August 31, 2023 – This is a true story.
I went to high school with a boy named Frankie. He was hotheaded and was always in trouble because he couldn’t control his temper. Scolding teachers, getting into fights – there may even have been a few run-ins with the law. We called him Frankie the Fuse, but never to his face.
Jump forward 20 years. I’m at a minor league baseball game and sitting across the aisle is none other than Frankie the Fuse. He looks at me, I look at him, and soon we are fast friends again. Towards the end of the match we made plans to play golf the following weekend.
And so began what would become a tortuous and ultimately fateful renewal of our relationship. Even though Frankie reached forty, his fuse had stopped growing. During our first round of golf, he took a chip shot, unleashed a string of curse words and threw his wedge into a pond. On other outings he bent a 5-iron around a tree and smashed the windshield of our cart with his fist. If we were paired with golfers we didn’t know, I would have to take them aside ahead of time and warn them about Frankie’s outbursts.
Eventually it got so bad that I started making excuses when he called or emailed until he got the hint.
The era of the jerk?
Everyone gets frustrated, upset and angry. It’s even normal to occasionally yell, curse, throw things, or hit a pillow. But some people, like Frankie, can spiral out of control.
Judging from the news reports and my social media feed, the number of ‘Frankies’ in the world seems to be multiplying. Perhaps we are becoming angrier as a society, or perhaps we are simply less inhibited in expressing our actions.
We’ve all seen videos of road rage, of someone on a plane yelling at a flight attendant, or of an irate customer running over a fast food restaurant.
I always thought these people were just dorks, but it turns out these angry outbursts could be caused by a little-known psychological condition called intermittent explosive disorder, or IED. Those who have it may not realize they have it or that it can be treated.
Over the past decades, science has steadily unraveled the IED, and in the most recent version of the IED Diagnostic and Statistical Manual of Mental Disorders (DSM5), there’s a whole section about it. (The fact that it shares an acronym with improvised explosive device is an unintentional but convenient coincidence, experts claim.)
The disorder is more than just “getting angry easily,” says Michael McCloskey, PhD, professor of psychology and neuroscience at Temple University and a leading IED researcher. “When they get angry, they behave aggressively: they yell and scream, break things and get into physical fights.”
That response is disproportionate to the trigger, he said. “For example, if someone tries to hit you and you hit them back, that’s not an IED. But if someone says he doesn’t like what you’re wearing and you slap him, that could be indicative.”
About 1 in 25 (or 13.5 million) Americans have the disorder, says Emil Coccaro, MD, the vice chairman of research in the Department of Psychiatry and Behavioral Health at Ohio State University and the recognized world expert on IED.
“We don’t have any data on whether it’s increasing or not,” he said. “But life is clearly moving faster, people are feeling more stressed, and that could be driving this forward.” Or we just see more incidents because everyone has a cell phone now, or the DSM5 input makes diagnosis easier.
About 80% of those with IED are untreated, Coccaro said. (As far as I know, Frankie has never sought help for his angry outbursts and has probably never heard of IED. But when I described his behavior to the experts, they agreed he probably has it.)
The science of anger
Two things happen in the brain that are thought to cause these types of responses. Coccaro points out that aggression is an evolutionary necessity. We need a defense mechanism to protect ourselves from threats. So when a threat is perceived, “the amygdala, the reptilian part of our brain, kicks into action to provoke a fight or flight response,” he explained. “But in people with IED, the amygdala responds faster and stronger. Their fuse is shorter.”
“Overly aggressive people tend to have lower serotonin function in the brain,” says Coccaro. This naturally occurring chemical messenger works, among other things, to reduce aggression. “Think of serotonin as your braking system,” he said. If your brake fluid is low, you won’t be able to stop.
People with IED don’t plan on having their outbursts. They just happen. They also generally do not use them to manipulate or intimidate others. (That would be antisocial or psychopathic behavior.) Instead, they simply misperceive threats and then cannot control their response to those threats. They snap.
But they are not aware of their behavior. While they may not apologize directly, “they feel the impact this has on their family and friends and how it alienates them,” McCloskey said. “It’s not something they enjoy. It bothers them.”
IED is more common in men. Men tend to be more physically aggressive, while women with IED are more verbal. IED is most common in teens, 20s, and 30s, then gradually declines with age, although the threat of an eruption always remains.
