Intermittent Explosive Disorder

Case: Jasmine, 15. Five chapters follow: the case, epidemiology, presentation, functional neuroscience, and treatment.

The case: Jasmine, 15

Jasmine is fifteen and in tenth grade. She plays midfield on the school field hockey team, keeps a B-plus average, and has had the same three close friends since middle school. Since her parents' divorce two years ago she alternates weeks between her mother, Lena, with whom her eleven-year-old brother, Sami, also lives, and her father, Omar.

Presenting concern

Jasmine was seen at pediatric urgent care on a Sunday evening with a swollen right hand after punching her bedroom door at her father's apartment. The X-ray showed no fracture. The note reads: "Fifteen-year-old with hand contusion after punching door during argument. Mother reports recurrent 'rages' over past year. No SI/HI. Refer behavioral health." Lena says: "Ninety percent of the time she's lovely. Then it's like a switch, and it's over as fast as it started." Omar says: "She gets it from me. I threw things at her age. I grew out of it."

Jasmine says: "It's like pressure that comes up in maybe two seconds, and then I'm yelling before I decided anything. After, I feel sick." Asked what she gets out of it: "I get grounded. What would I get?"

The episodes

Over the past twelve months her parents and school together count roughly fifteen outbursts. Most are verbal: shouting, insults, slammed doors. Six involved property: a phone thrown at a wall and cracked, a laptop lid slammed until it broke, the bedroom door, a plate. Two involved people. She shoved Sami into a bookshelf when he changed the channel, and at a party in June she slapped a friend who had repeated something Jasmine had told her in confidence; Jasmine had had two drinks. Most outbursts last under fifteen minutes. Afterward she is tearful, apologizes without prompting, and by the next morning is, in Lena's words, "completely herself."

Two episodes the adults describe as "blowing up at an adult" differ on closer inspection. In March, when Lena told her in front of a friend that she could not go out, Jasmine screamed, threw her phone, and was sobbing within a minute; she later said she "didn't even hear" what her mother said after the first sentence. In May, when a teacher accused her of copying a lab report, she argued loudly for several minutes, said "this is unfair," and walked out to the counselor's office; nothing was thrown, and she was composed once the counselor agreed to look at both reports. The school logged both as defiance.

Between episodes

Neither parent describes persistent irritability, sulking, or a low threshold for anger on ordinary days. Teachers describe her as attentive and organized. There were tantrums in preschool and two playground fights in fourth grade, "both times when someone teased Sami," and nothing since. No fire setting, theft, truancy, or cruelty. Sleep is regular in season. She drinks an energy drink before afternoon practice most days, vapes nicotine "sometimes," and has had alcohol at three parties; she denies cannabis and other drugs. No head injury, seizures, or loss of consciousness. Menses are regular; she has not noticed a monthly pattern to the outbursts and has not been asked to track one.

Family and history

The divorce was "loud," Lena says. Omar acknowledges shouting and, once, putting his fist through a wall in Jasmine's presence when she was twelve. There was no violence toward the children. Jasmine reports no nightmares, avoidance, or intrusive memories, and the outbursts are not clustered in her father's weeks. Omar's brother "has a temper." Lena has been treated for depression. Jasmine has had no prior mental health contact.

In session

Jasmine is articulate and makes eye contact. Describing the phone incident she becomes flushed and speaks faster, then stops and says, "See, even now." She can name what she would do differently and adds, "I know all that. It's not there when it's happening." Asked about Sami, she says she "would never actually hurt him," and looks at her bandaged hand.

Epidemiology

The evidence is adult, and says the disorder starts in adolescence

No source in the reference list reports the prevalence of intermittent explosive disorder in children or adolescents, and the NCS-A report gives no figure for it [53]. What the list supplies is the adult survey that defined the disorder's epidemiology and, within it, the finding that matters for a casebook of adolescents: the disorder begins early.

