in patients with hepatic dysfunction
Topiramate50 mg dailyN/ASedation
Lamotrigine25 mg dailyN/ARash, SJSSlow titration schedule
Valproate250 mg PO bid75-125 mcg/mlHyperammonemia, pancreatitis, hepatic impairmentCaution in patients with hepatic impairment
Oxcarbazepine150 mg PO bidN/AHepatic failure, SJS, blood dyscrasias, hyponatremia, SIADHHLA-B∗1502 testing for individuals at high risk for SJS (e.g., Asian ancestry)
Carbamazepine200 mg PO bid4-12 mcg/mlHepatic failure, SJS, blood dyscrasias, hyponatremia, SIADH, drug-drug interactionsHLA-B∗1502 testing for individuals at high risk for SJS (e.g., Asian ancestry)
Lithium300 mg PO bid0.6-1.2 mEq/LHypothyroid, nephrotoxicityCaution in patients with renal impairment

bid, Twice per day;PO, by mouth;SIADH, syndrome of inappropriate antidiuretic hormone secretion;SJS, Stevens-Johnson syndrome;tid, three times per day.

Selective serotonin reuptake inhibitors (SSRIs) are considered first-line therapy. Multiple studies have been performed on fluoxetine, up to 60 mg per day, though it is not unreasonable to try other SSRIs given similar mechanisms of action. Cost, side effects, drug half-life, and drug-drug interactions need to be considered.

Multiple large trials and meta-analyses also point to the efficacy of phenytoin, oxcarbazepine, carbamazepine, lamotrigine, topiramate, and valproate. Unless there is a contraindication to SSRIs, AEDs should be considered second line, given their potential side effects and toxicities.

Lithium has also shown to be helpful.

There is limited evidence to support use of antipsychotics in treating IED.

Anti-hypertensives: There is evidence that beta blockers (e.g., propranolol) can be helpful for IED and anecdotally alpha-2 adrenergic agonists (e.g., clonidine) have also been used though sedation can be a limiting side effect.

SeeTable E1 for details related to particular medications.

Intermittent Explosive Disorder

E.F. Coccaro, M.S. McCloskey, in Encyclopedia of Behavioral Neuroscience, 2010

Intermittent explosive disorder (IED) is a DSM-IV diagnosis defined by repeated acts of impulsive aggression that are disproportionate to any provocation and can include verbal assault (e.g., screaming), destructive and nondestructive property assault, and/or physical attack. These aggressive outbursts lead to considerable distress, relationship problems, and occupational difficulties. Initially thought to be rare, epidemiological research suggests that IED afflicts 4–6% of the population, typically beginning in adolescence and lasting much of one’s adult lifetime. IED appears to be heritable and is likely associated with serotonin dysregulation. IED may be amenable to pharmacological and psychosocial interventions.

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Disruptive, Impulse-Control, and Conduct Disorders

Robert M. Kliegman MD, in Nelson Textbook of Pediatrics, 2020

Description

Oppositional defiant disorder (ODD) is characterized by a pattern lasting at least 6 mo of angry, irritable mood, argumentative/defiant behavior, or vindictiveness exhibited during interaction with at least 1 individual who is not a sibling (Table 42.1). For preschool children, the behavior must occur on most days, whereas in school-age children, the behavior must occur at least once a week. The severity of the disorder is consideredmild if symptoms are confined to only 1 setting (e.g., at home, at school, at work, with peers),moderate if symptoms are present in at least 2 settings, andsevere if symptoms are present in ≥4 settings.

Intermittent explosive disorder (IED) is characterized by recurrent verbal or physical aggression that is grossly disproportionate to the provocation or to any precipitating psychosocial stressors (Table 42.2). The outbursts, which are impulsive and/or anger-based rather than premeditated and/or instrumental, typically last <30 min and frequently occur in response to a minor provocation by a close intimate.

