Treatment and coping strategies for rage episodes

The following is the finale in a three-part series first published on the blog of the Tourette Syndrome Foundation of Canada. Read the first part here and the second part here.

Rage episodes are anger outbursts that are out of proportion to the triggering event, they appear to come on suddenly, they are not “tics” but rather are a symptom of having multiple co-occurring conditions in addition to TS like ADHD, OCD and depression.

Rage episodes may result in harm to others and/or destruction of property. Keep in mind that a rage episode can be extremely frightening to the individual having it because they experiences a loss of self-control. After an episode, the person usually feels guilty, humiliated, and in some cases, they may feel that they are evil.

Consider how a rage episode may affect an individual in different scenarios.

In school…
the episode is often not met with tolerance or understanding. The risk of disruption to the other students is not one that the school can take on realistically, and in some cases, they must transfer the student to a school with more supports.

At work…
the rage episode results in dismissal from their job.

At home…
family members are vulnerable, stressed and uncertain. Parents may find themselves arguing about discipline. An older child poses a serious physical threat. The parents feel like failures. A loving spouse may not know what to do about their partner’s rage episodes. There may be significant financial stress, and it is possible that feelings of worthlessness can lead to drug use or excessive drinking. Divorce may occur.

Unsurprisingly rage episodes often cause the symptomatic individual to have low self-esteem.

This low self-esteem is no small problem. It can lead to loss of confidence in social situations and poor peer relations. The person’s environment may seem threatening and unpredictable. Children who experience this begin to feel that they are “no good.” Those around them, sadly, may reinforce this negative self-concept because they feel frustration, anger, and hopeless in the face of this perceived “extreme” behavior. This may culminate in depression, and even in expressing a wish to die.

On the positive side, doctors who work with children with rage episodes note that serious physical injury or harm rarely is inflicted on others. Where injury results from rage episodes, it is usually accidental or self-inflicted. Doctors also say that they are in awe of the sheer fortitude and patience of families with kids with rage episodes.

Treating rage episodes is a challenging task.

In the long term, a person or parents may choose to take medication (prescribed by a physician) to help treat rage episodes.  There is no one prescription for rage episodes because of the current state of our understanding of neurophysiology. Physicians hope to develop better treatment as they learn more about this field. Until then, patients need to work closely with their doctors and in some cases, go through a trail and error process to ascertain the best medication(s) and dosage.

A preventative approach could be adopted by attempting to decipher triggers through recording the lead up to storms and talking with the individual to understand what happened before they stormed. Next, everyone can take steps to try to minimize the triggers, hopefully minimizing the frequency of the rage episodes.

It is very important to correctly identify and treat the person’s co-morbid conditions. This may involve taking more than one medication. Additionally, some individuals find certain types of behavior therapy to be helpful. It some cases, hospitalization is the only answer when all other options are exhausted–this gives the family the chance to regroup. Respite for caregivers is extremely important to reduce burnout.

Some adults say that they find strenuous exercise or shouting outside helps to reduce the frequency of their neurological storms. Others say that these techniques do not work for them.

When someone begins a rage episode little can be done to deescalate the situation. It is near impossible to reason with someone in the middle of an episode because having a storm means he or she lacks the neurological resources to have a logic-based conversation. Instead, give the person space, if you can, by having others exit or move away from them. Let the storm pass if possible. If you must remove the person, for example, due to danger to property, self or others, try to put them in a location where they have privacy and room to move around.

Should you try to hold the person down? While some parents have said that hugging a child thorough it works, experts say that holding the person down usually makes he or she feel more frantic and actually makes things worse.

Should you call the police? This may be necessary; however, doing so is often unhelpful. The episodes often pass before the police get to the scene, and officers often have no better means to control the person aside from force and or intimidation. The threat of police intervention, says Drs. Budman & Bruun, does not prevent the rage episodes in their experience.

Should you take the person to the hospital? Drs. Budman & Bruun also say that going to the emergency room may be ineffective in the short run.

Should you punish someone for the destruction of property or the things they say during a storm? No. This is a symptom and is most likely not voluntary. Instead of punishing a person for the storm, work with that individual to repair the damage they caused. The person is responsible for the outcome of their storm even if they are not at fault for having the storm. Help them to clean up messes made or apologize for hurt feelings. Allow a cooling off period and approach the individual about dealing with the outcome of their storm once the person’s symptoms have subsided. Try to get the person on board with a plan for restitution or reparation.

To get help with dealing with storms, speak to your treating specialist.

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