ADDitude for Professionals

A Clinician’s Guide to Impulsive Aggression

Impulsive aggression is a feature observed in patients with ADHD, obsessive-compulsive disorder, disruptive mood dysregulation disorder, and bipolar disorder. Here, learn how to recognize and treat the symptoms of this maladaptive aggressive behavior.

Impulsive Aggression: Symptom Overview

Impulsive Aggression (IA) is characterized by reactive, overt, explosive responses to situations that exceed normal and appropriate levels of emotion for the situation. This negative emotional response is an associated feature observed in many psychiatric disorders, such as Obsessive Compulsive Disorder (OCD), Attention Deficit Disorder (ADHD or ADD), Disruptive Mood Dysregulation Disorder (DMDD), and Bipolar Disorder. Unlike adaptive aggressive behavior — aggression for the sake of defending oneself — impulsive aggression is maladaptive: aggression that occurs outside of an acceptable social context. It usually has a benefit for the individual but is harmful to others involved.

IA can be identified in patients as young as five years of age. Such a young diagnosis is also predictive of ADHD, psychosocial and psychiatric difficulties, comorbidities, and antisocial behavior.

A 2011 survey of children and adolescents aged 4 to 17 reported 54 percent of children with ADHD also had aggression, with impulsive aggression being the predominant subtype. There is no established rating scale or FDA-approved medicine for IA, so medical professionals often begin by diagnosing and treating co-occurring psychiatric disorders. Treating comorbid ADHD or depression, for example, may potentially improve the IA. Professionals must exercise caution when treating for IA because it commonly overlaps with other conditions. Patients should begin with a low dose and work with a team of professionals including psychiatrists and psychologists.

Impulsive Aggression: Treatment Options

Atypical Antipsychotics: Commonly used to treat schizophrenia, this medication may be used to effectively manage IA aggression by stabilizing big mood swings.

Stimulants: Exercise caution when treating with stimulants since they have the potential to cause agitation and irritability. Still, patients may prefer stimulants because of their “large effect size,” meaning they kick in immediately.

Non-stimulants: Some clinicians may treat IA with non-stimulants, though only one is indicated for adults use. Their “moderate effect size” means this medication isn’t felt as quickly as stimulants, but they also have less of an “on-off” of medication effect.

Contingency management programs: Since patients with IA and/or ADHD are at greater risk for lower self-esteem and mood struggles, it’s important to establish a behavioral plan built on positive reinforcement.

Medications used for seizure disorders — namely Lamictal, Lithium, and Depakote — are sometimes used to stabilize mood.

Risperdal: There has been moderate improvement recorded with Risperdal in cases of severe aggression. But potential side effects include an increase in Prolactin, enlarged breasts, or galactorrhea.

Birgit H. Amann, M.D., is a child, adolescent and adult psychiatrist. She is the medical director of the Behavioral Medical Center in Troy, Michigan. The content for this article came from her 2018 CHADD conference presentation titled “Impulsive Aggression: An Associated Feature Observed in ADHD.”