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

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“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. 


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