Conduct disorder (CD) is characterized by a repetitive and persistent pattern over at least 12 mo of serious rule-violating behavior in which the basic rights of others or major societal norms or rules are violated (Table 42.3). The symptoms of CD are divided into 4 major categories: aggression to people and animals, destruction of property, deceitfulness or theft, and serious rule violations (e.g., truancy, running away). Three subtypes of CD (which have different prognostic significance) are based on the age of onset: childhood-onset type, adolescent-onset type, and unspecified. A small proportion of individuals with CD exhibit characteristics (lack of remorse/guilt, callous/lack of empathy, unconcerned about performance, shallow/deficient affect) that qualify for the “with limited prosocial emotions” specifier. CD is classified asmild when few if any symptoms over those required for the diagnosis are present, and the symptoms cause relatively minor harm to others. CD is classified assevere if many symptoms over those required for the diagnosis are present, and the symptoms cause considerable harm to others.Moderate severity is intermediate between mild and severe.

Other specified/unspecified disruptive/impulse-control/CD (sub­syndromal disorder) applies to presentations in which symptoms characteristic of the disorders in this class are present and cause clinically significant distress or functional impairment, but do not meet full diagnostic criteria for any of the disorders in this class.

Disorders of Impulse Control

D.W. Woods, ... I. Snorrason, in Encyclopedia of Mental Health (Second Edition), 2016

Intermittent Explosive Disorder

IED involves impulsive angry outbursts that have a rapid onset (American Psychiatric Association, 2013). Only minor provocation occurs prior to these outbursts, and there is little or no prodromal period of anger escalation. Outbursts typically last less than 30min, but in that time they can involve verbal and physical assault as well as property damage (McElroy et al., 1998). These outbursts tend to wax and wane in intensity, with more severe outbursts being broken up by less severe or destructive episodes (Coccaro, 2011; Mattes, 1990).

Individuals with IED often engage in direct interpersonal aggression more often than simply threatening aggressive acts, and subclinical levels of the condition are associated with far fewer overt aggressive behaviors (Coccaro, 2012). Recently, items corresponding to IED on the Collaborative Psychiatric Epidemiological Survey (Alegria et al., 2007) showed that group membership is positively associated with family history of aggression, low age of onset, and male gender (Ahmed et al., 2010).

In the United States, prevalence of IED is estimated to be between 5.4% and 6.9% (Coccaro, 2012). The condition affects males at twice the rate of females in clinical reports (Coccaro et al., 1998; Mattes, 1990; McElroy et al., 1998), but community samples show slightly more equal gender distributions (Kessler et al., 2006; Ortega et al., 2008; Yoshimasu and Kawakami, 2011). IED is more common in younger people (<35–40 years) (Bromet et al., 2005; Kessler et al., 2006; Yoshimasu and Kawakami, 2011) and those with less than a high school education (Coccaro, 2012).

IED is commonly associated with mood (both unipolar depression and bipolar disorder), anxiety, and substance use disorders, as well as antisocial and borderline personality disorders (Bromet et al., 2005; Kessler et al., 2006; McElroy et al., 1998; Ortega et al., 2008; Yoshimasu and Kawakami, 2011). Onset of IED often precedes the development of Axis I comorbidities (Coccaro et al., 2005), and aggression caused by comorbid externalizing Axis II conditions does not appear to account for aggression in IED (Coccaro, 2012). IED does not appear to co-occur with other ICDs more often than by chance (McElroy et al., 1998). Also, while higher rates of co-occurrence between childhood disruptive behavioral disorders and IED has been reported, DSM criteria state that disruptive behavior disorders take precedence over IED, and evidence suggests that these diagnoses are in fact mutually exclusive (Coccaro, 2012).

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Distorted Capacity II

David Goldman, in Our Genes, Our Choices, 2012

Intermittent Explosive Disorder

Intermittent explosive disorder (IED) was discussed in Chapter 3 in the context of the “2B or not 2B” story, in which the 5-hydroxytryptamine (serotonin) receptor 2B (HTR2B) stop codon was found to contribute to severe impulsive behavior, and even violent, senseless, murders. IED of whatever cause is common relative to diseases such as schizophrenia and bipolar disorder, and it can co-occur with bipolar disorder and other diagnoses. It is marked by extreme expressions of anger, often to the point of uncontrollable rage, and the behavior is disproportionate to the situation at hand. IED outbursts are brief and are often accompanied by signs of heightened autonomic activation such as sweating, chest tightness, twitching and palpitations. Typically, the person is remorseful afterwards.

