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Mood stabilizers and stimulants for anger episodes

Date: Sat, 1 Feb 1997 10:12:40 -0800 (PST)
From: Jaime Smith <evb@yknet.yk.ca>
Subject: Valproate for anger episodes

I've been following a fellow in the local prison where he is doing time on drug charges. I was asked to see him because of anger episodes in the prison setting a few months ago.

I started him on a trial of valproate 125 mgm QID the first week, 250 QID the second week. Amazing change after two weeks now -- he has been elected chairman of the inmate committee, sleeps well, writes poetry, and says it subjectively is a major change in his ability to exercise self control. He denies using drugs in prison -- and in the controlled milieu compliance with medication is ensured. This seems almost too good to be true.

From: cprice@mem.po.com (Charles Sowle Price, MD)
Date: Sat, 1 Feb 1997 14:38:29 -0500
Subject: Valproate for anger episodes

I use this strategy often. It works a high enough % of the time that I use it often early in my decision tree.

Date: Sat, 01 Feb 1997 18:14:38 -0800
From: "Deborah Pines, MD" <deborahp@erols.com>
Subject: Valproate for anger episodes

I haven't seen anything so dramatic, but I do see major improvements over time with my conduct disordered, explosive adolescents who have spent years in different settings and on different meds. The valproate seems to really help them control the magnitude of their aggression, outbursts and irritability. Some kids really think valproate has "changed their lives".

Date: Sat, 01 Feb 1997 22:19:51 -0500
From: William Braden <braden@brown.edu>
Subject: Lithium for anger episodes

An article (probably 15 years old) reported that lithium decreased the rate of violent incidents in prisoners (no screening or selection for diagnosis). There were other reports that lithium suppressed aggressive behavior in others (with mentally retardation or borderline personality disorder).

Patients on lithium often report a lack of emotional response. Some of the patients who experienced control of aggressive behavior reported that the lithium created a sort of delay in the onset of anger which allowed them to develop a rational response. I haven't seen anything about whether valproate does or does not do these things.

Date: Sun, 2 Feb 1997 11:54:25 -0500
From: bret burquest <bret@vnet.net>
Subject: Valproate for anger episodes

I echo what Deborah and Jaime have written. The problem becomes asking the aggressive and violent adolescent to give up a part of his life. Some won't stay on medication, not valuing life as highly without violence. I guess we call that an axis II problem.

Date: Sun, 02 Feb 1997 13:48:58 -0800
From: leonard <leonardj@ucla.edu> (John Leonard)
Subject: Valproate for anger episodes

In the growth industry of the '90s (correctional psychiatry), VPA has a place in the treatment of impulsive aggression, but not predatory aggression. I have had some notable successes with it in doses up to the maintenance level recommended for control of seizures. I have not had too many problems: serious weight gain once, some stomach complaints. All-in-all a very useful agent.

Subject: Valproate and carbamazepine for short fuses
Date: 03 Feb 97 10:54 EST

We have had some good results at the VA using valproic acid and carbamazepine for short-fusers, especially PTSD patients who do not have seizure disorders. We have found them to be better than lithium. These patients do not have underlying bipolar disorder, either, but lithium has been tried, according to the literature, because of the "cyclicity" and sudden shifting of mood/behavior vis-a-vis the violent outburst.

We have also had experience with such patients who later reveal a childhood hx of poor concentration -- even in enjoyable tasks (e.g., a favorite TV show) -- and (retrospectively) receive a dx of ADHD/ADD. Perhaps they were "hyperactive" as kids and now more violently express this hyperactivity as adults. These folks still complain of concentration problems. They also have difficulty holding jobs and going for higher education and can exhibit disabling relationships and even violent/criminal behavior because of this continued concentration/attention impairment. For such patients stimulants have been useful. A very old reference:

Richmond JS, Young JR, Groves JE: Violent dyscontrol responsive to d-amphetamine. American J Psychiatry, 133: 365-366, 1978.

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[dr. bob] Dr. Bob is Robert Hsiung, MD, dr-bob@uchicago.edu

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