What medication can help a patient with vocal outbursts or loud yelling, possibly due to a condition such as intermittent explosive disorder (IED)?

From the Guidelines

For a patient with vocal outbursts or loud yelling, possibly due to intermittent explosive disorder (IED), lorazepam is a recommended medication, as it has a fast onset of action and can be effective in managing acute agitation 1. When considering medication for a patient with yelling behaviors, it's essential to identify underlying causes of the behavior, such as pain, delirium, or unmet needs. Non-pharmacological approaches should be tried first, including environmental modifications, consistent routines, and addressing sensory needs. Some key points to consider when managing agitation include:

• Using verbal restraint strategies, such as respecting personal space, minimizing provocative behavior, and establishing verbal contact 1
• Considering the use of benzodiazepines, such as lorazepam, which can be effective in managing acute agitation 1
• Using antipsychotics, such as risperidone or quetiapine, as an alternative or in combination with benzodiazepines, particularly in patients with known psychiatric illness 1
• Starting with the lowest effective dose and regularly reassessing for effectiveness and side effects
• Monitoring for metabolic effects, sedation, and extrapyramidal symptoms, especially in elderly patients who may be more sensitive to adverse effects. It's also important to note that the choice of medication may depend on the suspected etiology of the agitation, with benzodiazepines being a good option for medical or intoxication-related agitation, and antipsychotics being a better option for psychiatric-related agitation 1.

From the FDA Drug Label

The primary rating instrument used for assessing manic symptoms in these trials was the Young Mania Rating Scale (YMRS), an 11-item clinician-rated scale traditionally used to assess the degree of manic symptomatology (irritability, disruptive/aggressive behavior, sleep, elevated mood, speech, increased activity, sexual interest, language/thought disorder, thought content, appearance, and insight) in a range from 0 (no manic features) to 60 (maximum score).

Risperidone may help a patient with vocal outbursts or loud yelling, possibly due to a condition such as intermittent explosive disorder (IED), as it has been shown to be effective in reducing symptoms of irritability and disruptive/aggressive behavior in patients with bipolar mania 2.

• The medication has been found to be effective in reducing the Young Mania Rating Scale (YMRS) total score, which includes assessment of manic symptoms such as irritability and disruptive/aggressive behavior.
• However, it is essential to note that the medication's effectiveness for intermittent explosive disorder (IED) is not directly addressed in the provided drug label.

From the Research

Medication Options for Vocal Outbursts or Loud Yelling

• Typical antipsychotics such as haloperidol, alone or in combination with antihistaminergic and anticholinergic drugs like promethazine, can be used to treat agitation and aggression 3
• Atypical antipsychotics like aripiprazole, ziprasidone, and olanzapine are also effective in managing agitation and aggression, with olanzapine being a powerful sedative 3, 4
• Benzodiazepines such as lorazepam, diazepam, and midazolam can be used to treat acute agitation, but may have a more pronounced sedating activity 3, 5
• The combination of haloperidol and promethazine may be a good choice for treating agitation, as it combines the sedative properties of the antihistamine with the calming action of haloperidol, while reducing the risk of extrapyramidal effects 3
• Oral risperidone plus oral lorazepam has been shown to be effective in reducing symptoms, including aggression, in acutely psychotic patients, with a lower incidence of extrapyramidal symptoms compared to standard intramuscular conventional neuroleptic treatment 5

Considerations for Treatment

• The choice of medication should be based on the patient's specific needs and medical history, as well as the clinician's experience and availability of medications 3, 6
• It is essential to exclude other medical causes of agitation and consider the differential diagnoses before selecting a medication 4, 7
• The treatment of agitation and aggression should prioritize the safety of both the patient and staff, and may involve verbal de-escalation, chemical sedation, or physical restraints 4