NURS 753 Week 6 Case Analysis Evaluation 2 on Intermittent Explosive Disorder in an Adolescent Example

Three Holes in the Drywall and an Apology Every Time: A Case Analysis of Intermittent Explosive Disorder in a 15-Year-Old and a Twelve-Session Cognitive Behavioral Anger Plan With His Family

Case Presentation

T., a 15-year-old high school sophomore, was brought to the clinic by his mother after a three-day suspension for shoving a classmate into a locker during an argument about a basketball game. The classmate was bruised. T. describes his anger as "a switch that flips," usually after feeling disrespected or interrupted, and says that afterward he feels "sick about it." Over eighteen months he has punched three holes in his bedroom wall, broken his phone against the floor, been in two fights at school and screamed at his mother and younger sister several times a week. Between outbursts, his mother describes him as funny, kind to his grandmother and hardworking on the basketball team. After each episode he apologizes, often in tears.

His parents divorced three years ago, and he lives with his mother, a nurse who works night shifts, and his 11-year-old sister. He sees his father every other weekend. His grades have fallen from Bs to Cs. He denies drug use other than trying vaping once, and he has no history of abuse. His father, by his mother's account, "had a temper" that contributed to the divorce.

Assessment

Interviews and Informants

I interviewed T. and his mother separately and together. Alone, T. described the outbursts as coming "out of nowhere," lasting about ten minutes, with a racing heart and feeling hot before he acts. He denied planning any aggression or using it to get something. His mother confirmed the pattern and the remorse. With permission, his school counselor and basketball coach completed brief reports; both described a respected, generally cooperative student whose rare explosions are sudden and out of character.

Outburst Log and Measures

For four weeks before the second visit, T. and his mother kept a log of outbursts: date, trigger, behavior, duration and what happened after. The log recorded seven verbal outbursts, about two a week, triggered by being interrupted, losing at video games, his sister entering his room and a coach's correction, and one episode of throwing a chair, with no injury. I also used an anger expression inventory for adolescents, on which his scores for anger expressed outwardly were elevated while trait anger between episodes was average.

Screening for Co-occurring Conditions

Explosive anger rarely travels alone. In a matched electronic health record study of 30,357 people with intermittent explosive disorder, 95.7% had another psychiatric diagnosis, and every psychiatric subcategory was significantly associated with the disorder (Zhang-James et al., 2025). A 2026 meta-analysis of 47 studies found elevated odds of anxiety, depressive, posttraumatic and substance use disorders among people with the disorder (Liu et al., 2026). I therefore screened T. for ADHD with parent and teacher rating scales, for depression with the PHQ-A, for trauma and for substance use with the CRAFFT. ADHD screens were negative at home and school, the PHQ-A score was 7, he reported no traumatic events beyond the divorce, and the CRAFFT was negative. A pediatric visit within the past six months, including a normal physical examination, showed no medical cause.

Diagnosis

T. meets DSM-5 criteria for intermittent explosive disorder (American Psychiatric Association, 2013): recurrent outbursts reflecting failure to control aggressive impulses, both verbal aggression about twice a week over at least three months and, separately, three outbursts in twelve months involving property damage or injury; the aggression is grossly out of proportion to the provocation, impulsive and not aimed at a tangible goal; it causes marked distress and impairment, including suspension; he is older than six; and it is not better explained by another disorder, a substance or a medical condition. His tears afterward are not a footnote; they are the clinical sign that separates an impulse disorder from a pattern of choosing aggression.

Therapeutic Intervention

Formulation

In the cognitive behavioral model of anger, a trigger is interpreted, often as a deliberate slight, which raises physiological arousal; as arousal climbs, the capacity to consider options falls until behavior is driven by impulse (Wheeler, 2014). T.'s outbursts follow this pattern: interruption is read as disrespect, his body heats rapidly and he acts before he can think. The treatment targets each link: noticing arousal early, lowering it, reinterpreting the trigger and choosing a different response, while helping his family reduce the conflicts that set the cycle off.

Evidence for the Approach

Psychological treatment is the first choice. A 2025 meta-analysis of 12 randomized trials and 14 case studies of treatment for intermittent explosive disorder found that psychological treatments, particularly cognitive behavioral therapy, were significantly effective in reducing aggression and achieving full remission, while fluoxetine showed benefit for irritability and treatment response (Liu et al., 2025). Most trial participants were adults, so the plan adapts CBT for an adolescent and adds family sessions, consistent with developmental approaches to child and adolescent treatment (Yearwood et al., 2012).

