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Irritability

SOONER HAN Behavioral Health Lecture Series
by

Erik Vanderlip

on 26 August 2015

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Transcript of Irritability

Anger Management 101
Erik R. Vanderlip, MD MPH
Diagnosis
Treatment
Anger Management and Mood Stabilization
What are the indications for
pharmacotherapy,
and which drugs to use?
Lots of patients say they have a bad temper, say things they regret, and that's the chief complaint.
No anxiety.
No depression.
Should that complaint be treated with drugs?
Is it an
Axis II
problem?
How do you know if
Axis II
?
Even if
Axis II
, should you treat with drugs?
What
non-pharmacologic
treatments are worth considering?
1
Disruptive Mood Dysphoric Disorder - 1
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1.  The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property. 
2.  The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3.  The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
2
Disruptive Mood Dysphoric Disorder - 2
C. Mood between temper outbursts:
1.  Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2.  The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months.  Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
3
Disruptive Mood Dysphoric Disorder - 3
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting. 
F. The onset is before age 10 years
A sneak peak at new classifications of this phenom: DSM 5
Coccaro, E. F., Posternak, M. A., & Zimmerman, M. (2005). Prevalence and features of intermittent explosive disorder in a clinical setting. Journal of Clinical Psychiatry, 66(10), 1221–1227.

Kessler, R. C., Coccaro, E. F., Fava, M., Jaeger, S., Jin, R., & Walters, E. (2006). The prevalence and correlates of DSM–IV intermittent explosive disorder in the National Comorbidity Survey Replication. Archives of General Psychiatry, 63(6), 669–678.

McCloskey, M. S., Berman, M. E., Noblett, K. L., & Coccaro, E. F. (2006). Intermittent explosive disorder-integrated research diagnostic criteria: Convergent and discriminant validity. Journal of Psychiatric Research, 40(3), 231–242.

McCloskey, Michael S, Kurtis L Noblett, Jerry L Deffenbacher, Jackie K Gollan, and Emil F Coccaro. 2008. Cognitive-behavioral therapy for intermittent explosive disorder: a pilot randomized clinical trial.â Journal of consulting and clinical psychology 76 (5) (October): 876-86. doi:10.1037/0022-006X.76.5.876.
What is anger?
Anger (n)
a strong feeling of annoyance, displeasure, or hostility
anger is an emotion related to one's psychological interpretation of having been offended, wronged or denied and a tendency to undo that by retaliation.
The Rage of Achilles by Giovanni Battista Tiepolo
Anger is evolved, and may be advantageous.
Anger is not always bad.
Suppression of anger can be detrimental.
Anger has physical components.
Anger is the primary protective emotion, designed to protect us from harm or from loss of something of value. The most physical of all emotions, anger sends action signals to the muscles and organs of the body to prepare us for one purpose and one purpose only: to neutralize or defeat the perceived threat.

Two factors go into the formulation of anger: current vulnerability and magnitude of the perceived threat.
Relatively little threat will cause anger when vulnerability is elevated
, for example when physical resources are low - you're tired, hungry, sick, injured, depressed, anxious, stressed - or when self-doubt is high, making you more easily insulted.

Problem anger (that which leads you to act against your long-term best interests) is caused by high vulnerability. It is the most self-revealing of emotional states, pointing directly to a powerful cause of vulnerability: a sudden drop in core value.
Roger Peele, MD 2011
When you hear anger, think
fever
. It could mean anything.
Prevalence, cost and epidemiology?
Counseling
Dialectical Behavioral Therapy
FPINFO
at UIowa (Thanks Dr. Bergus!): http://www.healthcare.uiowa.edu/familymedicine/fpinfo/
Rape Victim Advocacy Program:
http://www.rvap.org/pages/home/
320 S. Linn St., Iowa City, IA 52240
Phone: 335-6000, 1-800-284-7821. 335-6001 for appointments.
Medication
Depakote
The authors consider that the body of evidence summarised in this review is insufficient to allow any firm conclusion to be drawn about the use of antiepileptic medication in the treatment of aggression and associated impulsivity.
Cochrane Review, 2010
Huband, N, M Ferriter, and R Nathan. 2010. Antiepileptics for aggression and associated impulsivity.€ Cochrane Database Syst Rev (2).
Eadward Muybridge, the Google Doodle from 4/9/12

"Murder, acquittal and paternity

In 1874, while still living in the San Francisco Bay Area, Muybridge discovered that his young wife Flora had a lover, a Major Harry Larkyns.