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Child and Adolescent Psychopathology☆

L.C. Wilson, A. Scarpa, in Reference Module in Neuroscience and Biobehavioral Psychology, 2017

Intermittent Explosive Disorder (IED)

IED is characterized by poor emotion regulation that results in anger outbursts disproportionate to the situation. The child or adolescent must display severe episodes, which is specified as at least three aggressive outbursts that result in property damage or physical injury within the last 12months. In between the severe outbursts, the individual must display less severe symptoms, which can include temper tantrums, verbal arguments, or physical aggression at least twice weekly over a course of 3months. These acts of physical aggression do not result in property damage or physical injury. The behavioral outbursts must be out of proportion to the situation and not be premeditated. These symptoms have a quick onset and the episodes often last for less than 30min. The key characteristic of IED is poor impulse control in reaction to psychosocial stressors that the child or adolescent perceives as provocation, even though it would not typically result in an aggressive response. This diagnosis is not given prior to the age of 6years and the symptoms typically first appear in late childhood or adolescence. IED is a chronic disorder that tends to persistent for many years. Disruptive mood dysregulation disorder can be differentiated from IED because it is characterized by persistent negative mood most days in between the temper outbursts.

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Impulse-control disorders

Mark R. Dixon, ... Taylor E. Johnson, in Functional Analysis in Clinical Treatment (Second Edition), 2020

Intermittent explosive disorder

IED is the inability to control recurring aggressive impulses. Individuals with this disorder demonstrate discrete violent outbursts significantly out of proportion with respect to the given situation. For example, an individual with IED may exhibit destructive aggression toward objects, such as mutilating a family pet in response to small psychological stressors like being scolded by a parent for wearing muddy shoes in the house. Following such an outburst, the individual may express feelings of remorse or guilt, but there may also be feelings of tension reduction or release. Physiological sensations such as tingling or built-up pressure have been reported to coincide with such a sense of release. For example, McElroy, Soutullo, Beckman, Taylor, and Keck (1998) questioned 24 subjects with IED regarding such feelings of tension. Eighty-eight percent reported the experience of tension prior to their aggressive impulses, 75% reported experiences of relief following their outbursts, and 46% reported feelings of pleasure connected with the aggressive acts. However, with IED, unlike many of the other impulse control disorders, feelings of tension and relief are not required for a diagnosis.

According to the DSM-V, the IED diagnosis mainly focuses on poorly controlled emotion and anger outbursts that appear disproportionate to interpersonal or psychosocial stressors (APA, 2013, p. 461). There are five specific diagnostic criteria. First, there must be verbal or physical aggression toward property, animals, or other individuals. This must occur either as higher frequency, less intense problem behavior or less frequent, high intensity problem behavior. Second, the aggression must be “grossly out of proportion to the provocation or to any precipitating psychosocial stressors” (p. 466). Third, aggression must not be premeditated to achieve a tangible outcome, but rather must be impulsive and/or angry. Fourth, anger must cause marked distress, and/or problems with occupational or interpersonal functioning, and/or financial or legal consequences. Finally, (a)the individual must be 6 years old or the developmental equivalent; and (b)the problems are not better accounted for by another mental disorder, medical condition, or to the effects of a substance. IED can be diagnosed alongside Attention-Deficit/Hyperactivity Disorder, Conduct Disorder, Oppositional Defiant Disorder, or Autism Spectrum Disorder if impulsive aggression occurs more frequently than typically observed, but cannot be diagnosed in an Adjustment disorder in children aged 6–18 years (APA, 2013, p. 466).

