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Intermittent explosive disorder

Christoph Anatol Dr. HERDA, Psychiatrist

Mrs. Wang, a 35 year old Chinese business woman, working as a consultant part time, and mother of 3 and 5 year old children comes for an assessment, after her British husband has threatened to leave her, if she doesn’t eventually go and seek help. She reports that she has always been emotional, outgoing and having clear opinions. She could get into heated discussions easily, but was also quick to cool down again. 
Sometimes she wondered why others can stay so calm and composed all the time. Since her life became more stressful with the two kids and her mother moving in with them, her temper changed:
“My fuse is so short now, I often just explode. In hindsight the matters are not that important, often it has something to do where I feel devalued in my efforts or my view is not taking seriously. But in the situations itself, I cannot think clearly. Often, afterwards, I see that I was looking at how something was said or what was said like through a magnifying glass or microscope. Often, what was said can be understood in different ways when I think about it later, but in that moment, I see it directed against me. For example, the other day I had a lot of stress at work, deadlines, the boss was pushy. I came home, the children were fighting, and I had promised to prepare dinner. Sitting at the table, my husband was asking for some salt, with this sound in his voice, you know, as if he wants to express: what you have cooked doesn’t taste good again. For a few seconds I felt my chest tightening up, somehow knowing, oh, it will happen again, but these few seconds are not enough to get a foot in the door, change what is coming. It is, as if I am on autopilot, a pilot of a war jet. I shouted at him that he never likes anything I do, that he is a stupid arrogant spoiled idiot, a typical British snob who treats me like an A Yi. I threw the salt box at him, hit him over the eye.
These explosions happen so often now, two, three, four times a week. The worst thing is, when I shout at my children. A moment later I feel so sorry and embarrassed. At times I feel I am the worst mother. The week before the period is especially difficult, but it’s so often at other times, it can’t be PMS (premenstrual tension syndrome). Sometimes I can’t help but hit my husband. I mean, he is tall and strong, but once I hit him with the wine bottle and he had a black eye.
It is like I am two different persons, the normal me and the furious one. I have to admit, that it sometimes feels good to explode, I feel relieved afterwards, all the pressure gone. Pressure, I often fail to recognize building up early on. But that feeling of relief is there only for a minute, then I realize the damage to the others, to our relationship, and I feel so much regret, wished I could turn time back.
My father was the same like me. He got these fits so often, and I hated it. Sometimes he hit us. But now I am like him.”
Mrs. Wang is a fictional patient, who shows the typical symptom pattern of “Intermittent explosive disorder”. People with intermittent explosive disorder are periodically unable to restrain impulses that result in verbal or physical aggression. These outbursts are impulsive, which means there is little to no time between trigger and action, are unplanned, and can go together with a strong feeling of anger.
The reason for intermittent explosive disorder is multi-factorial. There is evidence for a dysbalance in the serotonergic system in the brain, with an over-activity of some brain structures (amygdala) involved in emotion processing, and an insufficient activity of higher brain regions that normally control these emotional impulses. It is believed that genetic factors account for 50 % of the likelihood of developing aggressive behaviors. Very often family members of the patient show a similar impulsive aggressive pattern. And of course, individuals who have experienced a history of verbal or physical abuse themselves or witnessed family violence, are more prone to show these behaviors themselves, regardless of genetics.
Some patients might only show verbal aggression, like temper tantrums, arguments or verbal fights, while others also show physical aggression towards property, animals or other individuals.
It is nearly always the case in mental health that the combination of psychotherapy and medication is more effective than either one on its own. However, because of the strong genetic component some researchers see the medication as first line therapy. In this case it is the same medication used for treating depression. In my experience, they work with intermittent explosive disorder even better than in depression. The feedback from patients is very encouraging:
“It is a difference like day and night”, “I feel I have more time to control by impulses, and my explosions are less frequent and less severe”, “It was marriage saving.”
We always recommend psychotherapy as well, in order to help the patient to learn tools how to deal with aggressive impulses and get a more sensitive awareness of their inner emotional state. And we try to help them understand what inter- or inner-personal views might play the role of the ‘magnifying glass’, that turns the seemingly minor incidents into a bomb with no fuse.
This kind of anger – explosive, reactive, aiming to attack or punish the others is actually a kind of emotion that psychologist would call “secondary emotion” or “secondary anger”. It is secondary because the patient’s deep, real authentic feelings in those situations are often a mix of fear, sadness and shame. However, sometimes in their upbringing, they are not allowed to express their authentic primary feelings. In Mrs. Wang’s case, her husband’s words made her feel hurt and ashamed at first, as if she were not good enough. And the explosive anger was a reaction to that hurt and anger –“as my husband, you are supposed to love me, how can you hurt me like this?”The perceived hurt and shame triggered the only reaction she knew, anger.
In psychotherapy, change and growth happens when the patient learns to become more aware of her authentic emotions, to regulate them and to express real feelings instead of the secondary ones. Instead of attacking her husband, she can slow down and say:“I feel hurt as if I were blamed.”By that, she might go into a deep conversation with her husband about her unmet childhood needs and how they can resolve those emotional pain as a couple.
If you are in need for help for any mental health problems, be it intermittent explosive disorder, depression, anxieties, marital problems, sleeping difficulties, alcohol problems, ADHD or others, please make an appointment with our Mental Health Team, who work at QuanKou Clinic or Fengsheng Clinic.

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