IrritabilityAngerRage
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Causes and Medication Treatment of [IAR] Irritability, Anger & Rage
No 6 in the series” I want you to know what I know.”
Mental Health Problems that Shouldn’t be Missed and their Treatments
1. A Major Reason For Referral: Irritability, Anger and Rage [IAR]are a very common reasons for referral to mental heath professional and is one of the chief reasons that children and teens are referred for evaluation and treatment. Knowing the biologically causes is essential for the appropriate medication treatment that will go far in aiding other non biological interventions.
2. Medically Caused: IAR can be caused by medication for general medical conditions [prescribed and over the counter], drugs and alcohol, be medically induced, like thyroid illness, seizures, [see section on Seizures and IAR], sleep apnea, chronic pain, especially headaches, [see section on headaches], dementia, and others. Once these are adequately addressed then IRA may be appropriately treated with psychiatric medication based on the mental health diagnosis or predominant symptom cluster. For example thyroid diseased still presenting with IAR after proper thyroid medication may require Prozac if the Dx is Unipolar depression.
3. Non Biologically Based MH Dxs that may not be medication responsive, are basic temperament, personality traits, Conduct & Antisocial Personality & some Oppositional Defiant Disorders. These should be behaviorally treated, then consider medication for non specific effects. ODD with associated hyperactivity and impulsivity but good concentration may respond non specifically to Adderal.
4. Psychiatric Medications and preparations, and applications with Psychotropic Effects [ blood pressure meds causing IAR and depression, seizure meds causing ADHD] require special attention, for the most missed and underappreciated side effects are mental, behavioral and emotional including IAR, e.g. Prozac in Bipolar Depression.[See section on antidepressants and Akathisia.] One needs to cautious with preparations having known or alleged effects on mood,[often forgotten are light therapy boxes] emotions, behavior, concentration, sleep, pain, energy, weight control, any prescribed or not, including over the counter medications and preparations,[nicotine and other patches] like , vitamins, food supplement, energy foods and drinks, but also preparation not thought to have such effects like for allergy, cold, flu, asthma , all of which may have stimulating or sedating properties that may directly or indirectly, in a paradoxical fashion cause anxiety, depression, and IAR. When going trough causes think of everything that you might put into any orifice of your body, or on your body[saliycylates in pain creams], including full spectrum light exposure.
5. The most common MH Dxs causing IAR are Mood & Anxiety Disorders, ADHD & Psychotic Disorders like Schizophrenia. Telling these apart is crucial because the individual medications used are different, and though any one medication may be initially helpful, it may make matters much worse, it will delay the right Rx , and each of these Dxs may be present and require having specialized medication management.
6. The quality and quantity of IAR is different in the different disorders as is its presentation and history. Generally in Uncomplicated ADHD, most anxiety disorders and in the non Bipolar mood disorders the IAR is less intense, frequent and problematic, especially socially , yet maybe more internally distressing, because of its “quiet” nature it often goes undiagnosed and not treated though it may be leading to significant distress and impairment, and continues to fuel the primary dx, leading to relapses and lack of full recovery, in this subgroup of people often undiagnosed I call “ The Suffering Well”.
7. Eight Aspects of Adequate Medication Management: Medication management of the primary disorder if done early on, with the [a.] right medication and [b.] right dose, for an[c.] adequate length of time, with the goal of [d. ]total symptom relief, to the point of[e.] no or minimal impairment, with the goal of getting back to ones [f.] old self normally will also treat and eliminate the IAR, through a process of what I call micro diagnosis and micro fine tuning of the medication to ensure compliance for a duration to [g.] prevent relapses and [h.] complications.
8. The most dramatic and catastrophic presentations of IAR occurs in mood disorders with Bipolar features, and psychotic disorders, most commonly Schizophrenia . Less appreciated, but equally devastating are certain forms of Panic Disorder and its equivalents, and PTSD i.e. Post Traumatic Stress Disorder.