IED was first identified as a disorder in 1980 with its inclusion in the DSM-III (APA, 1980). The DSM-III and DSM-IIIR definitions included an additional criterion for diagnosis. Not only did the individual need to exhibit several aggressive outbursts far in excess of the given situation, but the individual should also exhibit “no signs of generalized impulsiveness or aggressiveness between the episodes” (APA, 1987, p. 322). This additional requirement made the true diagnosis of IED extremely infrequent, and the DSM-IV and DSM-5 broadened the category by excluding this criterion. However, even under the DSM-5, the diagnosis is relatively narrow. Because there cannot be another diagnosis which better explains the aggressive behavior, IED appears to be quite rare. For instance, out of 9282 people over the age of 18 years old surveyed across the United States, only 2.7% met the criteria for IED (Kessler etal., 2006). IED is thought to be predominantly exhibited in males, but it has been associated with menstrual cycles in females (McElroy etal., 1998). Additionally, IED is more common in individuals younger than 35–40 years (Kessler & Üstün, 2008). There is limited research on the life course of IED, but age of onset appears to most commonly later in childhood but typically onset does not occur past the age of 40 years (Coccaro, 2012).

Despite DSM inclusion, some clinicians feel that IED should be considered a symptom of other psychological disorders (McElroy etal., 1998). Other clinicians felt that the DSM-IV criteria were too narrow and therefore preclude diagnosis of patients with impulsive aggression problems (Coccaro, Kavoussi, Berman, & Lish, 1998). In fact, these researchers have suggested a modified diagnostic category, Intermittent Explosive Disorder-Revised. This revision broadened the criteria found in the DSM-IV. For example, out of the 76 subjects studied who met the revised criteria, only 19 would have qualified for IED as defined by the DSM-IV. The following is the suggested diagnostic criteria for Intermittent Explosive Disorder-Revised (Coccaro etal., 1998): “A. Recurrent incidents of verbal or physical aggression toward other people, animals, or property. B. The degree of aggressive behavior is out of proportion to the provocation. C. The aggressive behavior is generally not premeditated (e.g., is impulsive) and is not committed in order to achieve some tangible objective (e.g., money, power etc.). D. Aggressive outbursts occur twice a week, on average, for at least a period of 1month. E. Aggressive behavior is not better accounted for by mania, major depression, or psychosis. It is not solely due to the direct physiological effect of a substance (e.g., drug of abuse) or of a general medical condition (e.g., closed head trauma, Alzheimer's). F. The aggressive behavior causes either marked distress (in the individual) or impairment in occupational or interpersonal functioning”. (p. 369).

Individuals with IED have high rates of comorbidity with other psychiatric disorders, such as mood disorders, substance use disorders, anxiety and depressive disorders, and eating disorders (Cocarro, 2012; McElroy, 1999; Olvera, 2002). The functional significance of this comorbidity is difficult to understand without a case-by-case analysis of which disorder preceded and perhaps caused the other disorder. Studies have suggested that individuals with this disorder may respond to specific serotonin reuptake inhibitors (SSRIs) and mood stabilizers (McElroy, 1999; McElroy etal., 1998; Olvera, 2002). A case study of a young woman with autism, intellectual disability, IED, and bipolar mood disorder showed clinically significant reductions in problem behavior while on risperidone (Yoo etal., 2003). However, response rates and time to task completion during a matching task were also reduced. These undesirable reductions in response rate were lessened in comparison to a nonreinforcement condition by a continuous schedule of tangible reinforcement. This suggests that behavior producing strong reinforcement may be less influenced by pharmacological treatment. Thus, it appears that clinicians should consider functional consequences for behavioral challenges and not rush toward applying or continuing medications that may have been administered based on nonfunctional assessments.

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The Human Hypothalamus: Neuropsychiatric Disorders

Michele Rizzi, ... Carlo Efisio Marras, in Handbook of Clinical Neurology, 2021

Abstract

Intermittent explosive disorder can be described as a severe “affective aggression” condition, for which drugs and other supportive therapies are not fully effective. In the first half of the 19th century, experimental studies progressively increased knowledge of aggressive disorders. A neurobiologic approach revealed the posterior hypothalamic region as a key structure for the modulation of aggression. In the 1960s, patients with severe aggressive disorder, frequently associated with intellectual disability, were treated by bilateral stereotactic lesioning of the posterior hypothalamic area, with efficacy. This therapy was later abandoned because of issues related to the misuse of psychosurgery. In the last 2 decades, however, the same diencephalic target has been selected for the reversible treatment by deep brain stimulation, with success. This chapter presents a comprehensive approach to posterior hypothalamic surgery for the treatment of severely aggressive patients and discusses the experimental steps that allowed this surgical target to be selected. Surgical experiences are reported, together with considerations on target features and related encephalic circuits.

