Controlling rage induced by brain injury

Post-Bulletin

DEAR MAYO CLINIC: Our 42-year-old son suffered a brain injury 21 years ago as a result of a car accident. He still flies into rages -- puts fists through walls, feet through doors, etc. -- but he's never violent toward us. We need help in knowing how to deal with him. Nothing we do seems to help.

Physicians can choose from a number of drugs for reducing the rage attacks that often result from traumatic brain injury (TBI). But there is no guarantee any given medication will do the trick. Different drugs work or don't work with different patients, so your doctor must do some experimentation -- basically, a carefully controlled process of trial and error -- to find the most effective drug for controlling your son's problem.

A neurologist specializing in epilepsy should determine whether he has a form of that disease in which seizures present themselves as fits of rage. If so, anticonvulsant medications should obviously be tried first. But even if your son does not have epilepsy, anticonvulsants can sometimes help. Other classes of medicines -- including antidepressants, anti-anxiety agents and beta blockers -- have also been used to ease the episodes of rage induced by TBI.

An advantage of such drugs is that they have relatively mild side effects and enable a patient to function reasonably well. In the "old days" -- that is, until about a decade ago -- patients being treated for explosive rage were heavily sedated, with powerful tranquilizers or antipsychotic drugs, so the fits of rage were replaced with a soporific state. No anger, but not much function either. These practices are still sometimes pursued by those not in the know, so it is important that your son's doctor, or at least one of his doctors, be a physical medicine and rehabilitation (PM&R) physician, a behavioral neurologist, or a neuropsychiatrist, any of whom will likely be trained in addressing his kind of problem.

Drug treatment is only one part of the solution; the other is behavioral counseling -- a family affair involving you, your spouse and your son. The goal is to identify the things that trigger his anger or that reinforce it, and to develop strategies for preventing or dealing with them. For example, he may regularly fly into a rage when told he cannot do something, such as drive the family car, when he has expressed the wish to do so. But the rage can be minimized, or prevented, by the parent's tone of voice and method of presentation. A gentle "Remember what the doctor said about your driving the car?" helps alter the parent's image as the bad guy, and a sincere offer of an alternative -- such as "May I take you someplace?" -- helps make you a good guy.

For those rage-inducing situations that cannot be avoided, he should learn some relaxation techniques. Breathing exercises, shooting some baskets, or taking a brisk walk, for example, allow him to focus on more peaceful and adaptive responses. To employ such solutions your son and other patients with TBI need support from a "significant other" such as a parent or sibling. While patients' cognitive impairments often prevent them from acting effectively on their own to quell the impending rage, over time constructive responses can become more of a habit.

As with medications, developing specific behavioral interventions for your son will probably be a careful process of analysis and trial and error to find approaches that work. This process should be done in consultation with a rehabilitation neuropsychologist who is experienced in working with people with brain injury.

One-on-one psychotherapy is not a useful option here, though group therapy -- in which all members of the group are patients with TBI-related rage problems -- can help. Participants tend to accept feedback from individuals they identify as their peers; and as with people without TBI, they often give better advice to others than they do to themselves. -- James F. Malec, Ph.D., Psychiatry and Psychology, and Allen W. Brown, M.D., Physical Medicine and Rehabilitation, Mayo Clinic.

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