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Naim R, Dombek K, German RE, Haller SP, Kircanski K, Brotman MA. An Exposure-Based Cognitive-Behavioral Therapy for Youth with Severe Irritability: Feasibility and Preliminary Efficacy. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2024; 53:260-276. [PMID: 37851393 PMCID: PMC11024061 DOI: 10.1080/15374416.2023.2264385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2023]
Abstract
OBJECTIVE Clinically impairing irritability and temper outbursts are among the most common psychiatric problems in youth and present transdiagnostically; however, few mechanistically informed treatments have been developed. Here, we test the acceptability, feasibility, and preliminary efficacy of a novel exposure-based treatment with integrated parent management skills for youth with severe irritability using a randomized between-subjects multiple baseline design. METHOD N = 41 patients (Age, Mean (SD) = 11.23 years (1.85), 62.5% male, 77.5% white) characterized by severe and impairing temper outbursts and irritability were randomized to different baseline observation durations (2, 4, or 6 weeks) prior to active treatment; 40 participants completed the 12 session treatment of exposure-based cognitive-behavioral therapy for irritability with integrated parent management skills. Masked clinician ratings were acquired throughout baseline and treatment phases, as well as 3- and 6-months post-treatment. To examine acceptability and feasibility, drop-out rates and adverse events were examined. Primary clinical outcome measures included clinician-administered measures of irritability severity and improvement. Secondary clinical outcome measures included multi-informant measures of irritability, depression, anxiety, and attention-deficit/hyperactivity disorder symptoms. RESULTS No patients dropped out once treatment began, and no adverse events were reported. Irritability symptoms improved during the active phase of treatment across all measurements (all βs > -0.04, ps < .011, Cohen's d range: -0.33 to -0.98). Treatment gains were maintained at follow-up (all βs(39) < -0.001, ps > .400). Sixty-five percent of patients were considered significantly improved or recovered post-treatment based on the primary clinician-rated outcome measure. CONCLUSIONS Results support acceptability, feasibility, and preliminary efficacy of this novel treatment for youth with severe irritability. Limitations and future directions are also discussed.
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Affiliation(s)
- Reut Naim
- School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Kelly Dombek
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Ramaris E. German
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Simone P. Haller
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
| | - Melissa A. Brotman
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, MD, USA
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Boudjerida A, Guilé JM, Breton JJ, Benarous X, Cohen D, Labelle R. A Delphi consensus among experts on assessment and treatment of disruptive mood dysregulation disorder. Front Psychiatry 2024; 14:1166228. [PMID: 38260796 PMCID: PMC10800807 DOI: 10.3389/fpsyt.2023.1166228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 12/14/2023] [Indexed: 01/24/2024] Open
Abstract
Objective The aim of this study was to explore consensus among clinicians and researchers on how to assess and treat Disruptive Mood Dysregulation Disorder (DMDD). Methods The Delphi method was used to organize data collected from an initial sample of 23 child psychiatrists and psychologists. Three rounds of closed/open questions were needed to achieve the objective. Results Fifteen experts in the field completed the whole study. Finally, 122 proposals were validated and 5 were rejected. Globally, consensus was more easily reached on items regarding assessment than on those regarding treatment. Specifically, experts agreed that intensity, frequency, and impact of DMDD symptoms needed to be measured across settings, including with parents, siblings, peers, and teachers. While a low level of consensus emerged regarding optimal pharmacological treatment, the use of psychoeducation, behavior-focused therapies (e.g., dialectical behavior therapy, chain analysis, exposure, relaxation), and systemic approaches (parent management training, family therapy, parent-child interaction therapy) met with a high degree of consensus. Conclusion This study presents recommendations that reached a certain degree of consensus among researchers and clinicians regarding the assessment and treatment of youths with DMDD. These findings may be useful to clinicians working with this population and to researchers since they also highlight non-consensual areas that need to be further investigated.
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Affiliation(s)
- Assia Boudjerida
- Department of Psychology and Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal, Montréal, QC, Canada
| | - Jean-Marc Guilé
- Department Head, Child and Adolescent Psychiatry, EPSM Somme and CHU Amiens, Picardie Jules Verne University, Amiens, France
| | - Jean-Jacques Breton
- Department of Psychiatry, Rivière-des-Prairies Mental Health Hospital, Université de Montréal, Montréal, QC, Canada
| | - Xavier Benarous
- Department of Child and Adolescent Psychopathology CHU Amiens-Picardie, Amiens, France
| | - David Cohen
- Department Head, Child and Adolescent Psychiatry, Public Assistance-Hospitals of Paris, APHP, Pitié-Salpêtrière Hospital Group and National Center for Scientific Research-Joint Research Unit, Institute for Intelligent and Robotic Systems Sorbonne Université, Paris, France
| | - Réal Labelle
- Department of Psychology and Centre for Research and Intervention on Suicide, Ethical Issues and End-of-Life Practices, Université du Québec à Montréal, Montréal, QC, Canada
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Orsolini L, Longo G, Cicolini A, Volpe U. An expert opinion on the pharmacological interventions for Disruptive Mood Dysregulation Disorder (DMDD). Expert Opin Pharmacother 2024; 25:67-78. [PMID: 38186365 DOI: 10.1080/14656566.2024.2303422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Accepted: 01/05/2024] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Disruptive Mood Dysregulation Disorder (DMDD) was officially introduced as a new diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), under the category of depressive disorders. AREAS COVERED A comprehensive overview and a critical commentary on the currently investigated psychopharmacological approaches for the treatment of DMDD have been here provided. EXPERT OPINION Behavioral and psychosocial interventions should be considered as first-line treatment strategies. When ineffective or partially effective, psychopharmacological strategy is recommended. Overall, pharmacological strategy should be preferred in those individuals with psychiatric comorbidities (e.g. ADHD). Indeed, so far published studies on pharmacological strategies in DMDD are scant and heterogeneous (i.e. age, assessment tools, symptomatology profile, comorbidity, and so forth). Therefore, DMDD psychopharmacological guidelines are needed, particularly to guide clinicians toward the patient's typical symptom profile who could benefit from psychopharmacological strategy.
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Affiliation(s)
- Laura Orsolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Giulio Longo
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Angelica Cicolini
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
| | - Umberto Volpe
- Unit of Clinical Psychiatry, Department of Neurosciences/DIMSC, Polytechnic University of Marche, Ancona, Italy
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Grasser LR, Erjo T, Goodwin MS, Naim R, German RE, White J, Cullins L, Tseng WL, Stoddard J, Brotman MA. Can peripheral psychophysiological markers predict response to exposure-based cognitive behavioral therapy in youth with severely impairing irritability? A study protocol. BMC Psychiatry 2023; 23:926. [PMID: 38082431 PMCID: PMC10712194 DOI: 10.1186/s12888-023-05421-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Accepted: 11/29/2023] [Indexed: 12/18/2023] Open
Abstract
BACKGROUND Irritability, an increased proneness to anger, is a primary reason youth present for psychiatric care. While initial evidence supports the efficacy of exposure-based cognitive behavioral therapy (CBT) for youth with clinically impairing irritability, treatment mechanisms remain unclear. Here, we propose to measure peripheral psychophysiological indicators of arousal-heart rate (HR)/electrodermal activity (EDA)-and regulation-heart rate variability (HRV)-during exposures to anger-inducing stimuli as potential predictors of treatment efficacy. The objective of this study is to evaluate whether in-situ biosensing data provides peripheral physiological indicators of in-session response to exposures. METHODS Blood volume pulse (BVP; from which HR and HRV canl be derived) and EDA will be collected ambulatorily using the Empatica EmbracePlus from 40 youth (all genders; ages 8-17) undergoing six in-person exposure treatment sessions, as part of a multiple-baseline trial of exposure-based CBT for clinically impairing irritability. Clinical ratings of irritability will be conducted at baseline, weekly throughout treatment, and at 3-month and 6-month follow-ups via the Clinical Global Impressions Scale (CGI) and the Affective Reactivity Index (ARI; clinician-, parent-, and child-report). Multilevel modeling will be used to assess within- and between-person changes in physiological arousal and regulation throughout exposure-based CBT and to determine whether individual differences are predictive of treatment response. DISCUSSION This study protocol leverages a wearable biosensor (Empatica) to continuously record HR/HRV (derived from BVP) and EDA during in-person exposure sessions for youth with clinically impairing irritability. Here, the goal is to identify changes in physiological arousal (EDA, HR) and regulation (HRV) over the course of treatment in tandem with changes in clinical symptoms. TRIAL REGISTRATION The participants in this study come from an overarching clinical trial (trial registration numbers: NCT02531893 first registered on 8/25/2015; last updated on 8/25/2023). The research project and all related materials were submitted and approved by the appropriate Institutional Review Board of the National Institute of Mental Health (NIMH).