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Epilepsy

David Myland Kaufman MD, ... Mark J. Milstein MD, in Kaufman's Clinical Neurology for Psychiatrists (Eighth Edition), 2017

Intermittent Explosive Disorder

The condition listed in DSM-5 as Intermittent Explosive Disorder usually consists of violently aggressive, primitive outbursts, including screaming, punching, wrestling, and throwing objects that injure people or destroy property. Minor stimuli, such as verbal threats, anger, or frustration, especially after consuming even small amounts of alcohol, often trigger episodes (although if alcohol “fully accounts” for the episodes, the DSM-5 would not label them as Intermittent Explosive Disorder). A highly charged affect often precedes and accompanies the outburst. After it, patients typically claim justification, regret, or amnesia for the event.

In contrast to violent focal seizures (see before), which are rare, episodic dyscontrol episodes are nonstereotyped, at least momentarily purposeful, and highly emotional. Furthermore, the episodes have a clearly directed and aggressive intent. They occur predominantly in young men who have congenital malformations or TBI, borderline intelligence, and minor physical neurologic abnormalities. Many have interictal EEG abnormalities. Although the neurologic community does not equate episodes of episodic dyscontrol syndrome with seizures, physicians generally agree with the use of AEDs as mood stabilizers.

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Cognitive-Behavioral Treatment of Impulse Control Disorders

Dan Opdyke, Barbara Olasov Rothbaum, in International Handbook of Cognitive and Behavioural Treatments for Psychological Disorders, 1998

Intermittent Explosive Disorder

Description

Aggressive outbursts have long been the concern of clinicians. The Intermittent Explosive Disorder diagnosis is given only after a number of other diagnoses have been ruled out. Medical conditions and substance intoxication can result in aggressive behavior. Psychotic disorders, conduct disorders, and some of the personality disorders may feature aggressive outbursts. A culture-specific condition called Amok is characterized by aggressive outbursts with amnesia (APA, 1994). Simon (1987) described the Berserker/Blind Rage Syndrome as a subset of Intermittent Explosive Disorder deserving of study. Symptoms of “blind rage” have captured the imagination of the public for centuries.

Concerns have been voiced about the legitimacy of Intermittent Explosive Disorder as a separate disorder, especially because of the number of studies indicating abnormalities in serotonergic function, complex-partial seizures, and family histories of alcoholism (McElroy et al., 1992). Anger attacks have been posited as a variant of Panic Disorder (Fava, Anderson & Rosenbaum, 1990) and related to depression (Lion, 1992). Should such concerns seem moot, the legal defense of “irresistible impulse” highlights the importance of the nosology of this disorder.

Pure cases of Intermittent Explosive Disorder are found to be quite rare (APA, 1987) although reliable information is scarce. Onset is usually in the second or third decade of life and it is more common in males (APA, 1994). Patients with temper outbursts were previously considered to have limbic system dysfunction. The symptoms of Intermittent Explosive Disorder are found in so many of the disorders that it can be considered a diagnosis of exclusion (Lion, 1992). The category is retained in the DSM-IV with the elimination of the criterion indicating the lack of generalized impulsiveness or regression between episodes (APA, 1994). “Soft” neurological signs are acceptable in the new classification, and certain personality traits (e.g., narcissistic, paranoid, obsessive, schizoid) are listed as predisposing factors (APA, 1994).

Studies on Intermittent Explosive Disorder are few and far between, with most focusing on pharmacological interventions and neurological speculations as to etiology. A large study several years ago by Bach-y-Rita, Lion, Climent & Ervin (1971) examined 130 patients in a large metropolitan psychiatric emergency room. Conventional neuropsychological examinations proved negative, although histories of coma-producing conditions such as meningitis, febrile convulsions, and head injuries were often found. High incidence of family violence and alcoholism were found, and twenty five patients had idiosyncratic alcohol effects with violent eruptions after a few drinks. Pyromania was present in 21 cases. The average age was 28.

