Rage Takes Center Stage: Focus on an Underappreciated Aspect of Pediatric Obsessive-Compulsive Disorder

Abstract

T he article by Storch et al. 1 in this issue of the Journal points to an under-recognized yet highly clinically relevant aspect of pediatric obsessive-compulsive disorder (OCD). The article is well timed, as the field awaits publication of the next edition of the DSM-5, with probable removal of OCD from the anxiety disorders and into its own category. Rage attacks have been repeatedly described in the phenotype of Tourette’s disorder, a genetically related and often comorbid condition. These episodes also have been identified in the context of non-OCD anxiety disorders and in disruptive behavior disorders (DBDs). Although OCD and DBD are known to be comorbid, little attention has been paid to rage episodes in the clinical presentation of OCD. A recent editorial by Lebowitz et al. described a survey of 110 OCD clinicians in which nearly all respondents had experienced disruptive or coercive behavior, and most of whom reported physical violence or its threat in at least some pediatric OCD cases. However, they did not specifically query the presence of rage episodes. In the lone previous study of rage in pediatric OCD, 27.5% of parents qualitatively reported rage attacks within the previous week, although these episodes were not characterized systematically or quantitatively. Rage attacks are defined as “explosive anger outbursts that were grossly excessive or inappropriate to the situation and beyond the child’s control.” The study by Storch et al. examines, in a specialty clinic sample of 86 OCD-affected children and adolescents, the characteristics of rage attacks and their relations to the severity of OCD and to family accommodation. In the introduction, the role and functions of rage in pediatric OCD in relation to family accommodation and illness severity are postulated