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Affiliation(s)
- Lana Ruvolo Grasser
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA.
| | - Trinity Erjo
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Matthew S Goodwin
- Bouvé College of Health Sciences, Northeastern University, Boston, MA, USA
| | - Reut Naim
- School of Psychological Sciences, Tel-Aviv University, Tel-Aviv, Israel
| | - Ramaris E German
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Jamell White
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Lisa Cullins
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
| | - Wan-Ling Tseng
- Yale Child Study Center, Yale School of Medicine, New Haven, CT, USA
| | - Joel Stoddard
- Department of Psychiatry and Biomedical Informatics, University of Colorado, School of Medicine, Aurora, CO, USA
| | - Melissa A Brotman
- Neuroscience and Novel Therapeutics Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD, USA
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Evans SC, Shaughnessy S, Karlovich AR. Future Directions in Youth Irritability Research. JOURNAL OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY : THE OFFICIAL JOURNAL FOR THE SOCIETY OF CLINICAL CHILD AND ADOLESCENT PSYCHOLOGY, AMERICAN PSYCHOLOGICAL ASSOCIATION, DIVISION 53 2023; 52:716-734. [PMID: 37487108 DOI: 10.1080/15374416.2023.2209180] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/26/2023]
Abstract
Research on irritability in children and adolescents has proliferated over the last 20 years. The evidence shows the clinical and developmental significance of irritable mood and behavior in youth, and it has led to significant changes in mental health classification, diagnosis, and services. At the same time, this research (including our own) has led to relatively little new in terms of practical, empirically based guidance to improve interventions and outcomes. In this article, we briefly summarize some of these developments and current evidence-based practices. We then put forth two key substantive challenges (the "whats") for future research to address: (a) the need for more effective treatments, especially evaluating and adapting evidence-based treatments that are already well-established for problems related to irritability (e.g., cognitive-behavioral therapies for internalizing and externalizing problems); and (b) the need for a better mechanistic understanding of irritability's phenomenology (e.g., phasic vs. tonic irritability, how frustration unfolds) and putative underlying mechanisms (e.g., cognitive control, threat and reward dysfunction). Lastly, we suggest three methodological approaches (the "hows") that may expedite progress in such areas: (a) ecological momentary assessment, (b) digital health applications, and (c) leveraging existing datasets. We hope this article will be useful for students and early-career researchers interested in tackling some of these important questions to better meet the needs of severely irritable youth.
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Seok JW, Soltis-Vaughan B, Lew BJ, Ahmad A, Blair RJR, Hwang S. Psychopharmacological treatment of disruptive behavior in youths: systematic review and network meta-analysis. Sci Rep 2023; 13:6921. [PMID: 37117632 PMCID: PMC10147946 DOI: 10.1038/s41598-023-33979-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Accepted: 04/21/2023] [Indexed: 04/30/2023] Open
Abstract
To conduct a systematic review of the comparative efficacy of various psychotropic medications for the treatment of disruptive behavior (DBs) in youths. To this aim, we systematically reviewed randomized clinical trials (RCTs) of various psychotropic medications targeting symptoms of DBs and applied network meta-analysis to investigate their relative efficacy. Fifty-five RCTs meeting the inclusion criteria were selected. To predict and interpret relative treatment efficacy, we compared the efficacy of various psychotropic medications prescribed for DB symptoms based on their mechanism of action. Network meta-analysis revealed that for reducing DBs, second-generation antipsychotics, stimulants, and non-stimulant ADHD medications were more efficacious than placebo, and second-generation antipsychotics were the most efficacious. The dopaminergic modulation of top-down inhibitory process by these medications is discussed in this review. This study offers information on the relative efficacy of various psychotropic medications for the treatment of DB, and insight into a potential neurobiological underpinning for those symptoms. It also illustrates the potential utility of these neurobiological mechanisms as a target for future treatment studies.
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Affiliation(s)
- Ji-Woo Seok
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
- Digital Health Research Division, Korea Institute of Oriental Medicine, Daejeon, South Korea
| | - Brigette Soltis-Vaughan
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Brandon J Lew
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - Aatiya Ahmad
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA
| | - R J R Blair
- Child and Adolescent Mental Health Centre, Mental Health Services, Capital Region of Denmark, Copenhagen, Denmark
| | - Soonjo Hwang
- Department of Psychiatry, University of Nebraska Medical Center, 985578 Nebraska Medical Center, Omaha, NE, 68198-5578, USA.
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Transition from Animal-Based to Human Induced Pluripotent Stem Cells (iPSCs)-Based Models of Neurodevelopmental Disorders: Opportunities and Challenges. Cells 2023; 12:cells12040538. [PMID: 36831205 PMCID: PMC9954744 DOI: 10.3390/cells12040538] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 01/25/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023] Open
Abstract
Neurodevelopmental disorders (NDDs) arise from the disruption of highly coordinated mechanisms underlying brain development, which results in impaired sensory, motor and/or cognitive functions. Although rodent models have offered very relevant insights to the field, the translation of findings to clinics, particularly regarding therapeutic approaches for these diseases, remains challenging. Part of the explanation for this failure may be the genetic differences-some targets not being conserved between species-and, most importantly, the differences in regulation of gene expression. This prompts the use of human-derived models to study NDDS. The generation of human induced pluripotent stem cells (hIPSCs) added a new suitable alternative to overcome species limitations, allowing for the study of human neuronal development while maintaining the genetic background of the donor patient. Several hIPSC models of NDDs already proved their worth by mimicking several pathological phenotypes found in humans. In this review, we highlight the utility of hIPSCs to pave new paths for NDD research and development of new therapeutic tools, summarize the challenges and advances of hIPSC-culture and neuronal differentiation protocols and discuss the best way to take advantage of these models, illustrating this with examples of success for some NDDs.
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8
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Baweja R, Waxmonsky JG. Updates in Pharmacologic Strategies for Emotional Dysregulation in Attention Deficit Hyperactivity Disorder. Child Adolesc Psychiatr Clin N Am 2022; 31:479-498. [PMID: 35697397 DOI: 10.1016/j.chc.2022.02.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Emotional dysregulation (ED) manifesting as irritability or aggression produces appreciable impairment in children with attention deficit hyperactivity disorder and a main reason why they present for treatment. Central nervous system (CNS) stimulants seem to be a safe and tolerable treatment of most youth with these presentations. Optimization of CNS stimulants dose in combination with psychosocial interventions led to reductions in ED. Randomized controlled trials support that addition of risperidone further reduces aggression when these treatments are not sufficient. There is evidence for the efficacy of divalproex, molindone and selective serotonin reuptake inhibitor improve these outcomes when used as adjunct to CNS stimulants.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA.
| | - James G Waxmonsky
- Department of Psychiatry and Behavioral Health, Penn State College of Medicine, 500 University Drive, Hershey, PA 17033, USA
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9
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Ametti MR, Crehan ET, O’Loughlin K, Schreck MC, Dube SL, Potter AS, Sigmon SC, Althoff RR. Frustration, Cognition, and Psychophysiology in Dysregulated Children: A Research Domain Criteria Approach. J Am Acad Child Adolesc Psychiatry 2022; 61:796-808.e2. [PMID: 35074486 PMCID: PMC9275749 DOI: 10.1016/j.jaac.2021.11.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/30/2021] [Accepted: 01/13/2022] [Indexed: 10/19/2022]
Abstract
OBJECTIVE Dysregulated children experience significant impairment in regulating their affect, behavior, and cognitions and are at risk for numerous adverse sequelae. The unclear phenomenology of their symptoms presents a barrier to evidence-based diagnosis and treatment. METHOD The cognitive, behavioral, and psychophysiological mechanisms of dysregulation were examined in a mixed clinical and community sample of 294 children ages 7-17 using the Research Domain Criteria constructs of cognitive control and frustrative nonreward. RESULTS Results showed that caregivers of dysregulated children viewed them as having many more problems with everyday executive function than children with moderate or low levels of psychiatric symptoms; however, during standardized assessments of more complex cognitive control tasks, performance of dysregulated children differed only from children with low symptoms on tests of cognitive flexibility. In addition, when frustrated, dysregulated children performed more poorly on the Go/No-Go Task and demonstrated less autonomic flexibility as indexed by low respiratory sinus arrhythmia and pre-ejection period scores. CONCLUSION The findings of this study suggest that autonomic inflexibility and impaired cognitive function in the context of frustration may be mechanisms underlying childhood dysregulation.
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10
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Sorter M, Chua J, Lamy M, Barzman D, Ryes L, Shekhtman JA. Management of Emotion Dysregulation and Outbursts in Children and Adolescents. Curr Psychiatry Rep 2022; 24:213-226. [PMID: 35316849 DOI: 10.1007/s11920-022-01325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/08/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Emotion dysregulation and outbursts are very common reasons for referral to child and adolescent mental health services and a frequent cause of admission to hospitals and residential programs. Symptoms of emotion dysregulation and outburst are transdiagnostic, associated with many disorders, have the potential to cause severe impairment and their management presents a major challenge in clinical practice. RECENT FINDINGS There are an increasing number of psychosocial interventions that demonstrate promise in improving emotion dysregulation and outbursts. Acute care systems to manage the most severely ill patients have limited best practice guidelines but program advancements indicate opportunities to improve care models. Pharmacotherapy may be of assistance to psychosocial interventions but must be used with caution due to potential adverse effects. Much remains to be discovered however evidence informed, targeted treatments for specific populations show potential for future improvements in outcomes.