In the National Comorbidity Survey Replication, a face-to-face household survey of 9,282 US adults, the lifetime prevalence of DSM-IV intermittent explosive disorder was 7.3% and the 12-month prevalence 3.9% [3]. The mean age at onset was 14 years [3]. Those adults reported a mean of 43 lifetime attacks, with 180 injuries per 100 lifetime cases and property damage averaging $1,359, and sociodemographic correlates were "uniformly weak" [3]. The disorder was significantly comorbid with most mood, anxiety and substance use disorders, and the treatment gap was wide: 60.3% had ever received professional treatment for emotional or substance problems, 28.8% for anger specifically, and 11.7% in the prior 12 months [3]. Jasmine is 15, a year past the mean onset that adults recalled; the survey says her presentation, if it is this disorder, is arriving on schedule, and that most people with it do not reach treatment for the anger itself.

Childhood antecedents, seen from adulthood

A retrospective comparison of adults with DSM-5 intermittent explosive disorder, adults with other psychiatric disorders and healthy controls found three childhood characteristics specific to the IED group: not being raised by both parents, greater physical aggression by the participant, and more fighting with peers by age ten [62]. The authors list the design's limits themselves: retrospective, cross-sectional and self-reported, so no causal inference [62]. Jasmine's parents divorced two years ago, and she had two playground fights in fourth grade and none since; the antecedent profile is a population pattern, and a partial match to it does not make the diagnosis.

What the adult figures cannot supply

A prevalence in adults recalled to a mean onset of 14 implies that the disorder is present in adolescents, but it does not give an adolescent prevalence, a sex ratio at that age, or the proportion of adolescent outbursts that go on to meet adult criteria. The treatment studies in the list are adult as well: a pilot randomized trial of cognitive behavioral therapy in 45 adults [63], a secondary analysis of a fluoxetine trial in adults [65], and a systematic review of pharmacotherapy that includes six adult trials in the disorder [64]. One randomized trial of cognitive behavioral therapy in 42 adolescents with the disorder was published in 2026 [219]; it is the first adolescent treatment trial in the list. The presentation and treatment chapters mark every extrapolation from these sources.

Neighbors in the differential

The base rates for the conditions Jasmine's presentation must be separated from are in other chapters: DMDD at 2.5% to 3% at ages 10 to 12 with low stability [7, 9]; ODD at 12.6% and conduct disorder at 6.8% lifetime in adolescents [53]; and the general finding that 25% to 60% of adult disorders were preceded by juvenile conduct or oppositional problems [59]. Against those, a disorder recalled to begin at 14 with weak demographic correlates is the one for which the least is known in her age group.

What this case cannot establish

The adult figures make the diagnosis plausible for a 15-year-old with recurrent, brief, disproportionate outbursts and ordinary functioning between them. They cannot say how common that pattern is among her peers, or how often it persists.

Source status

#3 and #62 from published abstracts; #63 and #65 from published abstracts (adult trials); #53 from the article text; #7 and #9 from open-access full text; #59 from the abstract. #64 abstract recovered in the citation check of 2026-10-05; #219 added from it.

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Presentation

A note on the evidence

Most of what this casebook can cite about intermittent explosive disorder comes from adults. The national survey that describes the disorder's prevalence, onset, and comorbidity interviewed adults about their lives retrospectively [3]. The study of childhood characteristics compared adults with the diagnosis with adult controls [62]. The treatment trials enrolled adults [63, 65]. Each chapter in this module says where a claim is extrapolated from adults to a fifteen-year-old, and the reader should treat those claims as hypotheses about Jasmine rather than findings about her.

Perception, interpretation, participation

Jasmine arrives with a bandaged hand, a mother who describes a switch, and a father who describes himself. The urgent care note records the endpoint: a door, a contusion, "rages." The task is to describe what Jasmine perceives at the start of an outburst, what she makes of it, and what she does, and then to describe the same three things for the days in between.

