The Green Leaflet - Selected Articles
RISPERIDONE FOR RAGE ATTACKS IN TOURETTE SYNDROME
By Joe M. Dooley, MB. FRCP(C)
Most families who have had to deal with rage attacks, which are sometimes associated with TS, agree that coping with this aspect of the syndrome is one of the most physically and emotionally demanding parts of their lives. While behaviour management is an important component of dealing with the individual who has rage attacks, the majority of parents realize that despite all efforts, their child is out of control during these periods. We now believe that these episodes of "lost control" are also caused by the imbalance in neurotransmitters in the brain which is the basis of TS. It is therefore unlikely that behaviour modification alone will be completely successful in these children.
It is important to separate the various behaviours that your child has. Some emotional outbursts are typical childhood temper tantrums, while others may be caused by the impulsivity of attention deficit hyperactivity disorder (ADHD). Impulsivity means acting without thinking. Children who have ADHD as part of their Tourette Syndrome may therefore strike out before they have time to think. Families who have to deal with true rage attacks seldom have difficulty in distinguishing the rage episodes from other behaviours. Parents often describe the following behaviours in the child who has rage:
In the more severe cases the family may fear for the safety of others during these attacks of anger. For these children medication may have an important role.
Risperidone (Risperdal®) is a relatively new medication that was first licensed to treat schizophrenia in 1994. It was later found to be helpful in treating patients with TS. Like almost all medications that help in TS, risperidone is a dopamine antagonist. It also acts as a serotonin antagonist, although this effect is probably not important when used for patients who have TS. Antagonists are drugs which block the action of a chemical or drug. As dopamine is the neurotransmitter which is responsible for the symptoms in TS, almost all of the drugs which are effective in TS are dopamine antagonists. Risperidone is different to the other dopamine antagonists and although it also acts on the dopamine receptors (D2) in the brain, it seems to cause fewer side effects than other medications.
Risperidone has been used in children and adults with TS and is thought to be helpful against ties, obsessive compulsive behaviours and against rage. Most physicians and families who have used risperidone believe it is most helpful in controlling rage. It is not yet possible to say exactly how helpful it is as the scientific studies needed to prove its usefulness have not been completed.
The side effects which have been noticed by people taking risperidone have usually been mild. They have included low double vision, dizziness, drowsiness or insomnia (difficulty sleeping) and weight gain. It seems less likely to produce dystonia (muscle stiffness), restlessness, tremor and low blood pressure which are possible adverse effects with all medications in this group of dopamine antagonists.
The effect of risperidone is often seen in the first week or two after it is started but in some patients the benefits may not be seen for up to 4 weeks. The starting dose for most children is 1/2 to 1 mg twice per day for the first 3 to 5 days. At that time the dose can be increased but children often do well on doses as low as 2 mg per day and adolescents may be treated with 3 mg each day. The rate of increase depends on the size and age of the patient and their response to the medication. Even in adults the maximum dose is seldom higher than 6 mg per day. Risperidone is not affected by food and can therefore be taken with or without meals.
There are a number of ongoing studies at present which hopefully will demonstrate the role of risperidone in helping those with controllable rage. Some of these studies are being carried out in Canada and your doctor may be able to advise you if there is one in your area.
Is risperidone the answer for all patients with rage? No! As everyone is different, there is no medication which works for every patient. For some individuals, however, risperidone seems to be very helpful and it may assist families and individuals whose lives are disrupted by episodes of rage. We need more experience before we know exactly how valuable risperidone will be, but for the moment it appears to be an excellent addition to the list of medications which can help those with TS.