Session Plan

Family sessions are held with sessions 2, 5, 8 and 11. His mother learns to recognize his early signs, to use the agreed timeout signal without pursuing an argument, to avoid escalating with raised voices and to praise successful use of skills. His sister joins one session to agree on a rule about entering his room. With his consent, his father is invited to the eighth session, since consistency across both homes matters.

A Sample Session

Session 5 illustrates how the cognitive work is delivered. We begin by reviewing the week's log, choosing the outburst after the coach's correction. I ask T. what went through his mind in the moment. He says, "He's trying to embarrass me in front of everyone." We rate how strongly he believed it, 90 out of 100, and how angry he felt, 8 on the thermometer. I then ask what else might explain the correction, and he offers that the coach corrects everyone, that the coach wants the team to win and that he himself had missed the same play twice. When we re-rate, his belief in the first thought falls to 40 and his anger to 4. For homework he completes one thought record a day using the same three questions: what did I think, what else could explain it and how angry am I now. I praise his effort, ask him to rate how useful the exercise felt, and point out that he generated the alternatives himself, which builds his confidence that the skill is his.

Strengths and Barriers

T. brings real strengths: genuine remorse, a sense of humor, commitment to basketball, a coach he respects and a mother who sought help quickly. His wish to stay on the team is a powerful motivator, and the coach's willingness to support the timeout plan gives the therapy a setting in which to practice. Barriers include his mother's night shifts, which limit evening family time and make some sessions hard to schedule; his embarrassment about being in therapy, which he has asked us to keep from his teammates; and tension between his parents, which could undermine a shared plan. We scheduled sessions after school on his mother's days off, agreed that his participation is private, and offered his father a separate session so that he hears the plan directly rather than secondhand.

Medication

Because his outbursts are improving neither on their own nor with school discipline, I discussed medication with T. and his mother. Fluoxetine has the most evidence for irritability in intermittent explosive disorder, but most trials involved adults, and antidepressants carry a boxed warning for suicidal thinking in young people. Together we chose therapy first, with a medication discussion scheduled for session 6 if outbursts have not decreased by at least half.

Treatment Plan and Evaluation

The goals, written in T.'s words, are "no more holes in the wall," "finish the season without a suspension" and "stop yelling at my sister." Measurable targets are a reduction in outbursts from about two a week to no more than one every two weeks by session 12, no damaging or injurious outbursts and improvement on the anger expression inventory. The outburst log continues throughout. Safety planning covers what his mother will do if an outburst escalates, including leaving the room with his sister and calling for help if anyone is at risk. With consent, the school counselor will receive the timeout plan so that T. can use it in class. Booster sessions at one and three months will support maintenance. If outbursts return during a stressful period such as playoffs or exams, the first step will be to restart the daily log and the thermometer practice rather than to start over, and his mother will know she can call for an earlier booster. Progress will also be shared with T. himself at each review, using his own log, because seeing the number of outbursts fall is part of what keeps an adolescent engaged in therapy he did not choose.

Conclusion

T.'s eighteen months of sudden, disproportionate outbursts, each followed by remorse and separated by calm, meet DSM-5 criteria for intermittent explosive disorder after oppositional defiant, conduct, mood dysregulation and bipolar disorders were considered and set aside. A twelve-session cognitive behavioral anger plan with family involvement, grounded in evidence that CBT reduces aggression in this disorder, offers him skills he can use on the court, in class and at home, with medication considered if progress stalls.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596

Liu, F., Leonard, S., Xiao, Z., & Lennox, C. (2026). Hidden storms within: Psychiatric comorbidity in intermittent explosive disorder: A systematic review and Bayesian meta-analysis. Journal of Psychiatric Research, 199, 345-357. https://doi.org/10.1016/j.jpsychires.2026.05.007

Liu, F., Yin, X., & Jiang, W. (2025). Comprehensive review and meta-analysis of psychological and pharmacological treatment for intermittent explosive disorder: Insights from both case studies and randomized controlled trials. Clinical Psychology & Psychotherapy, 32(1), Article e70016. https://doi.org/10.1002/cpp.70016

Wheeler, K. (Ed.). (2014). Psychotherapy for the advanced practice psychiatric nurse: A how-to guide for evidence-based practice (2nd ed.). Springer Publishing.

Yearwood, E. L., Pearson, G. S., & Newland, J. A. (Eds.). (2012). Child and adolescent behavioral health: A resource for advanced practice psychiatric and primary care practitioners in nursing. Wiley-Blackwell.

Zhang-James, Y., Paliakkara, J., Schaeffer, J., Strayhorn, J., & Faraone, S. V. (2025). Psychiatric, neurological, and somatic comorbidities in intermittent explosive disorder. JAMA Psychiatry, 82(4), 358-367. https://doi.org/10.1001/jamapsychiatry.2024.4465