Her own account is unusually precise. Pressure "in maybe two seconds," then yelling "before I decided anything," then feeling sick. In the March episode she says she did not hear what her mother said after the first sentence. Perception narrowed to the first sentence; interpretation, if it occurred, was of that sentence alone; participation followed at once. In session, describing the episode, she flushes, speaks faster, and stops herself: "See, even now." That is a smaller version of the same sequence with participation interrupted, and it shows that she can perceive the rise when it is slow enough.

Asked what she gets from an outburst, she answers with what it costs her. That is an observation about expected gain, and it is the first thing that separates her episodes from those described in the Oppositional Defiant and Conduct Disorder module (Luis).

The shape of an outburst

Intermittent explosive disorder is defined by recurrent behavioral outbursts that reflect a failure to control aggressive impulses: either verbal aggression or physical aggression toward property, animals, or people occurring on average about twice weekly for three months without damage or injury, or three outbursts involving damage or injury within twelve months; grossly out of proportion to the provocation; not premeditated and not committed to achieve a tangible objective; causing distress or impairment; in a person at least six years old; and not better explained by another disorder [111]. The last clause carries most of the differential work. The definition also excludes the diagnosis in a child whose outbursts occur in the context of disruptive mood dysregulation disorder [111].

Jasmine's episodes fit the shape. Fifteen outbursts in a year, six with property damage and two with physical aggression toward a person, meet the frequency clause. A screamed refusal and a thrown phone in response to being told she cannot go out is out of proportion to the provocation. "I get grounded. What would I get?" speaks to the absence of a tangible objective. The distress is hers as much as her family's.

The dimensions that a count leaves out matter here as elsewhere. Target: mostly objects, twice people, once a younger sibling. Force: a cracked phone, a broken lid, a bruised hand; a shove into a bookshelf and a slap. Latency: seconds. Duration: under fifteen minutes. Recovery: tearful, apologetic, and "completely herself" by morning. Her own account of the moment before: pressure without a decision. These are what the neuroscience chapter works from.

Two episodes that look alike

The March phone and the May lab report were both logged as "blowing up at an adult." In March, the provocation was a refusal delivered in front of a friend; the response arrived within a sentence, involved an object, had no goal Jasmine can name, and ended in sobbing. In May, the provocation was an accusation; the response built over minutes, used words, was directed at an identifiable injustice, had a goal (getting the accusation examined), and ended as soon as the counselor agreed to look at the reports. The May episode is loud protest under accusation, proportionate in kind if not in volume, with recovery keyed to the outcome. The March episode is the disorder's defining event. Grouping them together inflates the count and, more importantly, would lead a school plan to treat a proportionate protest as an explosion.

The Sami shove and the party slap look alike too: both are physical aggression toward a person. The shove followed a trivial provocation, took a second, and was followed by regret. The slap followed a real betrayal, at a party, after two drinks. Whether the slap belongs to the same pattern or to alcohol acting on that pattern cannot be decided from one evening, but it is the only episode with a substance in it, and the question has to be asked.

The differentials as questions about the intervals

Every differential for Jasmine is a question about what she is like between outbursts, and the answer from every informant is the same: ordinary. That answer does much of the work.

Disruptive mood dysregulation disorder requires chronic, persistent irritability most of the day, nearly every day, between outbursts, with onset before age ten [111], and it precludes the IED diagnosis. Neither parent nor any teacher describes irritability between episodes, and the fourth-grade fights, which concerned Sami being teased, are the only childhood aggression on record. Oppositional defiant disorder would require a months-long pattern of angry mood, argumentativeness, or vindictiveness, as the Oppositional Defiant and Conduct Disorder module (Luis) sets out; the May episode is a single proportionate argument, and her teachers describe her as attentive and organized. Conduct disorder would require violations of others' rights or major norms, and none is reported. ADHD would show in inattention or impulsivity in ordinary settings, which no one describes; the impulsivity in Jasmine is confined to the two seconds before an outburst.