Bach-y-Rita’s (1971) patients were mostly dependent males with hyper masculine sex role identifications who were chronically anxious and insecure. Poor coping skills and inadequate ego defenses were noted. Childhood deprivation and cultural impoverishment were factors. Usually there was a very short prodromal period of increased anxiety and fear of losing control. Small stimulations could then precipitate full-blown rages.

Twenty five years later, Bitler, Linnoila & George (1994) discussed their sample of Intermittent Explosive Disorder patients who “lose control” and are physically violent toward spouse or significant others. Their four cases each reported feeling trapped, criticized, rejected, and insecure before losing control. Somatic changes accompanied the aggressive outburst. Verbal aggression usually preceded the outburst as well. These patients reported a heightened sense of arousal before the incident, with a sense of release and fatigue immediately following. Guilt feelings often ensued. Bitler and colleagues (1994) proposed that preexposure to violence in childhood could have led to PTSD phenomena triggered by feeling “trapped.” In each case, the reaction was out of proportion to any environmental stimulus or stressor. The autonomic symptoms suggest panic disorder, e.g., palpitations, feeling out of control, etc. These cases shed light on the topography of this peculiar disorder.

The nature of the Impulse Control Disorders is such that the impulsive behaviors are to varying degrees intermittent. The eliciting events and contingencies associated with the behaviors are often undetected by direct observation. Assessment may prove difficult, especially in cases where the behavior itself is a reinforcing event. In the case of Intermittent Explosive Disorder, there may not appear to be precipitants, but there are often noxious internal states preceding the outbursts. Negative reinforcement occurs with the escape from these aversive internal states. The behavior (outburst) itself is the reinforcer.

Feeling cornered, criticized, and rejected may be “setting events” (Wahler & Graves, 1983) for explosive behavior. Setting events are similar to what Michael (1982) described as “establishing operations.” Depriving a pigeon of food will increase responding if the reinforcement is food. Likewise, the probability of an aggressive outburst may be increased with the number of perceived rejections and criticisms. These aversive stimulations are the establishing operations or “setting events” for escape and avoidance behavior. In the case of Intermittent Explosive Disorder, the aversive stimulation is mostly internal and noxious (feeling trapped). The escape, in the absence of a learning history for modulating ones’ own mood states, is a violent outburst. Had there been demands put on the individual or even perceived slights, these stimuli will rapidly disperse once he explodes. A secondary function of the outburst may be to keep people at bay.

Treatment

Bach-y-Rita’s patients were treated with medication and referred for psychotherapy to deal with anxiety and anger control (Bach-y-Rita et al., 1971). Medications have long been used for these sorts of behaviors. They likely have a palliative effect because they reduce the internal stimuli. While medicines may work for a short while, the intermittent nature of Intermittent Explosive Disorder might indicate the use of constant medication. The medication remedy may prove costly and ineffective, however, because no learning has occurred. The escape behavior, i.e., violence, must be blocked in the presence of the aversive stimulation for extinction to occur. Nonpharmacological treatment is characterized by identifying the psychosocial stressors and affective cues. Precipitating events, both external and internal, are explored in detail with the client so that the rage “triggers” can be defused (Lion, 1992).

The protocol for Intermittent Explosive Disorder, if one existed, might then include the presentation of escape-provoking stimuli while at the same time blocking the violent sequelae. In many cases this might involve the use of physical restraint in an inpatient setting. This form of treatment has a precedent in its application to mentally retarded individuals. Studies with retarded children indicate that aggressive outbursts are often maintained by negative reinforcement, in that the child escapes demand situations by acting aggressively. Preventing the escape behavior will extinguish the aggressive behavior. Alternatively, reducing the demands on the child contingent on nonaggressive behavior is equally effective (Carr, Newsom & Binkoff, 1980).

In cases where extinction is applied without attention to the setting events, however, there remains the task of reducing the internal stimulation via some other means. The differential reinforcement of other (DRO) behaviors approach has been successful in treating self-injurious behavior (Steege et al., 1990). DRO is generally more effective when combined with extinction of the target behavior. Thus, alternative methods of emotional modulation need to be modeled and reinforced for Intermittent Explosive Disorder clients. Of course all this must be done with the endorsement and collaboration of the client. Despite the above speculations for the treatment of Intermittent Explosive Disorder, the authors could find no such application in the literature.

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