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The treatment of
"rage attacks" is complicated, since "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 have
reported that paroxetine 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.
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)
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 clinical data
from recent studies suggest 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 may be of
benefit, but in a head-to-head comparison of
clomipramine and haloperidol, haloperidol produced
significantly better results (Remington et al.,
2001). For other children, an anticonvulsant
medication such as divalproex may be of benefit
even if there is no history of a seizure disorder
(Hollander et al., 2001).
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