Tourette Syndrome Plus - Conditions - "Rage Attacks" Overview

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Information Section: Conditions
Condition: Rage Attacks
Article: Overview of "Rage Attacks"
Source: Leslie E. Packer, PhD

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Preface

"The best way I can describe it is it is a sudden and violent out of control explosion of temper. It usually happens very suddenly with no real warning that it is coming. Once started it cannot be stopped by willpower alone. Based upon my own experience it just has to run it's course. It usually doesn't run very long, a few minutes to as much as 30 or 40 minutes."
-- An adult describing their "rage attacks"

"When [he] has had rage attacks, they can be set off by what seems to be the most minor events. Maybe we didn't have something he wanted to eat for supper. Maybe I asked him to brush his teeth. He would start ranting and raving and wouldn't stop. Any attempt to cut him off would escalate even faster. It seemed that until he reached a certain point, he could not calm down. By then he was swearing at me and breaking things. He was totally out of control..... After the incident it was as if nothing ever happened. And if I tried to talk about it, he thought I was overreacted, and of course, said he didn't do anything. Those episodes were exhausting physically and emotionally."

-- A parent describing his teenager's "rage attacks"

WHAT ARE "RAGE ATTACKS" OR STORMS?

"Rage attacks" is not a recognized diagnostic disorder or term, and yet anyone who's parenting a child with them or working clinically with a child or teen with such outbursts can probably immediately relate to the phrase. As I use the term, a "rage attack" is a sudden, out-of-control explosive outburst that appears -- to the observer and the individual experiencing it -- to be without warning and totally out of proportion to any triggering event in the environment. It is also experienced as being a somewhat (but not completely) uncontrollable event that once it's started, just has to run its course.

A "rage attack" is not a "tantrum," because tantrum behaviors are goal-directed. The purpose of a tantrum is to get someone who is not doing what you want them to do what you want. If there is no one around, a tantrummer generally stops tantrumming because their tantrum isn't working. Some people describe "rage attacks" as "storms" that come without warning. Others describe them as a "meltdown."

HOW ARE THEY DIAGNOSED?

Because there is no formal diagnosis called "Rage Attacks," there are no agreed-upon diagnostic criteria. But there are a number of terms in the professional literature that seem related, if not identical to, "rage attacks." The closest diagnoses would appear to be "Intermittent Explosive Disorder" (IED) or "Oppositional Defiant Disorder" (ODD). Other terms used in the literature include "anger attacks," "explosive outbursts," and "episodic dyscontrol."

While the label "Intermittent Explosive Disorder" may seem to "fit," the diagnostic criteria do not really match what many patients or parents report, so let's consider how mental health professionals diagnose IED¹:

Criterion A. Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property.

While there are some children and adults with "rage attacks" who do hit or kick others, the common experience is that these attacks are unlikely to lead to serious assault on individuals or serious destruction of property, although there have been reports that children's "rage attacks" are more likely to be directed against their mothers.

Criterion B. The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors.

Criterion B seems to "fit well" with the reported experience of how seemingly innocuous events can trigger the attack.

C. The aggressive episodes are not better accounted for by another mental disorder (e.g., Antisocial Personality Disorder, Borderline Personality Disorder, a Psychotic Disorder, a Manic Episode, Conduct Disorder, or Attention-Deficit/Hyperactivity Disorder) and are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., head trauma, Alzheimer's disease).

Since many of the individuals who have "rage attacks" do have Attention Deficit Hyperactivity Disorder, Obsessive-Compulsive Disorder, and/or a mood disorder, and some people experience activation or agitation on medications used to treat ADHD and/or OCD, it seems that the 'rage attacks' in these individuals might be better accounted for by these conditions.

Thus, Criteria A and C both suggest a poor match between the diagnosis of IED and "rage attacks" as experienced by many individuals with neurobehavioral conditions. But what about the other terms in the literature? As with IED, the definitions of these other terms demonstrate some overlap with how the term "rage attacks" have been used colloquially by parents and patients, but are not identical. For example, Fava and Rosenbaum (1999), in discussing "anger attacks" in adults with depression, provide a definition that incorporates both emotional/behavioral and autonomic features:

Anger attacks are sudden intense spells of anger that resemble panic attacks but lack the predominant affects of fear and anxiety associated with panic attacks. Anger attacks typically occur in situations in which an individual feels emotionally trapped and experiences outbursts of anger. Dysregulated anger is a state in which the behavior must be provoked in order to be observed. Thus, an anger attack is a combination of predisposition--or some enduring state of vulnerability--and provocation.