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Affiliation(s)
- Michael Sorter
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA. .,University of Cincinnati College of Medicine, Cincinnati, USA.
| | - Jaclyn Chua
- Children's Hospital of Philadelphia, Philadelphia, USA
| | - Martine Lamy
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Drew Barzman
- Cincinnati Children's Hospital, University of Cincinnati, 3333 Burnet Avenue, Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
| | - Louis Ryes
- Xavier University, Cincinnati, USA.,University of Kentucky College of Medicine, Lexington, USA
| | - Joshua Abraham Shekhtman
- The Ohio State University, Columbus, USA.,University of Cincinnati College of Medicine, Cincinnati, USA
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Woo YS, Bahk WM, Seo JS, Park YM, Kim W, Jeong JH, Shim SH, Lee JG, Jang SH, Yang CM, Wang SM, Jung MH, Sung HM, Choo IH, Yoon BH, Lee SY, Jon DI, Min KJ. The Korean Medication Algorithm Project for Depressive Disorder 2021: Comparisons with Other Treatment Guidelines. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2022; 20:37-50. [PMID: 35078947 PMCID: PMC8813311 DOI: 10.9758/cpn.2022.20.1.37] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 10/13/2021] [Indexed: 11/18/2022]
Abstract
The Korean Medication Algorithm Project for Depressive Disorder (KMAP-DD) first was published in 2002, and has been revised four times, in 2006, 2012, 2017, and 2021. In this review, we compared recommendations from the recently revised KMAP-DD 2021 to four global clinical practice guidelines (CPGs) for depression published after 2010. The recommendations from the KMAP-DD 2021 were similar to those from other CPGs, although there were some differences. The KMAP-DD 2021 reflected social culture and the healthcare system in Korea and recent evidence about pharmacotherapy for depression, as did other recently published evidence-based guidelines. Despite some intrinsic limitations as an expert consensus-based guideline, the KMAP-DD 2021 can be helpful for Korean psychiatrists making decisions in clinical settings by complementing previously published evidence-based guidelines, especially for some clinical situations lacking evidence from rigorously designed clinical trials.
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Affiliation(s)
- Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Seok Seo
- Department of Psychiatry, College of Medicine, Chung-Ang University, Seoul, Korea
| | - Young-Min Park
- Department of Psychiatry, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Won Kim
- Department of Psychiatry, Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Se-Hoon Shim
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, College of Medicine, Soonchunhyang University, Cheonan, Korea
| | - Jung Goo Lee
- Department of Psychiatry, Haeundae Paik Hospital, College of Medicine, Inje University, Busan, Korea
| | - Seung-Ho Jang
- Department of Psychiatry, Wonkwang University Hospital, School of Medicine, Wonkwang University, Iksan, Korea
| | - Chan-Mo Yang
- Department of Psychiatry, Wonkwang University Hospital, School of Medicine, Wonkwang University, Iksan, Korea
| | - Sheng-Min Wang
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Myung Hun Jung
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Hyung Mo Sung
- Department of Psychiatry, Soonchunhyang University Gumi Hospital, College of Medicine, Soonchunhyang University, Gumi, Korea
| | - Il Han Choo
- Department of Neuropsychiatry, College of Medicine, Chosun University, Department of Psychiatry, Chosun University Hospital, Gwangju, Korea
| | - Bo-Hyun Yoon
- Department of Psychiatry, Naju National Hospital, Naju, Korea
| | - Sang-Yeol Lee
- Department of Psychiatry, Wonkwang University Hospital, School of Medicine, Wonkwang University, Iksan, Korea
| | - Duk-In Jon
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung Joon Min
- Department of Psychiatry, College of Medicine, Chung-Ang University, Seoul, Korea
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12
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Liu Q, Cole DA. The association of phasic irritability (aggressive outbursts) and tonic irritability (irritable mood) to depression occurrences, symptoms, and subtypes. J Affect Disord 2021; 293:9-18. [PMID: 34157615 DOI: 10.1016/j.jad.2021.06.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/03/2021] [Accepted: 06/05/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Research among adults has rarely differentiated between tonic irritability (i.e., irritable mood) and phasic irritability (i.e., aggressive outbursts) with respect to multiple dimensions of depression. The current study explored both tonic and phasic irritability in relation to depression severity, depression chronicity, age of depression onset, individual depressive symptom, and depression subtypes. METHODS The study included participants (N = 5692) from the National Comorbidity Survey - Replication (NCS-R) part two. The NCS-R used lay-administered, fully standardized diagnostic interviews. The current study implemented linear models, generalized linear models, Cox proportional hazard model, and latent class regression. RESULTS Both types of irritability were significantly associated with greater risk for MDD diagnosis, as well as risk for having at least one depressive symptom, early MDE onset, and MDE chronicity. Both phasic and tonic irritability were associated with greater odds of specific depressive symptoms and were differentially related to distinct depressive symptom constellations. Phasic irritability related only to severe depression. Lastly, both phasic and tonic irritability was associated with suicidal ideation, but only phasic irritability was associated with a suicide plan and attempt, above and beyond depression subtypes. CONCLUSIONS Both phasic and tonic irritability differentially related to almost all aspects of depression in adults. Specifically, tonic irritability showed overall stronger associations with various depressive features, whereas phasic irritability marked higher depressive severity.
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Affiliation(s)
- Qimin Liu
- Vanderbilt University, Nashville, Tennessee.
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Abstract
Explosive and aggressive behavior in children can pose safety risks, disturb family functioning, and lead to significant impairments. Pharmacologic management should be based on the first-line treatment of the primary psychiatric diagnoses of the patient and initiated in combination with appropriate psychosocial interventions. Review of the literature suggests that risperidone has the most supporting evidence in the treatment of explosive behavior. Stimulants have been shown to be helpful in the treatment of explosive behavior in attention-deficit/hyperactivity disorder. Medication treatment can be associated with significant side effects and therefore the risks and benefits of medication management must be weighed carefully.
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14
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Bell E, Boyce P, Porter RJ, Bryant RA, Malhi GS. Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention. CNS Drugs 2021; 35:619-641. [PMID: 34019255 DOI: 10.1007/s40263-021-00823-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/28/2021] [Indexed: 12/28/2022]
Abstract
Feeling irritable is a common experience, both in health and disease. In the context of psychiatric illnesses, it is a transdiagnostic phenomenon that features across all ages, and often causes significant distress and impairment. In mood disorders, irritability is near ubiquitous and plays a central role in diagnosis and yet, despite its prevalence, it remains poorly understood. A neurobiological model of irritability posits that, in children and adolescents, it is consequent upon deficits in reward and threat processing, involving regions such as the amygdala and frontal cortices. In comparison, in adults with mood disorders, the few studies that have been conducted implicate the amygdala, orbitofrontal cortices, and hypothalamus; however, the patterns of activity in these areas are at variance with the findings in youth. These age-related differences seem to extend to the neurochemistry of irritability, with links between increased monoamine transmission and irritability evident in adults, but aberrant levels of, and responses to, dopamine in youth. Presently, there are no specific treatments that have significant efficacy in reducing irritability in mood disorders. However, treatments that hold some potential and warrant further exploration include agents that act on serotonergic and dopaminergic systems, especially as irritability may serve as a prognostic indicator for overall clinical responsiveness to specific medications. Therefore, for understanding and treatment of irritability to advance meaningfully, it is imperative that an accurate definition and means of measuring irritability are developed. To achieve this, it is necessary that the subjective experience of irritability, both in health and illness, is better understood. These insights will inform an accurate, comprehensive, and valid interrogation of the qualities of irritability in health and illness, and allow not only a clinical appreciation of the phenomenon, but also a deeper understanding of its important role within the development and manifestation of mood disorders.
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Affiliation(s)
- Erica Bell
- Department of Psychiatry, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia.
- Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
- Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Level 3, Main Hospital Building, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia.
| | - Phil Boyce
- Department of Psychiatry, Westmead Hospital and the Westmead Clinical School, Wentworthville, NSW, 2145, Australia
- Discipline of Psychiatry, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Richard J Porter
- Department of Psychological Medicine, University of Otago, Christchurch, New Zealand
| | - Richard A Bryant
- School of Psychology, University of New South Wales, Sydney, NSW, Australia
| | - Gin S Malhi
- Department of Psychiatry, Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia
- Academic Department of Psychiatry, Royal North Shore Hospital, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
- Department of Psychiatry, CADE Clinic, Royal North Shore Hospital, Level 3, Main Hospital Building, Northern Sydney Local Health District, St Leonards, NSW, 2065, Australia
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15
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Abstract
Based on its course over time, irritability is linked to depression cross-sectionally and longitudinally. Cross-sectionally, irritability takes an episodic form as a symptom in pediatric depression; yet, irritability in the absence of depressed mood or anhedonia is rare. Longitudinally, chronic irritability has been shown to predict depression rather than bipolar disorder or externalizing disorders. Evidence suggests that the link between irritability and depression is explained mostly by shared genetic risk. Both conditions are also associated with higher rates of family history of depression, childhood temperaments and personality styles, and negative parenting styles. The treatment implications are discussed.
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Affiliation(s)
- Pablo Vidal-Ribas
- Social and Behavioral Science Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, 6710 Rockledge Drive, Building 6710B, Room 3153A, Bethesda, MD 20892, USA.
| | - Argyris Stringaris
- Section of Clinical and Computational Psychiatry, National Institute of Mental Health, National Institutes of Health, 9000 Rockville Pike, Building 15k, Room 208, Bethesda, MD 20892, USA. https://twitter.com/argStringaris
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16
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Mansur RB, Subramaniapillai M, Lee Y, Pan Z, Carmona NE, Shekotikhina M, Iacobucci M, Rodrigues N, Nasri F, Rosenblat JD, Brietzke E, Cosgrove VE, Kramer NE, Suppes T, Newport J, Hajek T, McIntyre RS. Effects of infliximab on brain neurochemistry of adults with bipolar depression. J Affect Disord 2021; 281:61-66. [PMID: 33296798 DOI: 10.1016/j.jad.2020.11.128] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/27/2020] [Accepted: 11/30/2020] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To explore the relationship between inflammation and neuronal metabolism in bipolar disorder (BD) by evaluating the neurochemical effects of the tumor necrosis factor-α (TNF-α) antagonist infliximab among individuals with bipolar depression METHODS: This is a post-hoc, exploratory analysis from a 12-week, randomized, double-blind, placebo-controlled trial with infliximab for adults with bipolar depression. We assessed the effects of infliximab on concentration of metabolites in the prefrontal cortex, using proton-magnetic resonance spectroscopy (1H-MRS), as well as its association with clinical outcomes (i.e. depressive symptom severity and cognitive function). RESULTS Eighteen participants in the placebo and 15 in the infliximab group were included in this analysis. In the pre-specified primary outcome, there were no significant effects of treatment on prefrontal concentrations of N-acetylaspartate (NAA; p = 0.712). In the secondary analyses, there was a significant treatment by time interaction for glutamate (Glx; p = 0.018), indicating that Glx levels decreased in infliximab-treated patients, relative to placebo. Treatment group significantly moderated the association between changes in Glx levels and changes in a neurocognitive test (i.e. Digit Symbol Substitution Test; p = 0.014), indicating that in infliximab-treated participants reductions in Glx were associated with cognitive improvement. CONCLUSIONS Treatment with infliximab did not affect prefrontal NAA concentration in adults with BD. Exploratory analysis suggested a potential effect of treatment on the glutamate system, a finding that should be confirmed and validated by additional studies.
