Managing Anger in Adults-medications and therapy

Problem anger in adults differs from anger in children that is developmental in nature.  It's often not just a sense of being disappointed, there are other ideas that go along with it.  There are ideas that other people are responsible for how angry someone feels, that anger is like a light switch and just suddenly flips on, and that rage is a reasonable response to a problem.  Problem anger is often associated with other mental disorders in adults.  Post-traumatic stress disorder, bipolar disorder, the personality disorders, some forms of depression and anxiety, and substance abuse disorders may all contribute to problems with anger.

Anger disorders are treated with psychotherapy, behavior therapy and or medication or a combination of the three.  There are several classes of medications used to treat anger disorders.  Atypical antipsychotics such as Zyprexa, Seroquel, Invega, and Abilify are often a first line of treatment.   These medications are all extremely sedating, cause impaired glucose metabolism resulting in increased risk for diabetes and weight gain.  If the option is suicide/homicide or incarceration versus one of these medications, the medications are selected as preferred.  When Zyprexa came out initially I had a patient I was following on a daily basis who had a plan to kill her employer.  The plan was serious, her employer had been notified for safety, and she was looking at a lengthy inpatient hospital stay.  Literally 12 hours after her first dose of medication she came in quite sleepy reporting that all those feelings went away.  She still didn't like her employer, but she no longer felt compelled to kill him.  The other medications in the list don't work as rapidly, but they are still effective. 

Antiseizure medications such as gabapentin, tegretol, and depakote are used as mood stabilizers, often effective with bipolar disorder when lithium is problematic.  These must be used consistently to be effective and often require a month or so for the onset of effectiveness.

Antidepressants that are sedating such as trazodone, and elavil, are used when depression is coupled with rage.  These are taken at bedtime.  Activating antidepressants such as prozac, paxil, or zoloft may worsen rage conditions and increase irritability.

Antipsychotics such as haldol, geodon, and others are used when there appears to be a thought disorder.  So paranoid ideas leading to rage would be treated this way.

Anti-anxiety medications are used when fear is coupled with rage.  Issues of abandonment, panic disorders, and difficulty tolerating discomfort and distress are treated with xanax, lorazepam, and many people use alcohol or marijuana to self medicate.   The problem with this class of medications is that they can be addicting, requiring more and more to produce the same effect and risking withdrawal reactions when they are discontinued.

Psychotherapy is extreme effective for rage.  There are a few types of specific therapy that are effective.  Cognitive Therapy (cognitive behavior therapy, rational emotive therapy, and other similar types of treatments) for anger, depression, or anxiety is one type of treatment.  Baseline measures are taken of the problems with tests at each visit.  Homework assignments are given to be completed prior to the subsequent visits.  And the therapy focuses on changing thinking patterns to change feelings and behavior.   Behavior Therapy (neurolinguistic programming, some types of hypnotherapy, dialectical behavior therapy, assertiveness training, negotiation skills training and others) is effective to change skills and physical behavior involved in anger. Mindfulness approaches (mediation, stress reduction, acceptance and commitment therapies) are also used successfully and come from a Buddist tradition of calming and centering.  All of these work.  Supportive psychotherapy, where a client tells the therapist what they have done during the week and the therapist listens, has not been shown to be effective as a treatment.

I used to do a 12 week group therapy for treatment of homicidal rage in adults.  I used a combined approach of behavior therapy and cognitive therapy.  In 12 weeks rage and homicidal thoughts were reduced to negligible levels in 85% of the participants.  Here's the 12 week program:

At every visit the participants completed several questionnaires on depression, homicidal rage, anxiety, and trauma.  At every visit they received homework assignments for the next week. 

Week 1 consisted of the introduction and an exercise designed to reduce shame over trauma.  The participants introduced themselves, discussed the event that brought them to the group and past physical injuries.  They received homework on completing questionnaires to bring back.

Week 2 was about correcting ideas and misconceptions about anger.  The anger/anxiety/depression model of anger and clarification on suicide, homicide, what constitutes self-defense and legal ramifications of assault in the State.  Homework was keeping track of events they got angry to.

Week 3 was about communication skills.  The model of styles of communication from ignoring to rage was explained.  Basic information on assertiveness was provided.  The group had the opportunity to work to clarify examples on changing other types of communications into assertive skills.  Homework was to take a dialogue and apply communication theory to it.

Week 4 was about calming down in the heat of the moment.  Physical techniques were explained.  The group worked in dyads with supervision to practice calming, assertion, and provide feedback.

Week 5 was about triggers to rage.  Ideas about post-trauma triggers and reintegration of information from traumatic events into present day was provided.  Dyads were again used with focus on clarifying what was triggering rage.

Week 6 was about cognitive techniques to change thinking.  Exercises to clarify thoughts were done.  Putting rage into words exercises were done.  Pantomimes for coping with feelings and movements to calm oneself were done.

Week 7 involved non-verbal communication techniques.  Body movements and voice tone were noted to clarify non-verbal triggers to rage. Substance use issues were discussed as non-verbal triggers.

Week 8 involved integrating assertion, cognitive techniques and non-verbal communications in dyadic exercises.  Stages of negotiation were reviewed. 

Week 9 involved specific triggers using weapons.  Weapons were either pantomimed or toy and coping and options were reviewed fo dealing with weapons as triggers and response.

Week 10 involved integrating data on triggers, responses, and events with specific focus on individual problem areas.

Week 11 involved reviewing diaries on triggers, coping skills, communication, and feedback.

Week 12 was a review of where the individual started to now.  The final cognitive measure was done in group.  Final diaries were reviewed.  The course ended.