In defining "anger attacks" for research purposes, Fava and his colleagues have used the following criteria: (1) irritability during the previous 6 months, (2) overreaction to minor annoyances with anger, (3) occurrence of one or more anger attacks during the previous month, and (4) inappropriate anger and rage directed at others during an anger attack. The additional criteria, which they note was modeled, in part, from the DSM-IV criteria for panic attack, include the occurrence of at least four of the following autonomic and/or behavioral features in at least one of the attacks: (1) heart palpitations, (2) flushing, (3) chest tightness or pressure, (4) paresthesias, (5) lightheadedness or dizziness, (6) excessive sweating, (7) shortness of breath, (8) shaking or trembling, (9) intense fear or anxiety, (10) feeling out of control, (11) feeling like attacking others, (12) physically and/or verbally attacking others, and (13) throwing or destroying objects.

Are these the kinds of experiences the online community have described, or is this a slightly different "beast?" Since there are no operational definitions of "rage attacks" being used online, it is difficult to say with any confidence, but while many of the individuals could meet the above criteria, there is something a bit different about the way they describe their experiences -- in terms of the total explosiveness at times and the "Jekyll and Hyde" quality that is so apparent to everyone.

THE MYTH OF "RAGE ATTACKS" BEING PART OF TOURETTE'S SYNDROME

About 10 years ago, some people talked about "Tourettic rage" as if rage attacks were associated with Tourette's Syndrome. In case anyone has heard that myth, let me take this opportunity to correct it yet again: there is no evidence (and never has been) that people who have Tourette's Syndrome without any other conditions are more likely to have "rage attacks." If they do have Tourette's Syndrome and rage attacks, it appears to be due to the presence of comorbid conditions -- and the more comorbid conditions they have, the greater the likelihood of having rage attacks. Does that mean that every person who has Tourette's plus comorbid conditions will experience such problems? No, it doesn't. While a significant percentage of individuals seen with TS+ in clinics have or have had problems with anger or outbursts at some point in their history, we need to be mindful that: (1) these are not random samples but clinic samples where you are more likely to encounter individuals with more serious symptomatology, and (2) in some cases, people who experience difficulty with anger without having these explosive outbursts may be included in the estimates.

That said, it is probably true to say that about one-third or more of patients who have Tourette's Syndrome plus comorbid conditions seen in clinics have experienced problems managing anger or explosive outbursts and that these problems are often the primary reason for them seeking medical attention. But it bears repeating that there is no evidence that Tourette's alone increases any risk of such problems.

WHAT CONDITIONS ARE ASSOCIATED WITH "RAGE ATTACKS?"

So what are the comorbid conditions that appear to be associated with "rage attacks" or increased risk of such explosive outbursts? If one were to ask what diagnoses are more likely to be associated with anger outbursts, explosive aggression, rage attacks, or Intermittent Explosive Disorder, the answer would probably be: depression, bipolar depression, OCD, ADHD, Conduct Disorder, temporal lobe epilepsy, head injuries, Oppositional Defiant Disorder, and sensory integration disorder (although not necessarily in that order). As but one example, du Toit et al. (2001) compared OCD patients with and without comorbid conditions commonly linked to OCD spectrum disorder. They reported that the highest prevalence rates were compulsive self-injury (22.4%), compulsive buying (10.6%), and intermittent explosive disorder (10.6%). Since OCD, ADHD, and mood disorders are all highly comorbid with Tourette's Syndrome in clinical settings, it is not surprising that a subset of Tourette's patients would experience explosive outbursts.

*FOOTNOTE

Sukhodolsky DG, Scahill L, Zhang H, Peterson BS, King RA, Lombroso PJ, Katsovich L, Findley D, Leckman JF. (2003). Disruptive behavior in children with Tourette's syndrome: association with ADHD comorbidity, tic severity, and functional impairment. J Am Acad Child Adolesc Psychiatry, 42(1), 98-105.

Information Section: Conditions
Condition: Rage Attacks
Article: Overview of "Rage Attacks"
Source: Leslie E. Packer, PhD

Article Page 1 2 3

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