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Affiliation(s)
- Rodrigo B Mansur
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | | | - Yena Lee
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
| | - Zihang Pan
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nicole E Carmona
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychology, Ryerson University, Toronto, ON, Canada
| | - Margarita Shekotikhina
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; University of Ottawa, Department of Psychiatry, Ottawa, ON, Canada
| | - Michelle Iacobucci
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Nelson Rodrigues
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Flora Nasri
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada
| | - Joshua D Rosenblat
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada
| | - Elisa Brietzke
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Kingston General Hospital, Providence Care Hospital, Department of Psychiatry, Queen's University School of Medicine, Kingston, ON, Canada
| | - Victoria E Cosgrove
- Department of Psychiatry & Behavioral Sciences, Stanford University, School of Medicine, Palo Alto, CA, USA
| | - Nicole E Kramer
- Department of Psychiatry & Behavioral Sciences, Stanford University, School of Medicine, Palo Alto, CA, USA
| | - Trisha Suppes
- Department of Psychiatry & Behavioral Sciences, Stanford University, School of Medicine, Palo Alto, CA, USA; VA Palo Alto Health Care System, Palo Alto, CA, USA
| | - Jason Newport
- Department of Psychiatry, Dalhousie University, Halifax, Canada
| | - Tomas Hajek
- Department of Psychiatry, Dalhousie University, Halifax, Canada
| | - Roger S McIntyre
- Mood Disorders Psychopharmacology Unit, University Health Network, Toronto, ON, Canada; Department of Psychiatry, University of Toronto, Toronto, ON, Canada; Institute of Medical Science, University of Toronto, Toronto, ON, Canada
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17
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Hendrickson B, Girma M, Miller L. Review of the clinical approach to the treatment of disruptive mood dysregulation disorder. Int Rev Psychiatry 2020; 32:202-211. [PMID: 31775528 DOI: 10.1080/09540261.2019.1688260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Though a decade of research led to the creation of disruptive mood dysregulation disorder (DMDD), it was not until the 2013 publication of the DSM-5 that DMDD became an official diagnosis. The conception of DMDD was largely due to increasing rates of paediatric bipolar disorder (PBD) diagnoses, which significantly impacted treatment for these youth. The core symptoms of DMDD include persistent irritability and recurrent outbursts; the absence of a previous diagnostic category for youth experiencing these symptoms may have led to the over diagnosis of PBD. Due to the chronicity of symptoms, these youth are impaired in multiple areas of functioning. This article will present background information about DMDD, discuss clinical assessment strategies including scales for measuring irritability and aggression, and review pharmacologic and psychosocial treatments for youth with DMDD and clinical phenotypes similar to DMDD.
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Affiliation(s)
- Brian Hendrickson
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Mahlet Girma
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Leslie Miller
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Börjesson J, Gøtzsche PC. Effect of lithium on suicide and mortality in mood disorders: A systematic review. INTERNATIONAL JOURNAL OF RISK & SAFETY IN MEDICINE 2020; 30:155-166. [PMID: 31381531 DOI: 10.3233/jrs-190058] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess if lithium treatment in patients with mood disorders, for instance depression, bipolar disorders, and schizoaffective disorders, has an effect on total mortality and suicide. DESIGN Systematic review and meta-analysis. MAIN OUTCOME MEASURE Total mortality. Secondary outcome was suicide. DATA SOURCES PubMed and ClinicalTrials.gov. Eligible trials were randomized double-blind trials comparing lithium with placebo in patients with mood disorders who were not already on lithium before randomization in order to avoid withdrawal effects in the placebo group. DATA EXTRACTION AND ANALYSIS Two researchers extracted data independently. Data were analysed with Review Manager 5.3 (Peto odds ratio). RESULTS We found 45 eligible studies. Only four studies reported any suicides or other deaths in the lithium or placebo group. There was a significant reduction in total mortality (two versus nine), odds ratio 0.28 (95% confidence interval 0.08 to 0.93). There was no statistically significant reduction in suicides, (none versus three), odds ratio 0.13 (0.01 to 1.27). CONCLUSION According to our study, lithium reduces total mortality in mood disorders but not suicide. Because of small numbers and unreliable data, the findings should be interpreted with caution.
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19
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Towbin K, Vidal-Ribas P, Brotman MA, Pickles A, Miller KV, Kaiser A, Vitale AD, Engel C, Overman GP, Davis M, Lee B, McNeil C, Wheeler W, Yokum CH, Haring CT, Roule A, Wambach CG, Sharif-Askary B, Pine DS, Leibenluft E, Stringaris A. A Double-Blind Randomized Placebo-Controlled Trial of Citalopram Adjunctive to Stimulant Medication in Youth With Chronic Severe Irritability. J Am Acad Child Adolesc Psychiatry 2020; 59:350-361. [PMID: 31128268 PMCID: PMC9706653 DOI: 10.1016/j.jaac.2019.05.015] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2018] [Revised: 03/08/2019] [Accepted: 05/03/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Despite the clinical importance of chronic and severe irritability, there is a paucity of controlled trials for its pharmacological treatment. Here, we examine the effects of adding citalopram (CTP) to methylphenidate (MPH) in the treatment of chronic severe irritability in youth using a double-blind randomized placebo-controlled design. METHOD After a lead-in phase of open treatment with stimulant, 53 youth meeting criteria for severe mood dysregulation (SMD) were randomly assigned to receive CTP or placebo (PBO) for 8 weeks. A total of 49 participants, 48 of them (98%) meeting disruptive mood dysregulation disorder (DMDD) criteria, were included in the intent-to-treat analysis. The primary outcome measure was the proportion of response based on improvements of irritability at the week 8 of the trial. RESULTS At the end of the trial, a significantly higher proportion of response was seen in those participants randomly assigned to CTP+MPH compared to PBO+MPH (35% CTP+MPH versus 6% PBO+MPH; odds ratio = 11.70, 95% CI = 2.00-68.16, p = 0.006). However, there were no differences in functional impairment between groups at the end of the trial. No differences were found in any adverse effect between treatment groups, and no trial participant exhibited hypomanic or manic symptoms. CONCLUSION Adjunctive CTP might be efficacious in the treatment of chronic severe irritability in youth resistant to stimulant treatment alone. CLINICAL TRIAL REGISTRATION INFORMATION A Controlled Trial of Serotonin Reuptake Inhibitors Added to Stimulant Medication in Youth With Severe Mood Dysregulation; https://clinicaltrials.gov; NCT00794040.
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Affiliation(s)
- Kenneth Towbin
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.,Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Melissa A. Brotman
- Neuroscience and Novel Therapeutics, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Andrew Pickles
- Institute of Psychiatry, Psychology & Neuroscience, King’s College London, UK
| | - Katherine V. Miller
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ariela Kaiser
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Aria D. Vitale
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Chana Engel
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | - Mollie Davis
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Beth Lee
- College of Nursing, University of Arizona, Tuscon
| | - Cheri McNeil
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Wanda Wheeler
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Catherine H. Yokum
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | | | | | | | | | - Daniel S. Pine
- Section on Development and Affective Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD
| | - Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Bethesda, MD.
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20
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Carlson GA, Klein DN. Editorial: Antidepressants to the Rescue in Severe Mood Dysregulation and Disruptive Mood Dysregulation Disorder? J Am Acad Child Adolesc Psychiatry 2020; 59:339-341. [PMID: 31128267 DOI: 10.1016/j.jaac.2019.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 05/17/2019] [Indexed: 01/12/2023]
Abstract
Children with irritability and outbursts pose a serous therapeutic problem. Many of them have attention-deficit/hyperactivity disorder (ADHD) with emotion dysregulation, which is sometimes captured in the diagnosis of disruptive mood dysregulation disorder (DMDD). Some follow-up data find a connection between DMDD and depression and anxiety in adults. This prompted Towbin and colleagues1 to launch a trial where children (ages 7-17) with DMDD were treated first with methylphenidate (MPH) and then randomized to citalopram (CTP) or placebo over 8 weeks. The response to CTP was complicated by lack of specific measures of both irritable mood and severity of outbursts. Future studies should include standardized and normed parent and teacher measures of both externalizing and internalizing behavior as well as irritability specific measures rating how the child feels. Studies also need better measures of the actual outbursts-not just their frequency but how agitated or aggressive the child gets during an outburst (ie, what the child does) and how long the outbursts last. Measuring DMDD on inpatient units is especially complicated because of the therapeutic nature of the setting. Further work is needed with much larger samples to identify who improves with the treatment, exactly which domains of psychopathology improve and by how much. Finally, It is also critical to conduct longer-term trials to determine the stability of the response beyond 8 weeks.