Substance effects are a live question rather than a closed one. Alcohol was present in one episode. Nicotine and a daily energy drink are present most days and are asked about as state contributors, not as explanations. Trauma-related reactivity is asked about because of the divorce and the wall: she reports no nightmares, avoidance, or intrusions, outbursts are not clustered in her father's weeks, and the provocations are mundane rather than reminiscent. That does not make the wall irrelevant. It makes it a model of what to do with pressure rather than a conditioned cue. A mood disorder would show in the intervals as well; a depressive episode or an activated period is not described. A premenstrual pattern has not been assessed and is worth a prospective diary rather than an assumption; the diary would separate premenstrual dysphoric disorder, premenstrual exacerbation, and outbursts unrelated to the cycle [210]. Medical contributors to episodic aggression, including seizures and head injury, are addressed by history and are negative here [211].

What the adult literature offers and what it cannot say

In the National Comorbidity Survey Replication, adults who met criteria reported onset, on average, in mid-adolescence [3]. Jasmine's first year of outbursts at fourteen is where the adult recollections place the beginning. That survey also found that most people who met criteria had never received treatment specifically for anger [3]; the direction, if not the figure, applies to a girl who has reached care through an urgent care visit for her hand rather than for her outbursts. Adults with the disorder, compared with healthy and psychiatric controls, more often reported not having been raised by both parents and more fighting with peers by age ten [62]. Jasmine's parents are divorced and she had two fights in fourth grade. Those facts should not be read forward. The study is retrospective and cross-sectional, and its authors say so; it describes what adults with the disorder recall about childhood, not what childhood features predict the disorder. Among adolescents surveyed in the National Comorbidity Survey Adolescent Supplement, behavior disorders as a group had a median onset around age eleven [53], a figure that includes disorders Jasmine does not have. One randomized trial has enrolled adolescents with the disorder, a small 2026 study of cognitive behavioral therapy [219]; the descriptive literature on adolescent samples remains thin.

What this case cannot establish

The presentation cannot establish that the party slap belongs to the same pattern as the sober episodes. It cannot establish the absence of a premenstrual pattern, since no one has tracked one. It cannot establish that the May lab-report episode was proportionate rather than a smaller explosion with a convenient object; the counselor's account supports proportion but was taken after the fact. It cannot establish, from a survey of adults recalling their adolescence, when Jasmine's pattern began or how it will run. And it cannot establish how much of Omar's "she gets it from me" is heredity, how much is modeling, and how much is a father's way of forgiving her.

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Functional neuroscience

Part 1. Functional layer

The functional variables in this chapter are the ones the Oppositional Defiant and Conduct Disorder module (Luis) developed: how a provocation acquires significance, how activation changes which actions are available, and what an outburst teaches. Jasmine's pattern differs from Luis's not in the variables but in their time course, and in what happens in the intervals. The circuit and pharmacological evidence that bears on intermittent explosive disorder comes almost entirely from adults [3, 62, 65]; where this chapter uses it, it says so, and what it says about Jasmine is extrapolated.

The provocation and what it comes to mean

A refusal delivered in front of a friend arrives with a history, as a laugh does for Luis. Mental-state inference is the operation of estimating another person's unobserved state from behavior and context; causal attribution concerns the explanation assigned to an event. For Jasmine the represented threat in March was not the refusal but its delivery: being told no in front of a friend is a loss of standing, and the friend's presence is part of the input. Adults with the disorder are reported, in group comparisons, to attribute hostile intent to ambiguous social cues more readily than controls [212]; that is an adult finding on a laboratory task, and it does not measure what Jasmine inferred about her mother in one sentence.

What is observable is different and more specific: Jasmine says she did not hear the rest of the sentence. The inference, if one was made, was made on the first clause. This places the important event before interpretation had much to work with. Whatever her attribution was, it had to be fast, and a fast attribution is drawn from what is already represented, which for Jasmine includes a household in which pressure has been answered with a fist through a wall.

