Tourette Syndrome Plus - Conditions - "Rage Attacks" Overview, p.2

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

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PATHWAYS TO RAGE

Some possible pathways to "rage attacks" include:

Medication side effects

Language processing deficits

Executive dysfunction (such as difficulties making transitions or difficulty multi-tasking)

Nonverbal learning disability (such as not reading facial expressions or other cues)

Difficult temperament

Social impairments

Anxiety

Sensory integration dysfunction

Mood lability

Obsessions and/or compulsions

Post-traumatic stress disorder

Mismatch between environmental demands and preferred style of learning or working

Frustration due to learning disabilities that have not been addressed

Mismatch between characteristics of the individual and characteristics of "significant others" in the individual's life

DIAGNOSIS VS. EXPLANATION

The failure to have a commonly agreed-upon definition and criteria has made integrating different studies more challenging, but the absence of a diagnosis does not preclude our understanding of an individual's behavior. If we really want to understand rage attacks, we will need to look at different factors or pathways to explosive behavior.

Thus, while many individuals use the same term -- "Rage Attacks" -- to describe their experiences, a review of their individual stories and the published literature suggests that there are various types of rage attacks or pathways to them, and that in order to understand the phenomenon, we need to look more comprehensively. For any one individual, we may need to look at whether they have neurocognitive executive dysfunction, language or communication difficulties, sensory issues, mood inconsistency or lability, and other factors such as environmental demands, environmental structures and supports, and the characteristics of key individuals in the individual's life such as their parents, teachers, spouse, etc. We will need to carefully assess the individual including observing any patterns and triggering events. We will also look at what happens after the explosive outburst, to see if there are any consequences that might be serving as a "secondary gain" for the individual.

In a recent report, Budman, Rockmore, et al. (2003) used a screening procedure and questionnaire on 48 children and adolescents presenting to their clinic with rage attacks. When the data were subjected to factor analysis, the final clustering identified four homogeneous subgroups that were differentiated by predominant clinical characteristics: (1) specific urge resolution, (2) environmentally secure reactivity, (3) nonspecific urge resolution, or (4) labile nonresolving. Thus, and as suggested previously, "rage attacks" may have diverse etiologies and for any one individual, identifying the etiology may have important treatment implications.

The assessment is crucial, and cannot be overemphasized. The assessment leads to our explanation of the how and why a particular individual has these explosive attacks, and it is our explanation that leads to a treatment plan or intervention(s) for that individual. If after our assessment, we suspect that the problem is that the individual is lacking in communication skills, then our treatment will focus on helping the individual acquire those skills. If our assessment leads us to suspect that the individual has a "short fuse" when frustrated and can't think rationally when they're frustrated, then our treatment intervention will focus on helping the individual stay calm and learning to think when they're frustrated.

HOW DO ATTACKS GET TRIGGERED?

For some children or adults, there seem to be fairly specific or predictable triggers, but for many, almost anything can serve as a 'releasing stimulus' if the individual's tension or stress levels have been building.

Even when you can't identify the 'reason,' if you start by assuming that there is a reason, then efforts can turn to identifying the causes so that proactive steps can be taken to reduce the likelihood of an explosive outburst.

One parent's recognition that there were causes that could be identified was expressed this way:

"For a long time I would have said that there was no reason for them, that she would "take off" for no reason at all. Little by little we have realized that, for her, there are causes though her reaction is about a bezillion times larger than even those causes call for.
Now she tries to deal with anger/situations/people as the conflicts arise. It calls for a lot of honesty with herself. And many things that I would never see as a reason for any anger she reacts to because of her need for things to be just so, or because she dwells on thoughts, or thought just attach themselves to her or the impulse control stuff happens. If she lets these things mount, then the rage is huge."

Here are some firsthand accounts or observations about what triggers "rage attacks" for other children or teens, in the parents' own words:

..... His last worse ones were during the fall of last year-tore off towel bars,broke his brothers toys,threatened me,etc. out of control anger.Finally he was able to speak and it was that school kids tormented him and he was being scrutinized so much at school that he did not want to go anymore. I told him I would help fix school and I still update him as I try to fix things for him at school.