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21
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Haller SP, Kircanski K, Stringaris A, Clayton M, Bui H, Agorsor C, Cardenas SI, Towbin KE, Pine DS, Leibenluft E, Brotman MA. The Clinician Affective Reactivity Index: Validity and Reliability of a Clinician-Rated Assessment of Irritability. Behav Ther 2020; 51:283-293. [PMID: 32138938 PMCID: PMC7060970 DOI: 10.1016/j.beth.2019.10.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 09/22/2019] [Accepted: 10/11/2019] [Indexed: 10/25/2022]
Abstract
Irritability is impairing in youth and is the core feature of disruptive mood dysregulation disorder (DMDD). Currently, there are no established clinician-rated instruments to assess irritability in pediatric research and clinical settings. Clinician-rated measures ensure consistency of assessment across patients and are important specifically for treatment research. Here, we present data on the psychometric properties of the Clinician Affective Reactivity Index (CL-ARI), the first semistructured interview focused on pediatric irritability. The CL-ARI was administered to a transdiagnostic sample of 98 youth (M age = 12.66, SD = 2.47; 41% female). With respect to convergent validity, CL-ARI scores were (a) significantly higher for youth with DMDD than for any other diagnostic group, and (b) showed uniquely strong associations with other clinician-, parent-, and youth-report measures of irritability compared to measures of related constructs, such as anxiety. The three subscales of the CL-ARI (temper outbursts, irritable mood, impairment) showed excellent internal consistency. Test-retest reliability of the CL-ARI was adequate. These data support that irritability can be feasibly, validly, and reliably assessed by clinicians using the CL-ARI. A validated, gold-standard assessment of pediatric irritability is critical in advancing research and treatment efforts.
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22
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Linke J, Kircanski K, Brooks J, Perhamus G, Gold AL, Brotman MA. Exposure-Based Cognitive-Behavioral Therapy for Disruptive Mood Dysregulation Disorder: An Evidence-Based Case Study. Behav Ther 2020; 51:320-333. [PMID: 32138941 PMCID: PMC9719109 DOI: 10.1016/j.beth.2019.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 03/13/2019] [Accepted: 05/10/2019] [Indexed: 10/26/2022]
Abstract
Severe, chronic irritability is one of the most frequently reported problems in youth referred for psychiatric care. Irritability predicts adult depressive and anxiety disorders, and long-term impairment. Reflecting this pressing public health need, severe, chronic, and impairing irritability is now codified by the DSM-5 diagnosis of disruptive mood dysregulation disorder (DMDD). Since DMDD has only recently been added as its own nosological class, efficacious treatments that specifically target severe irritability as it presents in DMDD are still being developed. In a recent pilot study, we described the general concept of exposure-based cognitive-behavioral therapy (CBT) for irritability. This mechanism-driven treatment is based on our pathophysiological model of irritability that postulates two underlying mechanisms, which potentiate each other: (1) heightened reactivity to frustrative nonreward, and (2) aberrant approach responses to threat. In this case report, we describe and illustrate the specific therapeutic techniques used to address severe irritability in an 11-year-old boy with a primary diagnosis of DMDD. Specific techniques within this CBT include motivational interviewing to build commitment and target oppositionality; creation of an anger hierarchy; in-session controlled, gradual exposure; and parent training focusing on contingency management to counteract the instrumental learning deficits in irritable youth. Parents learn to tolerate their own emotional responses to their youth's irritability (e.g., parents engage in their own exposure) and increase their adaptive contingencies for their youth's behavior (e.g., withdraw attention during unwanted behavior, praise desirable behavior). Future directions in the context of this CBT, such as leveraging technology, computational modeling, and pathophysiological targets, are discussed.
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Affiliation(s)
- Julia Linke
- Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health.
| | - Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health
| | - Julia Brooks
- Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health
| | - Gretchen Perhamus
- Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health
| | | | - Melissa A. Brotman
- Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health
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23
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Moran LV, Guvenek-Cokol PE, Perlis RH. Attention-Deficit/Hyperactivity Disorder, Hypomania, and Bipolar Disorder in Youth. JAMA Psychiatry 2019; 76:1119-1121. [PMID: 31411658 DOI: 10.1001/jamapsychiatry.2019.1926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Lauren V Moran
- McLean Hospital, Belmont, Massachusetts.,Harvard Medical School, Boston, Massachusetts
| | | | - Roy H Perlis
- Harvard Medical School, Boston, Massachusetts.,Center for Quantitative Health, Department of Psychiatry, Massachusetts General Hospital, Boston
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24
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Pisano S, Pozzi M, Catone G, Scrinzi G, Clementi E, Coppola G, Milone A, Bravaccio C, Santosh P, Masi G. Putative Mechanisms of Action and Clinical Use of Lithium in Children and Adolescents: A Critical Review. Curr Neuropharmacol 2019; 17:318-341. [PMID: 29256353 PMCID: PMC6482478 DOI: 10.2174/1570159x16666171219142120] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 10/09/2017] [Accepted: 11/28/2017] [Indexed: 01/17/2023] Open
Abstract
Background: Lithium is a first-line treatment for bipolar disorder in adults, but its mechanism of action is still far from clear. Furthermore, evidences of its use in pediatric populations are sparse, not only for bipolar disorders, but also for other possible indications. Objectives: To provide a synthesis of published data on the possible mechanisms of action of lithium, as well as on its use in pediatric samples, including pharmacokinetics, efficacy, and safety data. Methods: Clinical trials in pediatric samples with at least one standardized measure of efficacy/effectiveness were included in this review. We considered: i) randomized and open label trials, ii) combination studies iii) augmentation studies iv) case series including at least 5 patients. Results: Different and non-alternative mechanisms of action can explain the clinical efficacy of lithium. Clinical studies in pediatric samples suggest that lithium is effective in managing manic symptoms/episodes of bipolar disorder, both in the acute phase and as maintenance strategy. Efficacy on depressive symptoms/phases of bipolar disorder is much less clear, while studies do not support its use in unipolar depression and severe mood dysregulation. Conversely, it may be effective on aggression in the context of conduct disorder. Other possible indications, with limited published evidence, are the acute attacks in Kleine-Levin syndrome, behavioral symptoms of X-fragile syndrome, and the management of clozapine- or chemotherapy- induced neutropenia. Generally, lithium resulted relatively safe. Conclusions: Lithium seems an effective and well-tolerated medication in pediatric bipolar disorder and aggression, while further evidences are needed for other clinical indications.
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Affiliation(s)
- Simone Pisano
- Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Marco Pozzi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy
| | - Gennaro Catone
- Dept. of Mental and Physical Health and Preventive Medicine, Child and Adolescent Psychiatry Division, Campania University- Luigi Vanvitelli, Italy
| | - Giulia Scrinzi
- Department of Surgical Sciences, Dentistry, Gynecology and Pediatrics, Child Neuropsychiatry Unit, University of Verona, Verona 37126, Italy
| | - Emilio Clementi
- Scientific Institute IRCCS Eugenio Medea, 23842 Bosisio Parini, Lecco, Italy.,Unit of Clinical Pharmacology, CNR Institute of Neuroscience, Department of Biomedical and Clinical Sciences L. Sacco, "Luigi Sacco" University Hospital, University of Milan, 20157 Milan, Italy
| | - Giangennaro Coppola
- Clinic of Child and Adolescent Neuropsychiatry, Department of Medicine and Surgery, University of Salerno, Salerno, Italy
| | - Annarita Milone
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
| | - Carmela Bravaccio
- Department of Translational Medical Sciences, University Federico II of Naples, Italy
| | - Paramala Santosh
- Department of Child and Adolescent Psychiatry, Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.,Centre for Interventional Paediatric Psychopharmacology and Rare Diseases (CIPPRD), National and Specialist Child and Adolescent Mental Health Services, Maudsley Hospital, London, United States.,HealthTracker Ltd, Gillingham, United States
| | - Gabriele Masi
- IRCCS Stella Maris, Scientific Institute of Child Neurology and Psychiatry, Calambrone, Pisa, Italy
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25
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Perugi G, Pallucchini A, Rizzato S, Pinzone V, De Rossi P. Current and emerging pharmacotherapy for the treatment of adult attention deficit hyperactivity disorder (ADHD). Expert Opin Pharmacother 2019; 20:1457-1470. [PMID: 31112441 DOI: 10.1080/14656566.2019.1618270] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Introduction: ADHD is characterized by a developmentally inappropriate level of inattentiveness, impulsivity and/or hyperactivity. In adults, the disorder is frequently accompanied by Emotional Dysregulation (ED), associated to a variety of related psychiatric comorbidities, complicating its recognition and treatment management. Areas covered: This paper reviews randomized active comparator-controlled or placebo-controlled trials evaluating the use of pharmacotherapy in adults with ADHD and ED, other neurodevelopmental disorders, Bipolar Disorder (BD) and Anxiety Disorders (ADs). When controlled data are unavailable, the authors have included open-label and observational studies. Expert opinion: ED in adult patients with ADHD is a very common and impairing problem that can be treated with stimulants or atomoxetine. ADHD studies in adults with other neurodevelopment disorders are scarce; stimulants seem to be the most effective and safe drugs in treating ADHD symptoms, without worsening the core features of other neurodevelopmental disorders. In patients with ADHD and comorbid BD, the treatment of BD alone may result in residual symptoms of ADHD. Patients should be treated hierarchically: BD should be treated first, while ADHD should be treated combining ADHD medications and mood stabilizers after mood stabilization. The available evidence for treating patients with ADHD and comorbid ADs in adults supports the idea of an anti-anxiety/ADHD-specific treatment association.
