Medication Approaches for Anger
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Q:  24 yr.old daughter.autism-bipolar.  I've tried everything doc.
current meds
risperdal 1.5mg/dly
propanolo 120mg dly
epival 750mg dly
She continues to have 'out of the blue rages', rapid cycling ..mood swings. any suggestions
thank you from the bottom of my heart

Q: hello there, my name is Ms. D' and I would like to ask a question about medications that have been helpful in rage episodes.

 I have been diagnosed with bipolar disorder, and I have always had episodes where I get so angry that I just start throwing things and get even angrier if they do not break. Ihave tried many self help tricks, but the more that I do not throw something or yell at someone in an episode I actually get ill and vomit, it seems like Iam loosing either way. I have been telling my doctor, but they do not seem to be doing anything, I seen on tv documentry that there are medications that can control rage/anger/violence. but they did not mention them, is there anything that you can tell me that will lead me in the right direction of the correct medication? Thank you for your time

Blessed Be

Dear Shirley and Ms. D' -- 
Both of you are asking about medication approaches for anger, so I'm going to reply to you both together.  First, as you've surely considered yourselves, we want to look at why the anger episodes are happening; we want to do this really thoroughly so that we don't overlook some better solution than "treating the symptom". In other words, we're looking for some sort of root cause that we could treat, rather than treating the branches of the tree one at a time.  For example, if Ms. D' was actually having some sort of epilepsy, a seizure condition, in which she would have unprovoked rage episodes for no reason at all (it doesn't sound like this, because with great effort and some cost -- nausea -- you can control your behavior), we'd want to think in terms of treating seizures, not treating anger.  Or, for Shirley's daughter, we would want to make sure that she wasn't getting exposed to some uncontrollable stress outside the home then bringing her anger about that back home and unleashing it on mom (perhaps there is some unmanageable situation at school or her day-care arrangements). 

Secondly, we'd want to make maximum use of non-medication approaches. "Anger management" is a well-developed form of psychotherapy (a variation of the well-known "cognitive-behavioral therapy", CBT) that might be very appropriate for one or both of your situations; you should both at least know what that therapy looks like in some detail, if not using it.  A simple way to work on anger is to use a book that's actually written by a Tibetan Buddhist but ends up reading more easily, in my experience, than some of the western CBT books on anger: "Working With Anger", by Pima Chodron. The first and last chapters are somewhat more about Buddhism, but the middle chapters, most of the book, are just about one technique after another for handling anger (your own, or someone else's). The bonus of Chodron's approach is that you get a kind of a spiritual context in which to use these techniques that I think makes them even easier to use than what you might find in the CBT approaches. But either way, you might do well to try to find a therapist who knows CBT techniques, if that's affordable and practical, to see if they could be applied in some way to your situation. 

Then finally we come to medication approaches. This too is supposed to depend on the presumed basis of the symptoms (paragraph #1 above). In other words, we are supposed to be treating a condition that has anger as a symptom, not the anger itself. Presumably that will get us better results (going for the roots, not the branches). In the case of Shirley's daughter, the "bipolar-autism" might be that target. If so, we'd think of the medications for those two conditions. In the case of Ms. D', these rage episodes do not sound like "bipolar disorder" as such, but if they came along with a lot of other pretty classic bipolar symptoms (e.g. the rages always seemed to go along with phases of highly disturbed sleep and increased speed of thought and impulsive decision-making) then again, treating the bipolar disorder would be the target.  Or maybe they might correlate with something going on in personal relationships. 

But, finally, to get to what you both probably had in mind: are there specific "anti-anger medications"?  To my knowledge, the answer is no. One can see anti-anger effects from all five classes of psychiatric medications: 

Antidepressants Things that used to matter a lot don't seem to matter quite so much; can go too far and cause "indifference" or "apathy" as well
Antipsychotics The old "big guns" -- the first-generation medications like Haldol (haloperidol) and Thorazine (chlorpromazine); and the newer "velvet hammers" -- second-generation medications like Zyprexa (olanzapine) and Seroquel (quetiapine), or Risperdal (risperidone) such as Shirley's daughter is taking
"Benzodiazepines", the Valium family These are basically wet blankets, and they can all loose their "oomph" over time as the body gets used to them, but many psychiatrists think that one in particular, Klonopin (clonazepam) is different -- less likely to loose its benefit and more round-the-clock smooth coverage of symptoms (used a lot in PTSD, post-traumatic stress disorder, for example). 
Stimulants Sometimes anger is a feature of ADHD, and when these medications work, that might diminish. 
Mood stabilizers Last but definitely not least:  especially if some bipolar disorder component is potentially driving the anger, these are the major candidates to consider. The full list can be seen on my website on the Mood Stabilizers page. 

Though I saved the mood stabilizers for last, in a bipolar disorder context, they are probably first on this list. Depakote (valproate) and Tegretol or Carbatrol (carbamazepine), both antiseizure medications originally, are both candidates. Lamictal (lamotrigine) is one I like a lot for depression; it has not been described as having anti-anger properties but I have heard several practitioners describe cases where it seemed to do just that. Lithium is easy to try, especially at low doses, because it doesn't take long to find out if it's going to work.  

Pretty long answer that doesn't really say anything very specific, I know.  But I hope this framework might be of use to you both. 

Dr. Phelps

Published May, 2006


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