Rise, peak, and recovery

An emotion has a time course: a background state, a response to an event, a peak, and a return toward some reference condition. Peak and duration can vary independently, and describing both as "severe reactivity" loses a clinically meaningful difference. Jasmine's episodes have a steep rise, a high peak, a short duration, and a fast return. Her intervals are ordinary. Luis's episodes rise more variably, sometimes over minutes of argument, and his intervals contain a longstanding limit on waiting and pausing. The two patterns share the peak and differ in almost everything around it.

Affective response gain describes a relation between change in an eliciting input and change in a specified emotional response, and characterizing it requires defined inputs and responses across conditions. Jasmine's account supplies something rarer than a gain estimate: a description of the rise itself, "pressure in maybe two seconds." A rise that fast leaves little room for the slower operations that ordinarily shape a response. Reappraisal, the changing of an event's meaning, and attentional disengagement, the releasing of attention from the current input, are Processes that take time and working memory, and they are harder to deploy at the peak of distress than before it. "I know all that. It's not there when it's happening" is an accurate description of a capacity that is intact and inaccessible under the State the rise produces. In session, the same rise at a lower rate, while describing the March episode, was perceived and interrupted. Rate of rise, not the presence of the capacity, is the variable that differs between the two occasions.

The rate of affective recovery, how an evoked response approaches a defined reference condition after the eliciting event, is a separate quantity. Jasmine's is fast, and her remorse is immediate. This matters diagnostically, because it is the interval that rules out the chronic irritability of disruptive mood dysregulation disorder, and it matters functionally, because a child whose distress resolves quickly has an opportunity to learn from each episode that a child in a sustained irritable state does not.

Activation and the selection of action

Action selection concerns choosing from available alternatives under particular evidence and value conditions, and availability is narrowed by what the person expects to work and by the time available. For Jasmine, the time available is the two seconds she describes. Under those conditions the fast alternatives, shouting and throwing, have an advantage unrelated to their value once the moment has passed. Response inhibition, the Capacity to withhold or cancel a prepared action, is the capacity the two seconds demand [205]. In Luis it is limited at baseline by ADHD. In Jasmine there is no evidence of a baseline limit: teachers describe her as attentive and organized, and impulsivity outside the outbursts is not reported. What limits access to the capacity is the State, arriving faster than the capacity can be recruited.

That difference in baseline is the most important thing the intervals establish. An adolescent who is impulsive across settings and an adolescent who is impulsive for two seconds a week both hit doors. The first has a Capacity problem, the second an access problem confined to a State, and the treatment chapter treats them differently.

What an outburst produces

Instrumental learning makes a behavior more likely when it has produced a valued outcome, and escape from a demand counts as one [176]. The question for each of Jasmine's episodes is what it produced. "I get grounded. What would I get?" is her answer, and the record supports it: the March outburst did not get her out of the house, the shove did not get the channel back, the door did not change her father's decision. The May lab report episode is the exception. It had a goal, produced it, and stopped when it was produced. That is why the presentation chapter separated it. Emotional activation and expected gain can both influence the same action, and here the balance is visible: in March, activation without gain; in May, a proportionate response organized around gain.

One consequence is still worth tracking. After an outburst, Jasmine's parents comfort her and the household reorganizes around her remorse. That is a humane response and may be a small reinforcer of the sequence as a whole, not of the outburst but of the reconciliation. Whether it matters is an empirical question for the log, not a reason to withhold comfort.

Substances and state

In adults, experimental studies link acute alcohol to aggression under some conditions [213]; for a fifteen-year-old that is an extrapolation, and the party slap is the only episode with alcohol in it. Caffeine in the doses found in energy drinks raises arousal, and nicotine withdrawal is associated with irritability [146, 214]. None of these explains the pattern, which began before the parties and occurs on days without practice. They are state contributors: they change the background against which a provocation lands and the rate at which arousal rises. The diary the treatment chapter describes records them so their contribution can be estimated rather than assumed.

