Monday, September 17, 2012

14 year old with history of angry outbursts

Hi Dr. G., Today is the first I've ever heard of "anger overload", but I think this describes by 14 year old daughter.  But like most disorders, it's hard to to know if this really is the correct diagnosis.

My daughter is 14. She is a straight A student and always has been.  I can't say that all school work comes easy to hear, but she's willing to spend the hours needed to do well.  A classic overachiever.  She does not exhibit angry behaviors at school (that we know of) and respects authority figures.  She has friends and engages in extra-curricular activities.  She would appear to be a typical teenager.  She is a middle child; her brothers are 14 and 8.

As long as I can remember, she has had severe outbursts of anger.  It was and still is primarily directed at my wife or my sons.  Something that would seem so minor to someone else can set her off and she become verbally abusive.  Some of the things that she says are so horrible that I refuse to believe she actually means what she says.  When she was very young her outburst would result in prolonged screaming session.  Any attempt to speak to her (or console) her made it worse.  

As time went, the anger outbursts become shorter in length but no less traumatic for the family.  Early on we tried to use consequences for this behavior but it didn't change anything.  As much as she disliked the consequences, the anger remained.  We brought her to a nutritionist because we thought her diet was possibly triggering the anger. I still do. It seemed to help some but the anger continued.  As a family, we just learned to tolerate this behavior because we needed to get through the day and care for her brothers (and ourselves).  She refused therapy for a long time but currently we are seeing a social worker therapist to get help.  Unfortunately, I don't think she fully understands what we are trying to describe.

I've been a high school teach for over 20 years and have been in countless IEP's and 504 meetings.  I've heard about and dealt with children with many types of disorders.  I honestly believe that she cannot control her anger.  My wife has not always agreed with me on this point.  I think she can learn to deal with anger better but the anger will still be there.  I'd like to think that somehow we can find a way to make all the anger go away as this has taken a toll on our family.  This is something we deal with every single day.

Here are some other bit is information:

She has never really showed any empathy toward others.  She will NEVER admit she is wrong or apologize.  She's only said "I'm sorry" a few times in her life that I know of and even then there may have been an ulterior motive (facing consequences).  Outbursts last 10-15 minutes with the strength of a hurricane.  She retreats to her room for an hour or so and comes back down as if nothing has happened.  My wife, sons and I are still emotionally drained from the experience but she's completely fine.  As if nothing happened.  While in therapy she has admitted that she has a problem and doesn't want to continue being angry.

This may sound like she's a terrible girl but aside from the anger issues, she can be as normal and sweet as any girl.  She's very intelligent and has lots of interests.  One on one, without her brothers around, she can be so much fun.  At times even over the top giddy.  Sometimes we actually set her off unintentionally by calling her on a comment when she was just trying to be funny.  She has a  dry sense of humor.

Here is what I constantly struggle with in terms of consequences.  Is it fair to continually punish her for something that she can't control?  She has always had this anger.  I do feel that she can and should try to control this anger better so I try to distinguish between the two.  It is impossible to have a discussion with her about these issues (even when she's calm), she will not engage.  I have found that emailing or texting her is the only way we can communicate about the subject.  Never face to face.  I could go on and on but I hope this is enough to give you an idea of what we are dealing with.

Thank you.
Yes, what you describe fits with anger overload.  Anger overload is a term I began writing about ten years ago.  Other clinicians have written about children who have angry outbursts, and the next psychiatric diagnostic manual  will have a diagnosis called "disruptive mood dysregulation disorder" (or DMDD), which is similar to anger overload, but for DMDD there is negative mood even when the child or teen is not in the overload phase.  I have seen many children who have anger overload, but do not otherwise show signs of irritable or negative mood; that's why I prefer the term anger overload.   In the psychological research literature, there is discussion of children and adults who have recurring bouts of extreme anger, and there is more and more evidence that there is an area of the prefrontal cortex that seems to be involved.  These individuals have difficulty regulating anger.  However, with maturation and with practice, children can improve.  That is what my anger overload manual is about.  I offer strategies parents can use to help their children develop better self control.  The outbursts will be less frequent and less extreme.  

It is a good sign that your daughter agreed to therapy and wants to have better control.  If she is motivated to work on it, the second half of my book describes strategies parents can work on together with their children.  
Consequences do not work on a consistent basis for anger overload.  It is as if the brain is overheated, and the person is not thinking entirely rationally at that point.  This is why I tell parents not to take what their children say seriously when they are in overload.  It is also why I recommend ways for parents to catch their children's anger early, when possible, and suggest ways to change their children's expectations (it is often some kind of disappointment that precedes the angry outbursts) or change the sequence of events that sometimes lead up to an outburst.

Consequences sometimes help after everyone has calmed down if you are trying to stop one specific kind of behavior during the overload phase.  In other words, consequences do not generally work to stop anger, but if your child says a particular word, or throws things, you can target one of these extreme behaviors, and if the consequence is meaningful to your child, she may try to avoid it by stopping herself from saying the words you want to extinguish.  But sometimes this backfires, and the child says the "dreaded" words even more so.  Thus, the more useful approach is to teach your child strategies that will help her control herself before she reaches the overload phase.  Check out other blog entries or my book for other ways to limit anger overload.  All the best, Dr. Gottlieb

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