Wednesday, October 26, 2011

Therapeutic approaches to irritability

Irritability can be a challenging symptom, often present in a wide range of different clinical settings.  Unipolar depression can present with irritable mood, as can the manic states of bipolar disorder.  Irritability is also a common problem in borderline personality disorder, as well as in various other populations, such as in those with autism, dementias, brain injury, conduct or oppositional disorders, and addiction disorders.  In some cases, arguably, irritability could be considered the primary problem for some people, which either exists on its own as a solitary symptom, or is the direct single cause of the person's other life problems (e.g. in relationships, employment, conflicts with the law, ability to work or study, etc.)

A variety of simple factors usually make irritability worse:
1) sleep problems.  Insomnia or deliberate reduction of sleep hours will magnify irritability.
2) hunger.  For some individuals especially, allowing a hungry state without eating healthily will magnify irritability.

In both cases above, a vicious cycle can arise, as greater irritability may prevent sleep or cause a further lack of appetite.   

3) multiple environmental or medical irritants which are not improving:  for example, crowding, noise, poor air quality, physical pains or discomforts

Therefore, in approaching irritability, it is essential to take steps to improve sleep, nutrition, pain, and environmental stimuli.

Further therapy for irritability should of course involve healthy lifestyle practices, such as exercise, relaxation, and meditative activity (if not formal "meditation" then something which accomplishes something similar, such as music listening or performance, biofeedback, hot baths, massage, etc.)  Reduction of caffeine intake, etc. could be important to try. Developing healthy philosophical practices can be very useful; for example, some type of calm or peace-oriented religious or other community involvement may add to one`s ability to manage irritability, especially since there could be group-based support and healthy cultural activities. 

Pharmacological treatment of irritability, if necessary, would  depend on obvious underlying causes.  In substance withdrawal states, for example, temporary appropriate sedation (e.g. with benzodiazepines, clonidine, or anticonvulsants such as gabapentin) could ease the irritability.    In manic states, mood stabilizers, antipsychotics, and benzodiazepines which ease the manic symptoms, would be expected to ease the irritability.  In major depression, an antidepressant of any sort, if it works for the individual, could dramatically improve the irritability.  ADHD can be a cause of irritability, which--seemingly paradoxically--could improve with stimulant therapy. 

In this post, I am particularly interested in looking at specific pharmacological treatments for idiopathic irritability, or irritability which has existed as a long-term emotional dynamic such as in those with borderline personality traits or disorder.

Here are a few pertinent links to abstracts in the research literature:
this 12 week randomized study shows modest benefits from divalproex to treat irritability in autistic children (ages 5-17)  gabapentin useful for borderline patients over a 6 month period (this is a good article, but it's in German)--  review of anticonvulsant effectiveness in personality disorders.  There is evidence in this paper to support trials of valproate, topiramate, and possibility also lamotrigine.  They describe some data on carbamazepine as well.  The level of evidence is such that I think these medications could be worth trying cautiously on an individual basis, particularly to target symptom domains such as irritability.  However, I think expectations should be modest, due to there most likely being a lot of variability in an individual's response. 

I am interested in the use of clonidine for irritability.  This drug is effective for treating withdrawal states (including one of the most unbearable withdrawal states possible, from opiates), but has also been used for many years to treat ADHD.  It can help with tic disorders as well, so could be a good choice for managing ADHD + tic comorbidity, a difficult problem often made worse by stimulants.  Clonidine was originally developed as a treatment for high blood pressure.  My main concern about clonidine is about how well its effects persist if taken continuously for more than a few months.  Here is an article about treating borderline personality patients with clonidine:

Here's a study looking at treating children with conduct or oppositional problems with stimulants and/or clonidine:

In conclusion, there are various options to try in the treatment of irritability from most causes.  While the evidence base is limited, there is support for attempting a variety of different pharmacological treatments for idiopathic irritability, particularly anticonvulsant medications.

Monday, October 3, 2011

Parental behaviours associated with offspring personality traits

Johnson et al. have published an interesting article in the August 2011 edition of The Canadian Journal of Psychiatry (pp. 447-456) in which they describe a nice longitudinal study of 669 families, correlating parenting behaviour with future personality traits in the offspring.

To some degree, studies of this type might seem to be re-examinations of the obvious -- that is, children of friendly, gentle, stable, involved parents are more likely to be healthy and stable themselves.  The thing is, much of this effect is arguably due to heredity rather than parenting.  The genetic factors which influence temperament, mood, personality, etc. are likely to be present in both parents and children--the impact of parenting behaviours themselves are therefore likely to be overestimated.

A good method to tease out these factors would be to study  families with adopted children, provided there is good data about psychological characteristics of the birth parents.  In general studies of this sort have led to the surprising conclusion that genetic factors are quite a bit higher than expected, and parenting factors quite a bit lower.

But this particular study is quite good.  It was longitudinal, following parents and offspring  at various ages during the offspring's childhood years (ages 6, 14, and 16), then following up in the offspring's young adulthood years (ages 22 and 33).  Most importantly, the study carefully assessed parental psychological traits and symptoms, which in my opinion would help control for inherited traits confounding the results.

This article has some problems with lack of clarity in the writing.  It was not exactly clear when the interviews were done (particularly the data from when the children were 6 years old).  Also, in the tables, various items (such as "high praise and encouragement" in Table 2) are listed twice, with different numbers!  I'm surprised that the writers and editors didn't address these things before publication.  

In any case, the results show that various positive parental behaviours led to substantially reduced risk of future psychological problems in the offspring ("reduced aggregate offspring personality disorder symptoms levels" and "elevated aggregate offspring personality resiliency").  Here are a few examples (some of these things may seem like obvious truths -- but it is important to be reminded about just how important these are):
1) speaking kindly to child
2) being calm, not reactive with child
3) attention and dedication to child
4) raised child without reliance on punishment
5) lots of time spent with child
6) shared enjoyable activities with child
7) high affection toward child
8) good communication with child
9) high praise and encouragement

A few findings might be surprising to some.  For example, "encouragement of offspring autonomy" from fathers actually was associated with a higher risk of offspring psychological problems.

Studies about parenting may seem to have limited relevance to those of us who are not parents, or who are not currently being parented.  But I believe these findings can be generalized:  in a psychodynamic sense, all relationships have at least a partial "parental" quality to them.  We all also have a "parenting role" with ourselves!  This role, and the behaviours or stance we take in this role, are undoubtedly coloured by the type of parenting we have experienced in our childhoods.

Findings of this type encourage us to change our "self-parenting":

1) Speak kindly to self!
2) Be calm and not reactive to self!
3) Be attentive and dedicated with yourself!
4) Be with yourself without reliance on punishment!
5) Spend lots of time with yourself! 
6) Share enjoyable activities with yourself!
7) Have high affection toward self!
8) Communicate well with self!
9) And give self praise and encouragement!

10) If you are accustomed to "encourage autonomy in yourself" a lot, maybe you can give this one a rest.