9. Panic Disorder is the forgotten cause of some of the worse explosive rage seen in a previously quiet, subdued, generally compliant gentle, unaggressive, person with a previously stable mood, [the stable mood rules out a Bipolar type of mood disorder], is seen in a child, teen, or adult with previously unsuspected Panic Disorder with Agoraphobia, when challenged with the phobic or feared situation, where conforming with everyday routine mandated by authorities is necessary. Examples are the child and teen forced to go to school, or the adult forced on a business trip or even in a leisure situation to be force to face the feared situation.
10. A Panic Attack is a discrete period of intensive fear or discomfort coming on quickly reaching a peak in 10 minutes, with pounding heart, sweating, shaking, feelings of choking and shortness of breath, chest pain or discomfort, nausea, dizzy, not feeling real or not yourself, fear of losing control or going crazy or dying, chills or hot flashes, numbness or tingling. The situation or place where Panic occurs is avoided, and the avoidance can spread to the point the person is home bound.
11. A Matter Life and Death: Panic attacks are so intense and frightening that they cause severe anticipatory anxiety about panic attacks in the feared situation condition the person not only to avoid the situation but not even to think about the feared situation, where they may be alone, or without the phobic partner, and help will not be available, and they fear they may lose control, or actually die. This is caused by triggering of the fight- flight response, where it feels like it is a matter of life or death; it is a matter of survival, run, collapse, or fight for one’s life. Thus in the mind of the Panic Disorder victim it is justified the irritability, anger, and rage for the goal of self preservation.
12. The treatment of uncomplicated Panic disorder is with a traditional SSRI or SNRI medication, perhaps supplemented at least initially with a benzodiazepine like clonazepam. If very severe an atypical neuroleptic in small doses may be needed. The major problem with Panic is not the treatment which is usually straight forward, but that it is not thought of as cause of IAR.
13. In PTSD the person experienced [a] a serious traumatic event e.g. involving death, serious injury to self/ others, [b that causes intense fear, helplessness or horror;[c] the trauma is re experienced , in memories, dreams, physically [d] and there are efforts to avoid thoughts, feelings ,events that remind of the trauma, [e] with increased arousal manifested by insomnia, poor concentration, increase startle response and in some having extreme amount of IAR.
14. Treatment of PTSD: Cognitive, behavioral, and other psychosocial therapies are used to deal with PTSD together with medication. The medication approach is usually the same approach as in Panic Disorder, however the everyday and continuous nature of the symptom picture leads to more brain chemistry excitability, with severe anxiety feeding more anxiety in a vicious cycle, that may require that the neuroleptic meds be used not only for their mood stabilization properties, but also for the persistent and pervasive severe anxiety not controlled by other meds and for the near hallucinatory if not frankly psychotic nature of some of the symptoms.
15. Schizophrenia as a cause of IAR is representative of a psychotic disorder is easy to recognize, because of it lack of touch with reality symptoms of hallucination, delusions, and disorganized thinking and behavior. However in mild cases and in early stages of the illness especially in children these symptoms may be expressed in a subtle way and hidden and if not looked for may be missed. The medications of choice are the neuroleptics because of their antipsychotic properties. Though the atypicals are better tolerated then the typicals, they are statistically equally effective, and there are some individuals especially children who do actually better the older medications, and in some people typicals may be better for the core psychotic symptoms.
16. Mild and Childhood Schizophrenia: Mild Schizophrenia or Childhood Schizophrenia , which in itself is very rare, is a great pretender and may be confused with other disorders. Some are depression, especially bipolar depression with psychotic symptoms, severe anxiety states such as PTSD, Panic, Obsessive Compulsive Disorder, Social Anxiety, and others like Tourette’s Disorder, and ADHD. If the wrong dx is made the wrong medication is chosen and may paradoxically initially help, but the IAR will be worse then ever, perhaps even catastrophic even lethal. Family and developmental history and early prodromal symptoms , that is those that may be diagnostic or the syndrome and before the full onset are necessary to make the diagnosis. Symptoms to help dx these forms of Schizophrenia and are those found in the schizoid and schizotypal personality disorders which may be subtle and easy to miss, especially if you are not looking for them. These include the classical negative symptoms, of very little speech, feeling tone is blunted or inappropriate, lack of motivation or drive, others are unresponsive to praise or criticism, emotional detachment, odd beliefs and behavior , unusual and illogical speech patterns suspicious or paranoid ideas, excessive social anxiety that doesn’t diminish with familiarity, lacks close friends.