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Affiliation(s)
- Giulio Perugi
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Alessandro Pallucchini
- Department of Experimental and Clinic Medicine, Section of Psychiatry, University of Pisa , Pisa , Italy
| | - Salvatore Rizzato
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Vito Pinzone
- Psychiatry Residency Training Program, Faculty of Medicine and Psychology, Sapienza University of Rome , Rome , Italy
| | - Pietro De Rossi
- NESMOS Department (Neurosciences, Mental Health, and Sensory Organs), Sapienza University of Rome, School of Medicine and Psychology, Sant'Andrea Hospital , Rome , Italy.,Department of Neurology and Psychiatry, Sapienza University of Rome , Rome , Italy.,Department of Psychiatry, ASL Roma 5 , Rome , Italy
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Abstract
Mood disorders include all types of depression and bipolar disorder, and mood disorders are sometimes called affective disorders. We will discuss newly developing two issues in affective disorders in children and adolescents. Those are the new diagnostic challenges using neuroimaging techniques in affective disorders and the introduction of disruptive mood dysregulation disorder (DMDD). During the 1980s, mental health professionals began to recognize symptoms of mood disorders in children and adolescents, as well as adults. However, children and adolescents do not necessarily have or exhibit the same symptoms as adults. It is more difficult to diagnose mood disorders in children, especially because children are not always able to express how they feel. Child mental health professionals believe that mood disorders in children and adolescents remain one of the most underdiagnosed mental health problems. We are currently trying to introduce the new diagnostic technique-machine learning in children and adolescents with MDD. We will discuss the current progress in the clinical application of machine learning for MDD. After that, we would also discuss a new challenging diagnosis-DMDD. We are still suffering from a lack of evidence when trying to treat the patients with DMDD. In addition, there are some debates about the diagnostic validity of DMDD. We will explain the current situation of DMDD studies and the future directions in the study of DMDD.
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Pan PY, Fu AT, Yeh CB. Aripiprazole/Methylphenidate Combination in Children and Adolescents with Disruptive Mood Dysregulation Disorder and Attention-Deficit/Hyperactivity Disorder: An Open-Label Study. J Child Adolesc Psychopharmacol 2018; 28:682-689. [PMID: 30148656 DOI: 10.1089/cap.2018.0068] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVES Disruptive mood dysregulation disorder (DMDD) is characterized by nonepisodic irritability and has a high rate of comorbidity with attention-deficit/hyperactivity disorder (ADHD). This is the first study to explore the effects of aripiprazole combined with methylphenidate on clinical symptoms and cognitive functions in patients with DMDD and ADHD. METHODS Patients with DMDD and ADHD (the DMDD-ADHD Group, n = 24; aged 7-17 years) completed a 6-week, open-label trial of aripiprazole and methylphenidate. The pre- and posttreatment outcome measures included the parent-rated Swanson, Nolan, and Pelham Scale-version IV, Child Behavior Checklist, and self-reported Beck Youth Inventories-II, as well as a neuropsychological battery composed of the Children's Color Trail Test and Conner's Continuous Performance Test. The comparison group consisting of patients with ADHD (the ADHD Group, n = 27) was recruited to investigate the differences in clinical and neuropsychological profiles between the two groups at baseline. RESULTS The DMDD-ADHD Group showed worse irritability, disruptive behaviors, anxious/depressed symptoms, and social problems relative to the ADHD Group at baseline assessments. The combination treatment significantly improved irritability, externalizing symptoms, depression, anxiety, attention, social problems, and reaction time variability. The effect sizes of reductions in parent-rated irritability, oppositional defiant symptoms, and inattention were comparable (Cohen's d = 1.26, 1.11, and 1.40, respectively). CONCLUSIONS This pilot study showed the tolerability of the aripiprazole/methylphenidate combination by patients with DMDD and ADHD and its efficaciousness for treating clinical symptoms and for improving cognitive function. Further randomized, controlled, cross-over studies are needed.
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Affiliation(s)
- Pei-Yin Pan
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
| | - An-Ting Fu
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
| | - Chin-Bin Yeh
- Department of Psychiatry, National Defense Medical Center , Tri-Service General Hospital, Taipei, Taiwan
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Safety and efficacy of lithium in children and adolescents: A systematic review in bipolar illness. Eur Psychiatry 2018; 54:85-97. [DOI: 10.1016/j.eurpsy.2018.07.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/30/2018] [Accepted: 07/31/2018] [Indexed: 01/04/2023] Open
Abstract
AbstractIntroduction:Many clinicians are reluctant to use traditional mood-stabilizing agents, especially lithium, in children and adolescents. This review examined the evidence for lithium’s safety and efficacy in this population.Methods:A systematic review was conducted on the use of lithium in children and adolescents with bipolar disorder (BD). Relevant papers published through June 30th 2018 were identified searching the electronic databases MEDLINE, Embase, PsycINFO and the Cochrane Library.Results:30 articles met inclusion criteria, including 12 randomized controlled trials (RCTs). Findings from RCTs demonstrate efficacy for acute mania in up to 50% of patients, and evidence of long-term maintenance efficacy. Lithium was generally safe, at least in the short term, with most common side effects being gastrointestinal, polyuria, or headache. Only a minority of patients experienced hypothyroidism. No cases of acute kidney injury or chronic kidney disease were reported.Conclusions:Though the available literature is mostly short-term, there is evidence that lithium monotherapy is reasonably safe and effective in children and adolescents, specifically for acute mania and for prevention of mood episodes.
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Stringaris A, Vidal-Ribas P, Brotman MA, Leibenluft E. Practitioner Review: Definition, recognition, and treatment challenges of irritability in young people. J Child Psychol Psychiatry 2018; 59:721-739. [PMID: 29083031 DOI: 10.1111/jcpp.12823] [Citation(s) in RCA: 117] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/29/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND Irritability is one of the most common reasons for referral to child and adolescent mental health services and is the main characteristic of the new diagnosis of disruptive mood dysregulation disorder (DMDD). However, the recognition and management of irritability presents a major challenge in clinical practice and may be partly responsible for the dramatic increase in antipsychotic prescribing in recent years. METHODS In this review, we provide up-to-date information on the definition and mechanisms underlying irritability, and its assessment in clinical practice. We aim to discuss the latest research on DMDD, and the presence of severe irritability in the context of other disorders, as well as to recommend a treatment algorithm. RESULTS Severe irritability is associated with aberrant reward processing and bias toward threatening stimuli. Several measures are available to easily assess irritability. The recent diagnosis of DMDD captures children whose main problem is severe irritability and differ from those with bipolar disorder in longitudinal outcomes, family history, and behavioral and neural correlates. Treatment of irritability might depend on the context it appears. Indirect evidence suggests that parent management training (PMT) and cognitive behavioral therapy (CBT) are the most supported psychological treatments for irritability. CONCLUSIONS Irritability, recognized as a mood problem rather than a purely behavioral manifestation, is a common condition for young people. Practitioners should not ignore irritability as it is associated with substantial morbidity and impairment. Although there are no trials with irritability as main outcome, clinicians can apply several existing pharmacological and psychological interventions for its treatment. Also, new promising approaches relying on pathophysiological findings, such as exposure-based cognitive behavioral therapy techniques and interpretation bias training (IBT), are being currently investigated.
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Affiliation(s)
- Argyris Stringaris
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Pablo Vidal-Ribas
- Mood Brain and Development Unit, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA.,Institute of Psychiatry, Psychology and Neuroscience, Department of Child and Adolescent Psychiatry, King's College London, London, UK
| | - Melissa A Brotman
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD, USA
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Miller L, Hlastala SA, Mufson L, Leibenluft E, Yenokyan G, Riddle M. Interpersonal psychotherapy for mood and behavior dysregulation: Pilot randomized trial. Depress Anxiety 2018; 35:574-582. [PMID: 29719093 PMCID: PMC11108175 DOI: 10.1002/da.22761] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2017] [Revised: 01/18/2018] [Accepted: 03/08/2018] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Youth with chronic irritability and excessive reactivity, diagnosed as disruptive mood dysregulation disorder (DMDD), have social impairment in multiple settings (i.e., peers, school, and home). This paper presents a pilot randomized trial assessing the feasibility, acceptability, and preliminary efficacy of interpersonal psychotherapy (IPT) for mood and behavior dysregulation (IPT-MBD), an adapted version of IPT for depressed adolescents. IPT-MBD focuses on decreasing outbursts and irritability and improving interpersonal interactions. METHODS Nineteen adolescents (aged 12-17) with DMDD or its research precursor, severe mood dysregulation, were randomly assigned to IPT-MBD (n = 10) or treatment-as-usual (TAU, n = 9) in a 24-week psychosocial intervention study. Assessments of mood symptoms and overall functioning were conducted by an independent evaluator, blinded to treatment, every 4 weeks. Parent and self-report irritability measures were collected every 4 weeks. RESULTS Eighty percent of participants randomized to the IPT-MBD arm completed the study. Also, participants enrolled in the IPT-MBD arm attended >80% of therapy sessions. Parents and teens agreed that the frequency and duration of therapy were appropriate and were satisfied with IPT-MBD treatment. Clinical global impression scales for severity and improvement showed statistically greater improvement in the IPT-MBD group compared to TAU. CONCLUSIONS In this small pilot randomized trial, IPT-MBD was feasible and acceptable to parents and teens. There was significantly more improvement in the IPT-MBD group compared to TAU. IPT-MBD holds promise as a potentially effective psychosocial intervention for clinically impaired youth with DMDD and warrants further investigation in a larger randomized trial.
