Child and adolescent IRRITABILITY is a transdiagnostic symptom and has a broad differential diagnosis

Irritability is a "transdiagnostic" symptom. That means it is not specific to one disorder and child and adolescent irritability can be a factor in multiple disorders. Irritability issues can wreak havoc on a family, school, or peer system. Irritability can manifest with both externalizing (badgering, talking back, defiance, violence) and internalizing (avoidance, withdrawal, rumination, depression, anxiety, insomnia) symptoms. It is considered transdiagnostic because irritability is not pathognomonic for one specific disorder. Rather, it can be seen in multiple different psychiatric disorders and psychosocial situations.

• Depression, Anxiety, Obsessive Compulsive Disorder (OCD), Tourette Disorder, Psychosis, Bipolar, Acute Stress Disorder, Post Traumatic Stress Disorder (PTSD) Oppositional Defiant Disorder (ODD), Disruptive Mood Dysregulation Disorder (DMDD), Attention Deficit Hyperactivity Disorder (ADHD), Eating Disorders, Phobias, Personality Disorders, Sleep Disorders, Premenstrual Dysphoric Disorder (PMDD), Medical and Pain Disorders can all have manifest with irritability symptoms.

• Psychosocial situations that may not fall into a well described psychiatric disorder can also manifest with irritability such as Bullying, Family Dynamics, Sexual and Gender Identity Conflicts, Domestic Violence, Abuse, Neglect, Malnutrition, Dehydration, Discrimination, Displacement and Marginalization.

It is critical to have a comprehensive evaluation to have an understanding of what factors are contributing to irritability. With a multifactorial assessment that includes, genetic, environmental, psychological, and behavioral influences, an accurate conceptualization of the problem can be gained. From here, a discussion about the etiology and evidence-based approaches to managing the symptoms can be had.

Misdiagnosis may occur when irritability is viewed without nuance or context. The psychotherapeutic interventions and medication options can be vastly different depending on the underlying diagnosis.

Examples:

• if a person's irritability is generated by excessive worry, overwhelm, fear, and bodily discomfort, a cognitive behavioral therapy (CBT) to target anxiety might be most beneficial.

• if a person's irritability is driven by rejection sensitivity, mood dysregulation, and extreme oscillations in mental states in which they can idealize and then rapidly devalue something or someone, a dialectical behavioral therapy (DBT) approach might be most beneficial. (or Transference Focused Psychodynamic Psychotherapy or Mentalization Based Therapy or Good Psychiatric Management of Borderline Personality Disorder)

  
  

• if irritability is impulsive, fleeting, and in the context of chronic executive functioning impairments, ADHD medication and therapy would need to be investigated.

  
  

The same is true with medication options. While an atypical antipsychotic, like risperidone may help some cases of irritability and aggression, it may miss the specificity of targeting the underlying fuel to the fire and carry a side effect profile that might be burdensome. A selective serotonin reuptake inhibitor (SSRI) may be far superior if the underlying disorder is anxiety or depression. Or if the underlying disorder is ADHD, a stimulant or non stimulant would be preferable.

Adults similarly can have non specific irritability that can be difficult to conceptualize.

Working with a specialist to get an accurate diagnosis and targeted treatment plan is critical when dealing with challenging symptoms and problems.

#ficuspsych #irritability #transdiagnostic #comprehensivetreatment