
Assessment and Management of Severe Irritability from Preschool to High School Jeffrey Hunt, MD 1 Disclosure Statements Sheppard Pratt holds the standard that its continuing medical education programs should be free of commercial bias and conflict of interest. In accord with Sheppard Pratt's Disclosure Policy, as well as standards of the Accreditation Council for Continuing Medical Education (ACCME) and the American Medical Association (AMA), all planners, reviewers, speakers and persons in control of content have been asked to disclose any relationship he /she (or a partner or spouse) has with any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients, during the past 12 months. 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Learning Objectives Describe the historical conceptualization of irritability as a symptom in psychiatric disorders Highlight the differences between episodic vs chronic irritability Define the criteria for DMDD Discuss severe irritability in the context of preschool age children Briefly discuss neuroscience and genetic research trends related to irritability Describe evidenced-based approaches in managing irritability 5 Case history: Jed Jed is a 9 year old male referred for evaluation of 2 year history of nearly daily temper tantrums. He is very easily frustrated and becomes rageful, most often toward mother, when his needs are not met. He has difficulty making friends and prefers to spend time on video games. Since COVID-19 quarantine began his moodiness has increased. The parents report substantial stress from parenting him. Mom reports “constant walking on egg shells” PPH: he has a therapist but “hates going.” no medication SH: only child – mom is teacher; father is engineer – recent treatment for glioblastoma FH: post partum depression in mom; pat grandmother “I think she had bipolar disorder” PMH: Healthy Picture courtesy of www.dbsalliance.org 2 7 Objectives Describe the historical conceptualization of irritability as a symptom in psychiatric disorders Highlight the differences between episodic vs chronic irritability Define the criteria for DMDD Discuss severe irritability in the context of preschool age children Briefly discuss neuroscience research trends Describe evidenced-based approaches in managing irritability 8 Pediatric Bipolar Disorder and Irritability: Primary Controversy The frequent diagnosis of bipolar disorder in children with chronically irritable mood redefined bipolar disorder in early life as a non- episodic syndrome This diagnostic approach contributed to the dramatic rise in the rate of pediatric visits for bipolar disorder in the United States Rise in polypharmacy Rise in use of atypical antipsychotics Led to introduction of DMDD Roy, Lopes & Klein 2014, Carlson 2011; Francis 2012 3 • Of the 43 children who met criteria for mania • 77% (n=33) – persistent irritability • 14% (n=6) – elation • 9% (n = 4) - full of energy or many thoughts. – Only 16% (n=7) were episodic (> 1 episodes of mania) remainder were chronic – This study was very influential - irritability and chronicity as hallmark of BP JAACAP 34(7), 1995 Bipolar Disorder: Over diagnosed? 1994-19952002-2003: Ped BD 40-fold increase! <19yo 25/100,0001003/100,000 DSM-IV >20yo 905/100,0001679/100,000 Published National Ambulatory Medical Care Survey (NAMCS) annually by National Center for Health Statistics. Moreno et al. Arch Gen Psych 2007 Irritability is Not Specific Bipolar disorders Major depressive episode Gen. anxiety disorder PTSD Oppositional defiant disorder ADHD Conduct disorder Intermit. explosive disorder Autism spectrum disorders 4 Irritability: Terminology Frustration: Irritability: Emotional state increased proneness Anger: Consciously induced by block to anger relative to perceived Rage: goal attainment; similarly developed emotion/feeling Intense anger Frustrative non- peers with irritability reward resulting in increased aggression 13 Stringaris A. J Child Psychol Psych 59;7 2018 721-739 Kraepelin Description of irritable mania “.…On the other hand there often exists a great emotional irritability. The patient is dissatisfied, intolerant, fault-finding… he becomes pretentious, positive, regardless, impertinent and even rough, when he comes up against opposition to his wishes and inclinations; trifling external occasions may bring about violent outbursts of rage.” Kraepelin, 1921 Irritability: Long recognized as a problem 15 5 Irritability: Terminology Chronic irritability: Worse than peers but not different than child’s baseline (DSM >12 months) Episodic Irritability: Change from child’s baseline and worse than peers; Found in MDD and BD Tonic Irritability: Persistent irritable mood in between outbursts (part of DMDD) Phasic Irritability: Temper outbursts on top of Tonic Irritability Stringaris A. J Child Psychol Psych 59;7 2018 721-739 16 Irritability common in BP and ADHD Geller et al., 2002 Irritablity as symptom of Bipolar Disorder across studies Rates of irritability and elation vary significantly across study samples. 100 50 elation irritability 0 Findling Wozniak Geller Axelson Adapted from Kowatch, et al., 2005 6 Hunt et al., JAACAP 2009 10% 15% both 75% ela on irritability Hunt et al, JAACAP, 2009 Identifying Irritability only subgroup in the COBY Sample Secondary analysis using KSAD-MRS Category A symptoms to define three groups 361 subjects had both most serious past and current MRS ratings Looking for between group differences at baseline and longitudinally Hunt et al., JAACAP 2009 K-SADS MRS: Irritability • Mild: Often feels definitely more angry, irritable Subjective feeling of irritability, anger, than called for by the situation. relatively crankiness, bad temper, short tempered, frequent but never very intense resentment, or annoyance, externally directed, whether expressed overtly or not. • Moderate: Most days irritable/angry or over 50% of awake time. Rate the intensity and duration of such • Severe: At least most of the time child is aware feelings. of feeling very irritable or quite angry or has frequent homicidal thoughts (no plan) or thoughts of hurting others. Or
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