OT RAGE ATTACKS

PHARMACOLOGICAL MANAGEMENT

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).

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.

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.






Information Section: Conditions
Condition: Rage Attacks
Article: Treatment of "Rage Attacks:" Medications and
Non-Medication Approaches
Source: Leslie E. Packer, PhD
This File Last Updated: December, 2004
Article Page 1 2 3







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