Tourette Syndrome Plus - Conditions - "Rage Attacks" Treatment of "Rage Attacks"

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Information Section: Conditions
Condition: Rage Attacks
Article: Treatment of "Rage Attacks:" Medications and Non-Medication Approaches
Source: Leslie E. Packer, PhD, 1998
This File Last Updated: February 2009

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PHARMACOLOGICAL MANAGEMENT

The treatment of "rage attacks" is complicated because "rage attacks" generally do not represent a discrete disorder, but can be symptomatic of a number of different conditions (not all of which are even medical) or their interaction. Indeed, "rage attacks" may be linked to neurocognitive and/or social skills deficits and the effective "treatment" isn't pharmacological at all but rather remediation of the neurocognitive and/or social skills deficits.

There are two main lines of treatment for "rage attacks," then: psychopharmacological and therapeutic. Some cases will require one or the other; some cases will require both. We'll begin by discussing medication approaches and the use of herbals or supplements, but then turn to a non-medication intervention approach.

All of the medications that are used to treat OCD, ADHD, mood disorders, or their associated conditions may be of value to individual patients, depending on their particular history. Determining which medication class or specific medication to try requires that the clinician take a very thorough and comprehensive assessment of situations in which the patient is experiencing explosive dysregulation to determine if there are any factors that need to be addressed pharmacologically or if the treatment plan needs to focus more on treatment interventions and accommodations for factors such as sensory integration problems, cognitive rigidity/inflexibility, nonverbal learning disabilities leading to frustration, etc.

Budman and Bruun (1998) reported that paroxetine (a selective serotonin reuptake inhibitor, SSRI) was of some benefit to some patients; this is consistent with their previous finding that such attacks correlated with increased obsessive-compulsiveness. But not all patients who have explosive outbursts have OCD. In some cases, the clinician will find that treating any depression or anxiety may reduce the problem. SSRIs are also the first line treatment for those disorders, so if a child or adult has any of those disorders plus explosive outbursts, treatment with an SSRI might be of some benefit. In a more recent retrospective study, Budman, Coffey, et al. (2008) found that aripiprazole (Abilify®) produced improvement in explosive outbursts of children and adolescents with Tourette's Syndrome comorbid with ADHD and OCD.

Atypical neuroleptics, particularly risperidone (Risperdal®), have been anecdotally reported to be of benefit in managing such behavioral symptoms in some patients, as have mood stabilizers. When Bipolar Disorder is present, medications such as lithium and depakote may be prescribed (although the latter may be complicated in the use of females). Some research suggests that olanzapine may also be of benefit.

Morant et al. (2001, translation of abstract) also investigated the behavioral effects of risperidone on children and young adolescents with serious behavioral problems who had not responded well to other medications. The 16 participants had been treated for ADHD, mental retardation with nonspecific behavior disorder, Tourette's plus ADHD and generalized disorder of development. Risperidone doses ranged from .01 to .05/mg/kg/day. Ten of the 16 patients responded to the medication in terms of improved behavior, two did not complete the study, and there was no change in the remaining four patients. The investigators report that the children with mental retardation showed the most improvement with risperidone when compared to other diagnoses.

While some clinical data suggests that at least some children may benefit from risperidone, more controlled research is needed. At the present time, there is insufficient research to suggest any algorithm for prescribing for patients who may have a lot of comorbidity.

What about children or adolescents with diagnoses of autism or Asperger's Disorder who have explosive aggression? The available clinical literature suggests that in some cases, SSRIs or clomipramine (Anafranil®) may be of benefit, but in a head-to-head comparison of clomipramine and haloperidol with autistic patients, haloperidol produced significantly better results (Remington et al., 2001). There are also some data suggesting that an anticonvulsant medication such as divalproex may be of benefit in patients with Autism Spectrum Disorder (Hollander et al., 2001).

HERBALS AND SUPPLEMENTS

Given the problems inherent with adverse effects and polypharmacy, is there any nonpharmacological alternative that might be equally or more effective? In my opinion, the answer is "yes." But before turning to psychological or language-based interventions, let's consider one other question: could malnutrition be the problem for some of these children, and if so, could vitamins help?

In February 2000, Stephen Schoenthaler and Ian Bier reported that for some children, vitamin-mineral supplementation might be just the thing.*

Using 6 - 12 year-old school children, the investigators randomly assigned children to either the vitamin-mineral or placebo conditions; neither the children nor the observers knew which condition the children were in. Children in the vitamin-mineral supplement group received daily supplementation at 100% of the U.S. recommended daily allowance (USRDA) for four months.

The measures of interest were measures of antisocial behavior on school property, with records kept of threats/fighting, vandalism, disrespect, use of obscenities, defiance, refusal to work or serve, endangering others, and nonspecified offenses. Of the 468 students in the study, 80 who were disciplined at least once between September 1st and May 1st served as the research sample. During intervention, the 40 children who received active tablets were disciplined, on average, 1 time each, a 47% lower mean rate of antisocial behavior than the 1.875 times each for the 40 children who received placebo.

Their data provide some confirmation for the notion that dietary issues need to be considered if a child is disruptive or engaging in a lot of antisocial behavior, but it is important to note that: (1) they were not studying the explosive kinds of outbursts colloquially referred to as "rage attacks," and (2) there was no attempt to identify whether any of the students had neurobehavioral diagnoses. The sole question was whether there would be a reliable difference between those getting vitamin-mineral supplements and those who didn't.

In terms of herbals, there is no controlled research showing that they would be of benefit specifically for explosive outbursts. Be a cautious consumer in investigating any claims about efficacy.

FOOTNOTE

Schoenthaler SJ, Bier ID: The effect of vitamin-mineral supplementation on juvenile delinquency among American schoolchildren: a randomized, double-blind placebo-controlled trial. J Altern Complement Med 2000 Feb;6(1):7-17.

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