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Affiliation(s)
- Leslie Miller
- Department of Psychiatry and Behavioral Sciences, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stefanie A. Hlastala
- Department of Psychiatry and Behavioral Sciences,
University of Washington Medical Center, Seattle, WA, USA
| | - Laura Mufson
- Department of Psychiatry, Columbia University College of
Physicians and Surgeons and New York State Psychiatric Institute, New York, NY,
USA
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of
Mental Health, Bethesda, MD, USA
| | - Gayane Yenokyan
- Department of Biostatistics, Johns Hopkins Bloomberg School
of Public Health, Baltimore, MD, USA
| | - Mark Riddle
- Department of Psychiatry and Behavioral Sciences, Johns
Hopkins University School of Medicine, Baltimore, MD, USA
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Winters DE, Fukui S, Leibenluft E, Hulvershorn LA. Improvements in Irritability with Open-Label Methylphenidate Treatment in Youth with Comorbid Attention Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder. J Child Adolesc Psychopharmacol 2018; 28:298-305. [PMID: 29708762 PMCID: PMC6016730 DOI: 10.1089/cap.2017.0124] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
OBJECTIVE The purpose of this open-label study was to examine the effects of long-acting methylphenidate (MPH) treatment on irritability and related emotional symptoms associated with disruptive mood dysregulation disorder (DMDD) in youth with comorbid attention-deficit/hyperactivity disorder (ADHD). METHODS The sample included 22 medication-free male and female subjects (ages 9-15) who met criteria for both DMDD and ADHD. Participants underwent a 4-week trial of long-acting MPH treatment (Concerta®), with weekly dosing increases until a therapeutic dose was reached. Repeated measures t-tests were used to compare pre- and posttreatment ratings of primary and secondary measures. The primary outcome was self-report irritability. Secondary outcomes included parent and child ratings of emotional frequency, emotional lability, and negative affect (NA). Multiple regression was used to examine the impact baseline hyperactivity, age, gender, race, socioeconomic status, or comorbid diagnosis had on treatment outcomes. RESULTS Significant improvements (medium to large effect sizes) in child-rated irritability as well as parent and child ratings of emotional lability, NA, and anger were found. As anticipated, ADHD symptoms also improved. While a majority of the sample saw improvement in child-rated irritability (71%), symptoms worsened a small proportion (19%), and an even smaller portion experienced no change (10%). No demographics, psychiatric comorbidities, or severity of ADHD symptoms influenced treatment outcomes. CONCLUSIONS Study findings suggest that MPH treatment significantly improved mood and emotional symptoms associated with DMDD comorbid with ADHD. These findings, coupled with good tolerability in this open-label pilot study supports further research into the use of MPH as a first-line treatment for DMDD. Future work examining MPH treatment of youth with DMDD with and without comorbid ADHD is needed.
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Affiliation(s)
- Drew E. Winters
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Sadaaki Fukui
- School of Social Work, Indiana University, Indianapolis, Indiana
| | - Ellen Leibenluft
- Section on Mood Dysregulation and Neuroscience, Intramural Research Program, National Institute of Mental Health, National Institutes of Health, Bethesda, Maryland
| | - Leslie A. Hulvershorn
- Section of Child and Adolescent Psychiatry, Indiana University School of Medicine, Indianapolis, Indiana
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Dugand N, Thümmler S, Pradier C, Askenazy F. Tentative de suicide chez l’enfant et l’adolescent et bipolarité. Encephale 2018; 44:215-223. [DOI: 10.1016/j.encep.2017.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2016] [Revised: 01/08/2017] [Accepted: 01/09/2017] [Indexed: 10/20/2022]
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Abstract
This article outlines diagnostic criteria and features of the newly established diagnosis disruptive mood dysregulation disorder (DMDD), and discusses how this disorder differs from bipolar disorder in childhood. The chronic, severe, nonepisodic irritability seen in patients with DMDD contrasts with the characteristic episodic mood swing symptoms of bipolar disorder. Differentiating between the two diagnoses is important in regard to prognostic and treatment considerations, as children with DMDD are more likely to develop a mood disorder later in life rather than to develop classic bipolar disorder. Research is needed to establish clear treatment guidelines for DMDD.
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Melvin GA, Tonge BJ, Mulraney M, Gordon M, Taffe J, Klimkeit E. The Cranky Thermometers: Visual analogue scales measuring irritability in youth. J Adolesc 2018; 64:146-154. [PMID: 29475011 DOI: 10.1016/j.adolescence.2018.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 02/01/2018] [Accepted: 02/07/2018] [Indexed: 11/15/2022]
Abstract
This study assessed the psychometric properties of two visual analogue scales of irritability, known as the Cranky Thermometers (CT), in both an Australian community secondary-school sample (N = 164) and a sample of adolescents with a depressive disorder (N = 127). The first scale Cranky Now measures current irritability, and the second, Cranky Two Weeks, measures peak irritability within the last two weeks. CT scores were significantly higher in adolescents with major depressive disorder than in the school sample and showed improvement following treatment for depression. Positive associations were found between CT and irritability scores as determined by Kiddie Schedule for Affective Disorders and Schizophrenia (not irritable, sub-threshold, threshold irritability) and Affective Reactivity Index scores. Results suggest that the CTs are rapidly administered, have promising psychometric properties and demonstrate utility in measuring irritability in clinical and community settings.
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Affiliation(s)
- Glenn A Melvin
- Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia.
| | - Bruce J Tonge
- Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia
| | - Melissa Mulraney
- Centre for Community Child Health, Murdoch Childrens Research Institute, 50 Flemington Rd, Parkville, Victoria, 3052, Australia
| | - Michael Gordon
- Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia; Early in Life Mental Health Service, Southern Health, Monash Medical Centre, 246 Clayton Rd, Clayton, Victoria, 3168, Australia
| | - John Taffe
- Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia
| | - Ester Klimkeit
- Centre for Developmental Psychiatry & Psychology, Department of Psychiatry, School of Clinical Sciences at Monash Health, Monash University, Building #1, Ferntree Gully Rd, Notting Hill, Victoria, 3168, Australia
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36
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Goldstein BI, Birmaher B, Carlson GA, DelBello MP, Findling RL, Fristad M, Kowatch RA, Miklowitz DJ, Nery FG, Perez‐Algorta G, Van Meter A, Zeni CP, Correll CU, Kim H, Wozniak J, Chang KD, Hillegers M, Youngstrom EA. The International Society for Bipolar Disorders Task Force report on pediatric bipolar disorder: Knowledge to date and directions for future research. Bipolar Disord 2017; 19:524-543. [PMID: 28944987 PMCID: PMC5716873 DOI: 10.1111/bdi.12556] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Accepted: 08/14/2017] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Over the past two decades, there has been tremendous growth in research regarding bipolar disorder (BD) among children and adolescents (ie, pediatric BD [PBD]). The primary purpose of this article is to distill the extant literature, dispel myths or exaggerated assertions in the field, and disseminate clinically relevant findings. METHODS An international group of experts completed a selective review of the literature, emphasizing areas of consensus, identifying limitations and gaps in the literature, and highlighting future directions to mitigate these gaps. RESULTS Substantial, and increasingly international, research has accumulated regarding the phenomenology, differential diagnosis, course, treatment, and neurobiology of PBD. Prior division around the role of irritability and of screening tools in diagnosis has largely abated. Gold-standard pharmacologic trials inform treatment of manic/mixed episodes, whereas fewer data address bipolar depression and maintenance/continuation treatment. Adjunctive psychosocial treatment provides a forum for psychoeducation and targets primarily depressive symptoms. Numerous neurocognitive and neuroimaging studies, and increasing peripheral biomarker studies, largely converge with prior findings from adults with BD. CONCLUSIONS As data have accumulated and controversy has dissipated, the field has moved past existential questions about PBD toward defining and pursuing pressing clinical and scientific priorities that remain. The overall body of evidence supports the position that perceptions about marked international (US vs elsewhere) and developmental (pediatric vs adult) differences have been overstated, although additional research on these topics is warranted. Traction toward improved outcomes will be supported by continued emphasis on pathophysiology and novel therapeutics.