Part 2. Circuits, development, and genes

What adult imaging shows and what it cannot show here

In a small fMRI study, adults with intermittent explosive disorder showed, in group comparisons, greater amygdala responses to angry faces and reduced coupling between amygdala and orbitofrontal or ventromedial prefrontal cortex during the task [215]. These findings make the functional account plausible: a rapid threat-evaluation system and a slower system that contextualizes it, with the balance tipped toward the first. They are adult findings, on tasks that present faces for seconds, and they do not measure Jasmine's brain or her mother's sentence. Developmental imaging in people aged six to twenty-three shows age-related change in prefrontal recruitment and prefrontal-amygdala relationships during reappraisal; the study concerns performance on a specified strategy, not a maturity score [327]. At fifteen, Jasmine's reappraisal is available in conversation and not yet reliably available at a two-second rise, and part of that gap is her age.

Frustration paradigms in young people have examined attention orienting and neural responses after an omitted reward, across clinical groups and healthy participants aged eight to eighteen [343]. The work concerns processing after frustration under task conditions and cannot establish the mechanism of an individual outburst; it is cited here because it is the closest pediatric study of the relevant process in this book's corpus.

Serotonin: a hypothesis with adult evidence

A serotonergic contribution to impulsive aggression has been proposed, but a meta-analysis of human studies found only a weak and heterogeneous inverse relation between serotonergic function and aggression [216]. Fluoxetine has reduced aggression relative to placebo in adults with the disorder in a randomized trial [217]. In a secondary analysis of such a trial, higher baseline neuroticism and harm avoidance predicted poorer antiaggressive response to fluoxetine, and the authors note that a large proportion of patients do not reach full remission on adequate treatment [65]. A systematic review of pharmacotherapy for impulse control disorders includes six trials in intermittent explosive disorder [64]; the treatment chapter takes up what they show. Two cautions follow. A drug response is evidence about a drug, not about the cause of the disorder; and every one of these findings is adult. Nothing in this reference list tests a serotonergic hypothesis in adolescents.

Development and childhood characteristics

Adults who met criteria in the National Comorbidity Survey Replication reported onset in mid-adolescence on average [3]. Adults with the disorder, compared with controls, more often reported not having been raised by both parents and more fighting with peers by age ten [62]. Jasmine's parents are divorced, and she had two fights in fourth grade defending her brother. These correspondences are worth noticing and worth refusing to over-read: retrospective adult recall of childhood cannot be turned into a prediction about a particular fifteen-year-old, and the study's authors list recall bias and the cross-sectional design as limitations. What can be said about development in Jasmine is what the case shows: an ordinary childhood with two protective fights, a loud divorce, a modeled fist through a wall at twelve, and a first year of outbursts at fourteen.

Genes

A meta-analysis of twin and adoption studies of antisocial behavior, a broader phenotype than impulsive aggression, found moderate heritability [218], and aggression aggregates in families. Omar and his brother supply a family history of temper, and Omar supplies, in the same person, a modeled response to pressure. Heritability estimates describe populations; they cannot say through which route his temper reaches her, and a twin design is what would separate the routes.

Moving between levels

An adult scanning study, an adult fluoxetine trial, and an adult survey each answer a question at one level in one population. For Jasmine they support the plausibility of a fast threat-evaluation State that removes access to intact capacities for a short time. What the case establishes directly is narrower: a two-second rise, a fifteen-minute episode, fast recovery, remorse, ordinary intervals, no goal she can name, and one episode with alcohol in it.