Another parent comments how on the frustration in school led to similar rage outbursts in their home:

"This sounds very much like my 10yo son. We, too, had a problem with being tormented at school. This led to rages and waxing of his tics. When he finally told us what was going on and we took steps to correct it, he became his normal sweet self. And I can't emphasize enough the importance of remaining calm during his rages. This makes a distinct difference in the amount of stress I experience and helps him calm down much faster."

To read more first-hand accounts about triggers to Rage attacks, see the companion Triggers file.

DO THEY KNOW WHAT THEY'RE SAYING OR DOING?

When a child or an adult has a rage attack, are they aware of what they're doing? Although some people have no awareness, others report that they do have some level awareness, often as if they are watching themselves or hearing themselves from a distance. Others have reported greater or lesser degrees of awareness, as the following first-person account demonstrates:

"Several years ago I was feeling very frustrated about something. I'm not even sure I knew what it was that had me feeling this way. I was in the kitchen and accidentally dropped a glass of coke on the floor. Normally this is no big deal. But I just went nuts. I started throwing things and kicking things. If I could damage it or break it I did. The whole time this was happening I knew exactly what I was doing. I was NOT out of my mind. I was NOT crazy. I was NOT looney tunes. I knew exactly what was happening, I just could NOT stop myself. What finally stopped me was complete and total exhaustion. I was so tired that I could not stand up."

Most children and adults I have talked to have indicated that yes, they usually do have some level of awareness during the rage attack, but it seems to be in a distant kind of manner. The awareness may not be evident to those observing the attack, however. A teacher once commented to me on how scared she was by the look in her student's face -- it was if he had no recognition of the other children as his friends and didn't care about them at all as he kicked them or screamed at them. And yet when I spoke with the student, he had been aware of what he was doing, but felt that he couldn't stop himself.

CAN THEY STOP THEMSELVES?

As suggested above, many children I've spoken with tell me that they really feel that they have no control once a rage attack has started, as this first-person account describes:

"I used to have rage-episodes as a child. I remember very well how awful it felt to be stuck in a rage when I knew (on some level, at least as an older child) that there was no excuse for it. I knew, I mean, that my response (unrestrained expression of rage) was completely disproportionate to the trigger. The horrible part was that I could not get out of it or even indicate in any way (to my targets) that I knew I was being unfair, I could only wait for it to pass. It was as if a cloud of rage had floated by and seized upon me, filling me up for a while before it drifted off on its way again."

Adults often reiterate that theme of "I can't really stop it," but for a number of children and adults, it may be possible for them to modulate the attack in terms of relocating it or focusing on something that minimizes damage to property, others, and helps prevent erosion of significant relationships.

For more accounts describing rage attacks, see the companion Rage Attack Description file.

WHAT DO I DO IF MY CHILD OR STUDENT IS HAVING A RAGE ATTACK?

f a child or adult has already "lost it," then the best thing you can do is give them space. Most of the children and teens I know would rather not be "on display" when they have totally lost control, and the stress of trying to deal with others may only worsen the episode for them. If they're already into a full 'rage attack', then your priority is to protect safety -- theirs and yours. When they are not in the middle of an attack, then you can ask them what they'd like you to do if it ever happens again, but as one psychologist once commented, "You don't do an arson investigation while the fire's still raging."

The suggestion of "give them space" should not be taken as an empirically validated approach. And it is not to say that no intervention should ever be tried, but that for many people, your well-intentioned attempts to intervene may be overloading their overloaded system and make it more difficult for them.

Many people seem to think that there is some value in having a place to "let it all out safely," but many parents note that they can't get their children to those safe places in time, and the same problem may occur in the classroom: once the child has started an attack, they may not be willing to -- or able to -- leave the classroom to go to their designated "safe place." The value of the safe place, though, is tremendous if you can help the child make a "graceful exit" to get to that place before they totally lose control.

Note that it is commonly reported that following a "rage attack," a child or teen may be very sleepy. If that is the case, let the child sleep. Alternatively, let the child or teen engage in some calming activity that they enjoy, such as reading, listening to music, or even playing on the computer. Do not worry that you are "rewarding" the child for losing control. At that point, you are simply giving the child or teen an opportunity to restore themselves to balance.

Attempts to talk with the child during or right after a "rage attack" are usually nonproductive and can actually "rekindle" the problem. Plan on being quiet unless the child or teen lets you know that they want to talk.

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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