On 17 October, he sought out Larkyns and said, "Good evening, Major, my name is Muybridge and here's the answer to the letter you sent my wife."

He shot and killed the major pointblank.

wikipedia, accessed April 9, 2012
Tulsa, OK shootings, April 2012
Case Study


Erik says, "There's times when I just wanna
rage
on things, and I don't know why! Like the other day, I was hunting Easter eggs with the family, and I couldn't find the pink one, and I just blew up! I scared my kids and my wife, and the dogs ran. I yelled. It ruined everyone's Easter. I felt really bad about it. It seemed to come out of nowhere.
this talk for care managers for something or other, and people kept talking about anger problems, and I was like, '*&%$, this stuff happens all the time!'"
Also, there was this other time when I was at
"I just wanna feel better, and not have this happen anymore. It's embarrasing for my family. I can't be a physician like this. Or a dad. The last time this happened, my neighbors called the police to my house."
PMH:
Non-contributory.
SH:
Denies drugs, alcohol. Reports wife is supportive, but very stressed at work and with a move coming up!
FH:

Father was similar. Sometimes depressed.
ROS:
Negative for anxiety, depression.
PE:
Nice guy...now.
??
Instrumental aggression is more controlled and consciously goal-directed.
Reactive aggression involves an emotionally-driven reaction to frustration or perceived threat, and is more common.
Huband, N., Ferriter, M., & Nathan, R. (2010). Antiepileptics for aggression and associated impulsivity. Cochrane Database Syst Rev, (2).
Four studies involved valproate (full name: sodium valproate)
Doses at 20 - 30 mg/kg/day (2100 mg in 70 kg adult) in kids, 750 - 1500 mg/day in adults with drug levels at 80-120 üg/ml
Anti-epileptics:
Benzos:
Best avoided due to risk of substance abuse/diversion
SSRI?
Fluoxetine

has also been evaluated in treating IED.
There was significant improvement in reducing frequency and severity of impulsive aggression and irritability in a sample of
100 subjects who were randomized into a 14-week, double-blind study
.
Despite a large decrease in impulsive aggression behavior from baseline, only 44% of fluoxetine responders and
29% of all fluoxetine subjects were considered to be in full remission
at the end of the study (Coccaro et al., 2009).
Coccaro, E., Lee, R., and Kavoussi, R.
(2009). A double-blind, randomized,
placebo-controlled trial of fluoxetine
in patients with intermittent explosive
disorder. J. Clin. Psychol. 70,
653–662.

Schreiber, Liana, Brian L Odlaug, and Jon E Grant. 2011. Impulse control disorders: updated review of clinical characteristics and pharmacological management. Frontiers in psychiatry / Frontiers Research Foundation 2 (February) (January): 1. doi:10.3389/fpsyt.2011.00001.
Schreiber, Liana, Brian L Odlaug, and Jon E Grant. 2011. Impulse control disorders: updated review of clinical characteristics and pharmacological management. Frontiers in psychiatry / Frontiers Research Foundation 2 (February) (January): 1. doi:10.3389/fpsyt.2011.00001.
GOOD MORNING.
Erik V. is a 32 year-old father of four, married.
He hasn't had his coffee.
CC: "I just get so *&^%'d off!"
SOONER HAN Behavioral Health Lecture Series
August 28th, 2015
Tulsa, OK
Disclosures = None