What this case cannot establish

This chapter cannot establish that Jasmine's amygdala or prefrontal cortex behaves as adult group data suggest; nothing measures them. It cannot establish a serotonergic contribution; that hypothesis has adult evidence only, and drug response would not establish it in any case. It cannot separate heredity from modeling in what she has from her father. It cannot establish that the shove and the slap share a mechanism. And it cannot establish that the rate of rise, rather than the peak, is what distinguishes the March episode from the May one; her account supports that reading, and only prospective observation would test it.

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Treatment

Goals in Jasmine's terms

Jasmine wants the two seconds to be longer. Her mother wants the switch to stop; her father wants her to grow out of it, as he did. The school wants fewer incidents, and it has counted a proportionate protest among them. The functional chapters translate these into targets: the rate at which arousal rises after a provocation, access during that rise to capacities she demonstrably has, the state contributors that change the background, the household model of what pressure is answered with, and the log that keeps the March phone and the May lab report apart. Progress is measured on the dimensions the presentation chapter named: latency, force, object, target, duration, and recovery, and separately on episodes with and without a substance in them.

What the evidence is, and is not

All but one of the treatment trials of intermittent explosive disorder in this book's reference list enrolled adults. The pilot randomized trial of cognitive behavioral therapy enrolled forty-five adults [63]. The fluoxetine predictor analysis was a secondary analysis of an adult trial [65]. A systematic review of pharmacotherapy for impulse control disorders includes six trials in intermittent explosive disorder, all in adults [64]. The exception is a randomized trial published in March 2026, which assigned forty-two adolescents with the disorder to twelve weekly sessions of cognitive behavioral therapy or a wait-list [219]. Improvements were maintained at three months [219]; the small sample and inactive comparator limit certainty. The trial postdates the two reviews cited in this chapter [64, 220]. Everything below that rests on the adult studies is an extrapolation from adults, and the chapter says so at each step. What is not extrapolated is the plan's structure, which follows the formulation: a fast-rising State, intact capacities, no baseline impulsivity, ordinary intervals, and one episode with alcohol in it.

Cognitive behavioral therapy, adapted downward in age

In the adult pilot trial, twelve weeks of cognitive behavioral therapy delivered in either group or individual format reduced aggression, anger, hostile thinking, and depressive symptoms and improved anger control relative to a wait-list, with large effects maintained at three months, and the two formats did not differ [63]. The protocol combined relaxation training, cognitive restructuring, and coping skills training, including rehearsal of responses to imagined provocations [63]. The trial supports the recommendation; it does not show that the treatment works through the functional account, and it does not show that it works at fifteen.

The components map onto the formulation in a way that makes the extrapolation reasoned rather than reflexive. Relaxation training addresses the rise: a practiced physiological response that can be started at the first sign of pressure, which Jasmine can detect when the rise is slow, as she showed in session. Cognitive restructuring addresses the attribution made on the first clause of a sentence, and it is done between episodes, when the capacity is available, so that a more benign reading is already represented before the next refusal in front of a friend. Rehearsal under imagined provocation is the component that most directly targets access: it practices the slow alternatives under a small dose of the state that removes them. For a fifteen-year-old, the adaptation is not in the components but in their delivery: shorter sessions, provocations drawn from her own log, a parent in the room for some of the work, and an expectation that homework will be done in two households.

Jasmine's baseline is a reason to expect this treatment to have something to work with. She has no limit on inhibition outside the outbursts, she describes the rise accurately, and she has already interrupted a small version of it in front of a clinician. Trial participants were selected for the disorder, not for that profile, and the reports reviewed for this chapter identify no validated baseline predictor of response to cognitive behavioral therapy [219, 220].

Two households, one plan

Omar's account of himself is both a family history and a treatment target. A parent who put a fist through a wall at a moment of pressure has shown Jasmine what pressure is answered with, and his "I grew out of it" tells her that nothing needs to be done. The plan asks both parents to respond to an outburst the same way in both apartments: no argument during it, no consequence delivered during it, comfort afterward, and a consequence agreed in advance that is proportionate and does not remove field hockey. It asks Omar to say, in Jasmine's hearing, what he does now when he is angry. Whether he wants help in his own right is a question put to him directly.