17. Autistic Spectrum Disorders[ASD], especially if mild in a high functioning person with good language skills, may be easily confused with schizophrenia, and some other disorders, and may also present with IAR. ASD may require very different treatment including specialized medication approaches often requiring extremely small doses of multiple medications from different classes, because of very sensitive brain chemistry, though very small doses of Risperdal alone may be helpful alone, and can be tried first.
18. If the Dx of Uncomplicated ADHD, Combined Type, is accurately made, and other disorders have been excluded, the IAR should resolve with a neurostimulant. The Differential Diagnosis of IAR in Neurostimulant Responsive ADHD is as follows: a. due to ADHD, then increase the medication, b. due to rebound as med wears off, either increase the dose, or add extra dose, or move doses closer together, c. due to dose being too high, then lower the dose, d. due to the specific stimulant, then change to another stimulant e. all stimulants cause IAR, then use alternate medication f. due to Mood , Anxiety, Psychotic disorder, stop med, and treat with appropriate med for the primary disorder, g. due to temperament, personality, environment , treat with non medications approaches first, and use meds non specifically for target symptoms and clusters.
19. IAR in Mood Disorder vs. ADHD is very common diagnostic and treatment problem. The specifics are addressed in my outlines on Mood Disorders vs. ADHD, Where is the core of excitability?, and ADHD, ODD, Mood: Which is It? I will only summarize here. If one is sure of the Dx then start with the medication for the specific diagnosis, e.g. use a SSRI like Prozac for Unipolar Depression, a Stimulant like Dexedrine for ADHD, and one of the mood stabilizers like a neuroleptic like Risperdal , anticonvulsant like Depakote, or lithium carbonate for a Bipolar process. Otherwise consider an atypical neuroleptic like Risperdal If one is [A.] not sure of the diagnosis, or [B.] if it is severe and/or [C.] with complicating symptoms, such as thinking problems in content ,i.e. hallucinations, paranoia, or in process, i.e. loose, illogical, or blocked thinking , or emotional lability approaching instability, and / or one needs [D.] faster resolution of the IAR . The Atypical should be considered as the first choice, to get some initial control, and then depending on response and need, add the other medications depending on the desired symptom relief, and then if appropriate the atypical may discontinued. If ADHD and Mood Disorder are both present treat first the mood, using the appropriate medication for either Unipolar or Bipolar, and always err if not sure of what kind of mood disorder on the side of a Bipolar Medication[ see antidepressant warning], Treating the mood first may also treat the core ADHD symptoms sufficiently without using or needing another medication. Remember the core ADHD symptom of distractibility, impulsivity , hyperactivity are included in criterion for a mood disorder especially in the Bipolar variety.
20. Seizure Disorders, IAR and ADHD: Seizures especially partial complex seizures may present initially with IAR, and needs to be ruled out with history, mental status, neurological evaluation and EEG, but even when adequately treated with anticonvulsants IAR may still be present, and complicating this may be ADHD. Anticonvulsant Mood Stabilizers should be maximized first, and then an Atypical like Risperdal would be used, then adding a stimulant for the ADHD. It may be very difficult to manage this situation with medication in the best of cases and if the symptoms of IAR are severe, episodic, and the seizures are not under adequate control it may be next to impossible to achieve any reasonable control for and reasonable length of time. Part of the difficulty is differentiating seizures symptoms from, medication symptoms, from mental health symptoms, further complicated by ictal or seizure effects. What is causing what may be next to impossible before the seizure, during the seizure, and after the seizure, especially if there is little or no change of consciousness, that would be used as a diagnostic marker. The first priority is controlling the seizures and the IAR with seizure medications and then secondarily adequately medicating the symptoms due to mental health diagnoses.
