No pharmacotherapies are specifically FDA-approved for the indication of IED, said Olvera. Several studies have supported the use of fluoxetine10-13 or divalproex for reduction in impulsive aggressive behavior.14 Some evidence also supports the use of mood stabilizers, antipsychotics, b-blockers, a2-agonists, and phenytoin.15
“We try to tailor pharmacotherapy to the individual presentation,” reported Olvera. For patients whose presentation includes depression, anxiety or PTSD, “SSRIs have the best track record.”
For patients with the primary symptoms of impulsive aggression and paranoia, second-generation atypical antipsychotics — particularly risperidone, aripiprazole and quetiapine — are most helpful. Mood stabilizers can be useful in some patients, while others patients respond to b-blockers that slow down heart rate and blood pressure, leading to less adrenergic response.
Cognitive-behavioral therapy (CBT) that includes relaxation training, cognitive restructuring, and coping skills training has been shown to reduce impulsive aggression, anger, and hostile automatic thoughts.16 This approach might be especially helpful for those with poor reality testing, Olvera said.
Dialectical behavior therapy (DBT) can be helpful for people with patients with cluster B personality disorders, while patients with PTSD might need more trauma-focused therapy, he said. Role playing can be beneficial to teach patients how to self-soothe instead of exploding.
Because IED is a heterogeneous disorder, no single approach will be appropriate for all patients, Olvera noted. IED, like many other psychiatric conditions, is “dimensional” in nature, and cannot be regarded as if it is a distinct category. When symptoms of other disorders are addressed, the impulsive aggression may also improve. “We try to see what else might be driving the anger and try to use the best empirical literature we have to treat that profile,” he concluded.
Batya Swift Yasgur MA, LMSW, is a psychotherapist and freelance writer who lives in Teaneck, N.J. She practices therapy in New York City.
- Coccaro EF, Lee R, McCloskey M, et al. Morphometric analysis of amygdala and hippocampus shape in impulsively aggressive and healthy control subjects. J Psychiatr Res. 2015;69:80-86.
- Kessler RC, Coccaro EF, Fava M, et al. The prevalence and correlates of DSM-IV intermittent explosive disorder in the National Comorbidity Survey Replication. Arch Gen Psychiatry. 2006;63:669-678.
- Coccaro EF. Intermittent explosive disorder as a disorder of impulsive aggression for DSM-5. Am J Psychiatry. 2012;169:577-588.
- Coccaro, E.F., Posternack, M.A., Zimmerman M. (2005). Prevalence and features of Intermittent Explosive Disorder. Journal of Clinical Psychiatry, 66, 1221-1227.
- Fanning JR, Meyerhoff JJ, Lee R, Coccaro EF. History of childhood maltreatment in intermittent explosive disorder and suicidal behavior. J Psychiatr Res. 2014;56:10-17.
- Lee R, Meyerhoff J, Coccaro EF. Intermittent Explosive Disorder and aversive parental care. Psychiatry Res. 2014;220(1-2):477-482.
- Coccaro EF, Lee R, Kavoussi RJ. Inverse relationship between numbers of 5-HT transporter binding sites and life history of aggression and intermittent explosive disorder. J Psychiatr Res. 2010;44: 137-142.
- Coccaro EF, Lee R, Kavoussi RJ. Aggression, suicidality, and intermittent explosive disorder: serotonergic correlates in personality disorder and healthy control subjects. Neuropsychopharmacology. 2010; 35:435-444.
- American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Washington, DC: American Psychiatric Press, 2013.
- Coccaro EF, Kavoussi RJ. Fluoxetine and impulsive aggressive behavior in personality-disordered subjects. Arch Gen Psychiatry. 1997;54:1081-1088.
- Coccaro EF, Lee RJ, Kavoussi RJ. A double-blind, randomized, placebo-controlled trial of fluoxetine in patients with intermittent explosive disorder. J Clin Psychiatry. 2009;70:653-662.
- Silva H, Iturra P, Solari A, et al. Fluoxetine response in impulsive-aggressive behavior and serotonin transporter polymorphism in personality disorder. Psychiatr Genet. 2010;20:25-30.
- George DT, Phillips MJ, Lifshitz M, et al. Fluoxetine treatment of alcoholic perpetrators of domestic violence: a 12-week, double-blind, randomized, placebo-controlled intervention study. J Clin Psychiatry. 2011;72:60-65.
- Hollander E, Tracy KA, Swann AC, et al. Divalproex in the treatment of impulsive aggression: efficacy in cluster B personality disorders. Neuropsychopharmacology. 2003;28:1186-1197.
- Olvera RL. Intermittent explosive disorder: epidemiology, diagnosis and management. CNS Drugs. 2002;16(8):517-526.
- McCloskey MS, Noblett KL, Deffenbacher JL, et al. Cognitive-behavioral therapy for intermittent explosive disorder: a pilot randomized clinical trial. J Consult Clin Psychol. 2008;76:876-886.