Treatment of Sudden, Intense Rage Reactivity After Minor Head Injury
Treatment of Sudden, Intense Rage Reactivity After Minor Head Injury
This is a case of a man with Down syndrome whose recent brain injury likely caused him to regress to a rage state he had experienced when he was younger. Some details have been changed to preserve anonymity. We invite your comments below. Dr Ankenman will review your responses and give his feedback in coming weeks.
CASE VIGNETTE
Lionel, a 24-year-old man with Down syndrome, had some rage episodes during adolescence. For the past 4 years, he had exhibited no problems with rage behavior; his life was stable and he was employed at a local factory. He recently sustained a blow to his head, causing him to be unconscious for 18 hours. On awakening at the hospital, his neurological examination showed nonspecific changes. Electroencephalography showed slowing over the temporal areas—unchanged from the tracing made 3 years earlier. Within 48 hours, findings from the patient’s neurological examination were within normal range. A cerebral contusion was diagnosed, and he was discharged.
Two weeks after the accident, one of his parents contacted the discharging neurologist to report that Lionel had experienced several episodes of severe, frenzied rages. The parent commented, “The episodes are kind of like the ones he used to have when he was 15, except they are even more intense and they do not last very long.” The mother, an emergency department nurse, had recorded his blood pressure at 160/90 mm Hg and his pulse rate over 120 beats per minute during one episode.
Question to consider
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Dr. Ankenman's case and discussion are very interesting, and he and I have recently corresponded on the matter of a putative hyper-adrenergic etiology for "rage attacks"and other psychiatric disturbances. I think Dr. Ankenman and I would agree that more research is needed before we can reify this condition into a bona fide disorder; e.g., we need biochemical measures of adrenal system activity in persons hypothesized to be in various kinds of hyper-adrenergic states. A good response to a beta blocker, by itself, is not convincing evidence of the etiology of the patient's condition; indeed, in my view, the patient presented--who is described as having "several episodes of severe, frenzied rages"-- should be hospitalized for observation. Perhaps the rage attacks occur only in the home setting, or correspond to as yet undetected epileptiform activity (e.g., complex partial seizures, which are not ruled out by one or more EEGs; 24-hour EEG telemetry would be much more reliable, but epilepsy remains a clinical diagnosis). A patient's elevated blood pressure and pulse may signify a hyper-excited state of diverse etiologies, including, e.g., pheochromocytoma, amphetamine use, panic attacks manifest as rage, etc. Careful differential diagnosis is needed in order to avoid premature closure on the case. Still, the hypothesis put forth by Dr. Ankenman is interesting and worthy of further investigation.
Best regards,
Ron Pies MD