21. IAR in the Triad of Tourette’s, ADHD , OCD vs. Symptom Clusters: This triad is more common than appreciated and often mismanaged with medication, because the primary Dx or Dxs are missed and the symptoms are treated rather than medicating the underlying biochemical cause of the symptoms based on severity and impairment. The diagnostic and medication management involved can be used as a model that can be applied to any [A.]other situations where there are possibly multiple diagnoses and symptom clusters. It also is a good model for the [B.] Dx and Rx of episodic symptoms vs. continuous symptoms in mental health with an extremely strong biological basis. Thirdly it demonstrates the need [C.] to medicate based on symptom severity , distress and impairment rather than the actual presenting symptom cluster or diagnostic label. Fourthly this demonstrates[D.] the necessity of adequate treatment to prevent relapses and complications, like a mood disorder. First one must differentiate between the symptom cluster and the underlying actual diagnosis. Are all three Dxs present or are the symptoms representing only one or two Dxs. One medicates the underling cause of the symptom cluster, not the symptoms. Whether it is the triad of IAR or the one representing ADHD , if the underlying cause is Tourette’s brain chemistry then one uses a medication like Haldol or Risperdal. Prozac for the same symptoms caused by the serotonin based OCD , and Adderal if caused by the dopamine problem of ADHD. The Tics of Tourette’s , the vocalizations and motor movements may not get worse with a stimulant alone the 1/3 rd rule applying, equal chance of getting better, worse, or being neutral. Tics similar to the compulsions of OCD are episodic, where as the hyperactivity, impulsiveness, and anxiety are continuous, to make matter even more complex there may be a complicating mood disorder present also that may be either episodic or continuous. What to treat and when to treat again is based on symptom severity, distress and impairment.
22. IAR Headaches and Migraine: Headaches especially migraines are underestimated as being related to mental health problems causing IAR especially Anxiety and Mood Disorders. They are especially under diagnosed and treated in children and teens. Headaches especially migraines need be screened for and treated as target symptom, to assess the adequacy of medication treatment of IAR or any Dx, and be part of the micro diagnostic and fine tuning process. They are often among the first symptoms to occur and the last to be treated. Headaches are chief among the physical symptoms of biological based mental health problems associated with IAR that present to a health care provider, or known to the patient, their family, friends co workers, teachers and others. They are closely related to other physical problems such as eating disturbances, especially eating too much with weight gain, sleeping disturbances of any kind, too much , too little, waking up and not being able to get back to sleep, fragmented sleep, bad dreams, nightmares, stomach and intestinal problems in any age group. All of these respond remarkably well at times when the underling mental health Dx is adequately treated
23. IAR -Psychiatric Medications-SSRI/NRI’s: Warning for Patients on SSRI/NRI’s!!!! Generally these are very safe and effective medications that have treated many people successfully with little or no problems, giving symptom relief from anxiety disorders and Unipolar depression, with better quality or life, and literally have changed and have saved many lives. However, what ever your initial or working diagnosis if you develop symptoms similar to a bipolar process, or psychotic symptoms which I will describe below while you are taking these medications, this can a passing symptom or the beginning of something more serious. It dose not mean you have Bipolar Disorder, or a psychosis like Schizophrenia. It may mean you have a sensitivity to this class of medications, or may have similar brain chemistry to bipolar, or some other disorder, and the medication may cause more problems than it helps including worsening your anxiety, panic, making you more depressed, confused, and even psychotic and manic. This can lead to destructive feelings, thoughts, and behaviors to self and others. These things don’t usually happen over night or quickly. There is usually a family history that should make one cautious about using these medications of mood swing disorders, drug and alcohol abuse, some seizure disorders and forms of migraine, antisocial criminal violent and destructive behavior with anger management problems, psychosis like Schizophrenia to name the most common. Psychotic symptoms mean you may be losing touch with reality, confusing what is real and what is fantasy or pretend, like not sure if you dreams are real or not, and things that normally happening in a dream happen in real life or you are not sure, like your thoughts start sounding like voice, or you hear and see things that shouldn’t be there, your thinking get illogical, and your connections between you thoughts, or your thoughts and your feeling get too loose and off the track, other senses get too real and powerful