annoyance
rage
spectrum of anger
Spectrums of Anger
passive
aggressive
Instrumental
"pre-meditated"
Reactive
"impulsive"
Commentary:
1.
0.
Estimates place clinically significant anger control problems at
4-7%
of general population (Kessler)
Usually this begins in adolescence
Coccaro, E. F., (2010). A family history
study of intermittent explosive disorder.
J. Psychiatr. Res. 44, 1011–1015.
Coccaro, E., Schmidt, C., Samuels, J.,
and Nestadt, G. (2004). Lifetime and
1-month prevalence rates of intermittent
explosive disorder in a community
sample. J. Clin. Psychol. 65,
820–824.
Majority seem to be males, but not well studied
Only ~28% of persons with anger problems receive treatment by self-report (Kessler)
82%
have co-occuring mental health or substance use disorders
Co-morbidity is the
RULE
mood
anxiety
substance use
2.
good
vs.
evil
1) Get to the crux of the issue.
Blow it up!!!
2) Don't accept "I don't know" for an answer.
Ask pointed, detailed questions.
Require concrete examples of what happened, who said what - knowing that this will likely be
representative of a larger pattern of behavior
.
Understand what led up to the outburst, and also
what happened afterwards
.
Get an exact
timeline
of a recent event.

You may find a brain!
and a differential diagnosis
Depression
Anxiety Disorder
GAD
OCD
PTSD
Panic Disorder
Traumatic Brain Injury
Intellectual Disability
Bipolar Affective Disorder
ADHD/ADD
ODD/CDD
Pervasive Developmental Disorder
Have you done your PHQ-9 today?
Childhood
Disorders
Substance Use Disorders
DDX
What about
Axis II (personality)
?
Emotional Intensity Disorders
"Cluster B Traits" - THE
WILD
ONES
Borderline
Personality Disorder
Poor sense of self, emptiness
Emotional lability
Fear of abandonment
Antisocial
Personality Disorder
Disregard for others
Repeated lying
Little remorse
"Axis II"
Don't be afraid to dive deep!
Intermittent Explosive Disorder
Criteria for diagnosing IED:

DSM-5 criteria (2014):

Failure to control aggressive impulses that leads to behavioral outbursts as manifested by either
Verbal aggression (tantrums, arguments, tirades) or physical aggression directed towards property, animals or individuals not resulting in injury, occurring twice weekly for three months
Physical assaults that damage property or injure animals or other people, occurring at least three times in 12 months
The degree of the aggressiveness is grossly disproportionate to the circumstances or provocation
Behavioral outbursts are impusive, unplanned and/or a response to anger
Marked distress or impairment
The episodic violence cannot be better accounted for by another mental or physical medical condition.
(Now we're talkin...)
Nosology:
IED lives in the family of
Impulse Control Disorders
in your friendly DSM 5, Neighbors include:

-pathological gambling
-kleptomania
-trichotillomania
-pyromania

Diagnostic criteria have been proposed for:

pathological skin picking
compulsive sexual behavior
compulsive buying
hoarding (DSM 5!!!)

which are currently classified under ICDs not-otherwise specified (NOS)
3.
From this
do this.
Individualized
Group
Extrinsic
Intrinsic:
Self-directed
"Group and individual cognitive–behavioral therapy tended not to differ, with each reducing aggression, anger, hostile thinking, and depressive symptoms, while improving anger control relative to wait-list participants."
...further research is needed.
Proposed Criteria for IED in DSM 5
Coccaro, Emil F. 2011. €œIntermittent explosive disorder: development of integrated research criteria for Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition. Comprehensive psychiatry 52 (2): 119-25.
3/3 RCT's showed that VPA > Placebo for adults and late adolescents, including some persons with cluster B personality disorders (wild!)
1 RCT showed not better for children with PDD
All studies demonstrated headache, many physical complaints, and weight gain compared to placebo
Dilantin
5 RCT's evaluated phenytoin (300 mg/day), and few to none reported adverse outcomes or side effects.
Mostly adult males, not helpful in kids after 2 week exposure.
DBT.
Medication
...you say either...
...I say either...
4.
Anger =
Fever

medication mush

The Lecture
acknowledgements: Prezi, Bryan Touchet
Objectives
Reactive aggression?
cause
effect
chronic pain?
bereavement?
Histrionic
Narcissistic
Chronic, maladaptive patterns of behavior across multiple domains, in adulthood.
True BPAD may have irritability involved with mania, but is not what we typically think of as "mood swings".
DVIS,
Tulsa Website
5.
Summary
Expand upon irritability as a chief complaint. Understand the situation and underlying feelings involved.
Screen for co-morbid, common mental health and SUDs (depression, EtOH) and medical conditions (chronic pain)
Counsel to discuss anger dyscontrol, refer for either group or individual counseling
Treatment with fluoxetine is really first-line
to this.
Full transcript