Research has not determined whether jobs or socioeconomic conditions make people more likely to develop IED, but genes certainly can. “The more severe the manifestation of aggression, the more genetic influence underlies that aggression,” says Coccaro. That influence is weaker (mid 20%) for verbal aggression, stronger (mid 30%) for hitting things, and strongest (mid 40%) for hitting others.
Learning also plays a role. It is not uncommon for people with IED to have grown up in angry households with abusive parents.
Another possible cause of IED is inflammation, which also plays a role in other behavioral disorders, such as depression, schizophrenia and bipolar disorders. “There is research in cats showing that when you introduce inflammatory molecules into their brains, they become more aggressive,” says Coccaro. IED can also result from a head seizure that damages the temporal lobe of the brain, where the amygdala is located.
We don’t yet know whether angry outbursts, if left untreated, can become more serious. In other words, can years of tantrums lead to a particularly violent outburst – against others or against yourself?
“We don’t know if it will continue like this,” Coccaro said, “but we do know that about 20% of people with IED commit suicide or attempt some other form of self-harm.” And alcohol or drugs can make people more sensitive to provocations and more uncontrolled in their outbursts. IED could lead to domestic violence, but the experts we spoke to don’t link it to mass shootings. These are planned, while IED is spontaneous.
Get some help
Fortunately, there are ways to manage IED.
The first is cognitive behavioral therapy, the classic form of psychotherapy used to treat common behavioral problems. “We teach patients how to determine whether their perception of an anger-inducing situation is based on facts and how to then not behave aggressively. This type of therapy has been shown to reduce aggression by 50% or more in 12 weeks,” said McCloskey.
The second treatment, which can be combined with the first, is medication. “Serotonin reuptake inhibitors have been shown to be effective,” says Coccaro. These antidepressant-like medications improve the behavioral braking system mentioned earlier. Antiepileptic drugs also appear to have some benefit.
McCloskey’s lab is also working on a new computer intervention that shows some promise in treating aggression. It teaches coping skills by showing people threatening and non-threatening words or images on a screen. “Technology could make treatment more accessible and engaging,” he said.
These treatments require the patient to realize (or be convinced) that he needs help. Just like with alcoholism or drug addiction, this is not an easy threshold to cross.
“We all have our defense systems,” says Jon Grant, MD, professor of psychiatry and behavioral neuroscience at the University of Chicago. “It is easier to blame others than ourselves.”
What if you meet someone who is angry? “Don’t tell them to calm down or try to reason with them, just walk away and get to a safe position,” he said. “And don’t make videos. That’s insensitive. There is no reason to make them a subject of ridicule or shame. In fact, if they see you filming them, they might get even angrier.”
But later, once they’ve settled in, Grant recommends talking to them. “Say, listen, you just threw your bat into a pond and you scared the hell out of me. I’m not going to play golf with you anymore if you keep doing this. Season the ultimatum with sympathy. Suppose you want to better understand why they react the way they do and ask if you can help.
“Most people think it’s just bad behavior, and the person behaving needs an attitude adjustment,” says Coccaro. “But the truth is that there is a lot of biological evidence that IED really exists. It’s not just an attitude.”
“It takes a brave person to admit to this condition,” Grant said. “Also probably many athletes, celebrities and politicians [have] then no one steps forward as the poster child.”
Depression evokes sympathy, but aggression scares us, Grant said. “And when someone admits to abuse, we automatically want to focus our attention on the victim, not the abuser.”
Should we express our anger?
You may have heard of rage, rage or smash rooms. These are commercial places where you can pay to destroy computers, furniture, mannequins or whatever you want. The theory is that expressing your anger in a controlled environment is better and safer than expressing it in the real world.
“If you don’t have an aggression problem, it’s probably just fun,” McCloskey said. ‘But if you do, it’s unlikely to be an effective coping strategy. All it does is reinforce the way to approach a problem, which is to act aggressively.”
“There is also a concept called ‘acquired capabilities,’” he continued. “If you become more comfortable with a behavior and it becomes part of your repertoire, then you’re more likely to do it.”
McCloskey emphasized that anger is a normal human emotion and that anger (within limits) can be healthy. Occasional minor acts of excessive aggression are normal. But if it goes further, seek help.
“The interesting thing about all this,” McCloskey said, “is that people with depression or anxiety will say, ‘Oh, I’m getting treatment for that.’ But people with IED tend to think, “I’m just an aggressive person, and nothing can be done about it.” That is simply not true.”