Safety is addressed in the same conversation. Jasmine has hurt her hand, shoved an eleven-year-old into a bookshelf, and slapped a friend. There are no weapons in either home; that is confirmed rather than assumed [221]. Sami is asked, separately, whether he is afraid of her. Jasmine's statement that she would never actually hurt him is an observation about her intention, not about what her hand does in two seconds, and she looked at the bandage as she said it.

Substances and the diary

Alcohol was present in the only episode involving a friend. Jasmine is told this plainly, and told that alcohol can increase the risk of aggression [213]; the evidence is adult, and for her the risk is specific rather than general. Nicotine and energy drinks are asked about as state contributors. A daily diary records provocations, latency, duration, what she did, what ended it, recovery, and the day's caffeine, nicotine, alcohol, sleep, household, and menstrual day. It serves three purposes: it supplies the provocations for rehearsal; it tests the substance, household, and cycle questions the presentation chapter left open; and it gives the school a record in which a proportionate protest and an explosion are not the same entry.

Medication

No medication is approved by the US Food and Drug Administration specifically for intermittent explosive disorder [220]. In adults, fluoxetine reduced aggression relative to placebo in a randomized trial [217], and in a secondary analysis of that kind of trial, higher neuroticism and harm avoidance predicted poorer antiaggressive response, with a large proportion of patients not reaching full remission on adequate treatment [65]. A systematic review of pharmacotherapy for impulse control disorders covers six adult trials in the disorder [64]. That is the pharmacological evidence base, and it is adult.

The functional account makes a serotonergic rationale intelligible: a drug that raises the threshold at which a provocation produces the rise might change the State. That is a reason the adult trials were done, not a reason to prescribe to Jasmine now. Medication is not part of her initial plan. It would be reconsidered if a comorbid condition with its own pediatric evidence base emerged, such as a depressive episode or ADHD, neither of which is present; or if outbursts with injury continued after the psychological treatment and household plan had been delivered as intended, in which case the family would weigh an option whose benefit in adolescents is unmeasured against adverse effects that are known [131]. Pediatric trial evidence for antipsychotics in aggression with disruptive behavior disorders is chiefly for risperidone, and comes from samples of average as well as below-average IQ [144]. Antipsychotics have no trial evidence in this disorder, and their metabolic costs make them a poor fit for an adolescent with ordinary intervals [145].

The school

The school's count of Jasmine's "defiance" includes the lab report. The plan asks the school to reclassify it and to log future episodes on the same dimensions as the diary. It also asks for what the May episode showed she can use: an adult who listens. The counselor's agreement to look at both reports ended that episode at once. A standing arrangement that Jasmine can leave a classroom to find the counselor, without penalty, gives her a slow alternative with a known destination.

The treatment gap as a reason to act

In the adult survey, most people who met criteria had never received treatment specifically for anger [3]. Jasmine reached care through her hand. In a prospective cohort followed to adulthood, most adults with a mental disorder had met criteria for some diagnosis before eighteen [59]; the disorder in adulthood was often not the one in childhood. Neither finding says what will happen to Jasmine. Together they say that a fifteen-year-old with a year of outbursts, an accurate account of them, and intact intervals is being seen at the point where adults with the disorder recall it beginning, and that the adults mostly were not.

What this case cannot establish

The plan cannot establish that a treatment tested in forty-five adults will work at fifteen; it tests that in one person. It cannot establish that rehearsal under imagined provocation transfers to a real refusal in front of a friend. It cannot establish whether Omar will change what he models, or whether that change would matter. It cannot establish that alcohol accounts for the slap; the diary tests that prospectively. And it cannot say, if Jasmine improves, whether the improvement is the treatment, the log, the household plan, her age, or the fact that someone finally asked her what the two seconds are like.

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