like smell, touch and taste. The symptoms to look for are what I already mentioned above , plus those associated with bipolar disorder, primarily a changes in mood from too happy ,to too sad, to irritable, excitable, angry, mean, nasty with mood swings that also have some the following symptoms, including [A] increased distractibility and problems with concentration, focus and memory, or confusion [B] any serious change in sleep pattern, more sleep, less sleep, fragmented sleep, nightmare, increased dreaming, sleep walking and talking, waking up in middle of night, especially waking up and eating, and most especially a decreased need for sleep, with more or normal energy during the next day, [C] a rapid increase of a good mood, feeling too high and good, and other people notice, inflated self worth, feeling your on top of the world, you’re the boss, have to right, getting big ideas about the future, that are unrealistic,[D] a sense that your ideas are too fast, you cant shut down your mind, racing thoughts, [E] increased energy, you start doing more than usual, many things at once, maybe getting none completed, and you enjoy it, and you want to do more and more, get more done, you start multiple project, take on more work, [F] people notice you are talking faster, your thinking and speech is going off on tangents, slightly illogical and disorganized, [H] you are becoming more impulsive not thinking before you talk and act, not thinking of the consequences of you behavior, taking risks you normally wouldn’t take, especially pleasurable one. If these symptom occur, or you are suspicious they may be in you or some one you know, and the history above fits , you should immediately call your doctor, or the local emergency room if you are concerned and ask for advice about he symptoms and the medication, and about what should you do, stay on, stop it, wait, be seen. Bad things would happen only infrequently, or not as much with these effective and life saving medications if people knew these warning signs and symptoms and discussed them with appropriate professionals when they first happened and didn’t ignore them or allow them to get worse.
24. IAR-Psychiatric Medications -Akathisia: Akathisia is neurological syndrome closely related to the brain chemistry and neurology that causes some form of restless leg syndrome. The person having this feels like they have to move all the time, mostly the legs, but it could be the whole body, and sometimes this spills over to the mind, and the mind has to keep moving, thus fast ideas and rapid speech. Like restless leg it may get worse in the evening when one is ready to go to sleep, or if one tries to sit , or lie down to rest, and just as one begins to rest or start to fall asleep there is an urge to move that is only relieved by moving and continuing to move. One gets tired and or sleepy and tries to rest , sit down, go to sleep and again it starts, no sooner is one resting when again this motor and mental restlessness start again only to be relieved by constant movement. This as you imagine can be very tiring, frustrating, exhausting mentally and physically leading to anxiety, for the person has no reason to be doing this and seems like some force is propelling them to keep moving and thinking and wont let them rest , relax, sleep. There person mentally and physical is on edge, with a growing short fuse, with increasing worry, anxiety, frustration, anger, irritability, until it can turn into rage. Some people start feeling like they are getting out of control, and feel like they may be going crazy, and start acting the part. They don’t take well to being told to sit still, just relax, calm down, because they just cant no matter how they try. This may be idiopathic that is self caused, like in restless leg, but it may also be caused by many medications, prescribed and OTC, and among the most common are psychiatric medications. Not all individuals are suceptiple to this, a good example is the OTC med Benadryl, but I could be any anti histamine, or sedating medication in a suceptiple individual where it causes an imbalance in dopamine, and acetylcholine. Common medications used in mental health that may do this in susceptible individuals would be on the top of the list, the neuroleptic antipsychotic medications like Thorazine, Haldol, Trilafon, Risperdal, Zyprexa, Seroquel, Geodon, Abilify, closely followed could by any of the antidepressants, like Prozac, Zoloft and others, Lithium Carbonate, Depakote, Tegretol, the list can go on and on. The important thing is to recognize this syndrome and if there is an offending agent stop it, or lower it, or taper it if you can, try an antidote, like Cotentin, Benadryl, yes it can be an antidote to, not just an offending agent, or Inderal a beta blocking blood pressure medication, or a medication like Klonipin or Ativan. The worse thing one can do is keep increasing the offending agent confusing the agitation with the underlying condition one is treating, like keep increasing the Prozac of an anxious, agitated depressed person, or the Risperdal or Abilify for the irritable, angry, rageful Bipolar or Schizophrenic person, only to make matters worse rather than better.