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Affiliation(s)
- Benjamin I Goldstein
- Centre for Youth Bipolar DisorderSunnybrook Health Sciences CentreTorontoCanada,Departments of Psychiatry and PharmacologyUniversity of TorontoTorontoCanada
| | - Boris Birmaher
- Department of PsychiatryUniversity of Pittsburgh School of MedicinePittsburghPAUSA
| | - Gabrielle A Carlson
- Department of PsychiatryStony Brook University School of MedicineStony BrookNYUSA
| | - Melissa P DelBello
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | - Robert L Findling
- Department of Psychiatry & Behavioral SciencesThe Johns Hopkins UniversityBaltimoreMDUSA
| | - Mary Fristad
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | - Robert A Kowatch
- Ohio State University Wexner Medical Center/Nationwide Children's HospitalColumbusOHUSA
| | | | - Fabiano G Nery
- Department of Psychiatry & Behavioral NeuroscienceUniversity of CincinnatiCincinnatiOHUSA
| | | | - Anna Van Meter
- Ferkauf Graduate School of PsychologyYeshiva UniversityBronxNYUSA
| | | | - Christoph U Correll
- The Zucker Hillside HospitalDepartment of PsychiatryNorthwell HealthGlen OaksNYUSA,Department of Psychiatry and Molecular MedicineHofstra Northwell School of MedicineHempsteadNYUSA
| | - Hyo‐Won Kim
- Department of PsychiatryUniversity of Ulsan College of MedicineAsan Medical CenterSeoulKorea
| | - Janet Wozniak
- Clinical and Research Program in Pediatric PsychopharmacologyMassachusetts General HospitalHarvard Medical SchoolBostonMAUSA
| | - Kiki D Chang
- Department of PsychiatryStanford UniversityPalo AltoCAUSA
| | - Manon Hillegers
- Department of Child and Adolescent Psychiatry and PsychologyErasmus Medical Center‐SophiaRotterdamThe Netherlands
| | - Eric A Youngstrom
- Department of Psychology and NeuroscienceUniversity of North CarolinaChapel HillNCUSA
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Wang HR, Bahk WM, Seo JS, Woo YS, Park YM, Jeong JH, Kim W, Shim SH, Lee JG, Jon DI, Min KJ. Korean Medication Algorithm for Depressive Disorder: Comparisons with Other Treatment Guidelines. CLINICAL PSYCHOPHARMACOLOGY AND NEUROSCIENCE 2017; 15:199-209. [PMID: 28783928 PMCID: PMC5565074 DOI: 10.9758/cpn.2017.15.3.199] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 12/05/2016] [Accepted: 12/06/2016] [Indexed: 12/11/2022]
Abstract
In this review, we compared recommendations from the Korean Medication Algorithm Project for Depressive Disorder 2017 (KMAP-DD 2017) to other global treatment guidelines for depression. Six global treatment guidelines were reviewed; among the six, 4 were evidence-based guidelines, 1 was an expert consensus-based guideline, and 1 was an amalgamation of both evidence and expert consensus-based recommendations. The recommendations in the KMAP-DD 2017 were generally similar to those in other global treatment guidelines, although there were some differences between the guidelines. The KMAP-DD 2017 appeared to reflect current changes in the psychopharmacology of depression quite well, like other recently published evidence-based guidelines. As an expert consensus-based guideline, the KMAP-DD 2017 had some limitations. However, considering there are situations in which clinical evidence cannot be drawn from planned clinical trials, the KMAP-DD 2017 may be helpful for Korean psychiatrists making decisions in the clinical settings by complementing previously published evidence-based guidelines.
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Affiliation(s)
- Hee Ryung Wang
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Won-Myong Bahk
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jeong Seok Seo
- Department of Psychiatry, Konkuk University School of Medicine, Chungju, Korea
| | - Young Sup Woo
- Department of Psychiatry, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young-Min Park
- Department of Psychiatry, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
| | - Jong-Hyun Jeong
- Department of Psychiatry, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Won Kim
- Department of Psychiatry, Inje University Seoul Paik Hospital, Inje University School of Medicine, Seoul, Korea.,Stress Research Institute, Inje University, Seoul, Korea
| | - Se-Hoon Shim
- Department of Psychiatry, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jung Goo Lee
- Department of Psychiatry, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea.,Paik Institute for Clinical Research, Inje University, Busan, Korea.,Department of Health Science and Technology, Graduate School of Inje University, Busan, Korea
| | - Duk-In Jon
- Department of Psychiatry, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung Joon Min
- Department of Psychiatry, Chung-Ang University College of Medicine, Seoul, Korea
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Affiliation(s)
- Melissa A. Brotman
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Katharina Kircanski
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
| | - Ellen Leibenluft
- Emotion and Development Branch, National Institute of Mental Health, Bethesda, Maryland 20892;, ,
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Birkle SM, Legenbauer T, Grasmann D, Holtmann M. Disruptive Affektregulations- störung: eine umstrittene neue Diagnose im DSM-5. ZEITSCHRIFT FUR KINDER-UND JUGENDPSYCHIATRIE UND PSYCHOTHERAPIE 2017; 45:98-103. [DOI: 10.1024/1422-4917/a000496] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Zusammenfassung. Die Disruptive Affektregulationsstörung wurde in die 5. Auflage des DSM erstmals als Störungsbild aufgenommen. Den Anlass, eine eigenständige diagnostische Kategorie im Kapitel „Depressive Störungen“ für einen Verhaltensphänotyp aus chronischer, nichtepisodischer Reizbarkeit und häufigen plötzlichen Wutanfällen zu entwickeln, gab die transatlantische Kontroverse um das klinische Bild und die Prävalenz früh beginnender bipolarer Störungen. Die vorliegende Arbeit stellt erste vorliegende Arbeiten dar, die auf die neuen Kriterien zurückgreifen. Während die Abgrenzbarkeit der Disruptiven Affektregulationsstörung in Symptomatik und Verlauf von bipolaren Störungen gut gelingt, finden sich Hinweise auf starke Überlappungen mit oppositionell-gereizten Symptombildern. Für die anstehende Revision der ICD sollte daher diskutiert werden, keine neue Diagnose, sondern eher eine Zusatzcodierung einzuführen, die kennzeichnet, ob eine oppositionelle Störung auch reizbar-wütendes Verhalten umfasst. Unabhängig von der nosologischen Einordnung besteht die Herausforderung, den Verhaltensphänotyp hinsichtlich Ätiologie, Entwicklungspsychopathologie und Prognose besser zu verstehen und hilfreiche Behandlungsmöglichkeiten zu entwickeln.
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Affiliation(s)
- Sarah Maria Birkle
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
| | - Tanja Legenbauer
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
| | - Dörte Grasmann
- Verhaltenstherapie-Ambulanz für Kinder und Jugendliche, Klinische Psychologie und Psychotherapie, Goethe-Universität, Frankfurt am Main
| | - Martin Holtmann
- LWL-Universitätsklinik Hamm der Ruhr-Universität Bochum, Klinik für Kinder- und Jugendpsychiatrie, Psychotherapie und Psychosomatik
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Baker M, Bellonci C, Huefner JC, Hilt RJ, Carlson GA. Polypharmacy and the Pursuit of Appropriate Prescribing for Children and Adolescents. ACTA ACUST UNITED AC 2017. [DOI: 10.1521/capn.2017.22.1.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Megan Baker
- Stanford Child and Adolescent Psychiatry, Fellow
| | - Christopher Bellonci
- Vice President of Policy and Practice/Chief Medical Officer at Judge Baker Children's Center,
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Benarous X, Consoli A, Guilé JM, Garny de La Rivière S, Cohen D, Olliac B. Evidence-based treatments for youths with severely dysregulated mood: a qualitative systematic review of trials for SMD and DMDD. Eur Child Adolesc Psychiatry 2017; 26:5-23. [PMID: 27662894 DOI: 10.1007/s00787-016-0907-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 09/16/2016] [Indexed: 01/14/2023]
Abstract
The aim of this literature review was to examine the evidence for psychotherapeutic and pharmacological treatments in subjects with severely dysregulated mood and to identify potential areas for improvements in research designs. A literature search was conducted using several databases for published (PubMed, PsycINFO) and ongoing (clinical trial registries) studies conducted in youths who met NIMH's criteria for Severe Mood Dysregulation (SMD) or the DSM-5 diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). Eight completed studies were identified: three randomized trials, four open pilot studies and one case report. Seven ongoing studies were found in trial registries. The available evidence suggests potential efficacy of psychotherapies which have previously been developed for internalizing and externalizing disorders. The two main pharmacological strategies tested are, first, a monotherapy of psychostimulant or atypical antipsychotic such as risperidone, already used in the treatment of severe irritability in youths with developmental disorders; and second, the use of a serotonergic antidepressant as an add-on therapy in youths treated with psychostimulant. Ongoing studies will further clarify the effectiveness of psychotherapeutic interventions for DMDD individuals and whether they should be given alone or in conjunction with other treatments. The short duration of the trials for a chronic disorder, the low number of studies, the lack of placebo or active comparator arm, and restrictive inclusion criteria in most of the controlled trials dramatically limit the interpretation of the results. Finally, future research should be conducted across multiple sites, with standardized procedures to measure DMDD symptoms reduction, and include a run-in period to limit placebo effect.
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Affiliation(s)
- Xavier Benarous
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.
| | - Angèle Consoli
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,INSERM U-669, PSIGIAM, Paris, France
| | - Jean-Marc Guilé
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,Groupe de Recherches sur l'Analyse Multimodale de la Fonction Cérébrale, INSERM U1105, CHU, Université Picardie Jules Verne, Amiens, France.,Department of Psychiatry, McGill University, Montreal, Canada
| | - Sébastien Garny de La Rivière
- Groupe de Recherches sur l'Analyse Multimodale de la Fonction Cérébrale, INSERM U1105, CHU, Université Picardie Jules Verne, Amiens, France
| | - David Cohen
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,CNRS UMR 7222, Institute for Intelligent Systems and Robotics-ISIR, Paris, France
| | - Bertrand Olliac
- Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l'Hôpital, 75013, Paris, France.,Pôle Hospitalo-Universitaire de psychiatrie de l'enfant et de l'adolescent, Centre Hospitalier Esquirol, Limoges, France
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42
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Mason BL, Brown ES, Croarkin PE. Historical Underpinnings of Bipolar Disorder Diagnostic Criteria. Behav Sci (Basel) 2016; 6:bs6030014. [PMID: 27429010 PMCID: PMC5039514 DOI: 10.3390/bs6030014] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 06/24/2016] [Accepted: 07/06/2016] [Indexed: 12/16/2022] Open
Abstract
Mood is the changing expression of emotion and can be described as a spectrum. The outermost ends of this spectrum highlight two states, the lowest low, melancholia, and the highest high, mania. These mood extremes have been documented repeatedly in human history, being first systematically described by Hippocrates. Nineteenth century contemporaries Falret and Baillarger described two forms of an extreme mood disorder, with the validity and accuracy of both debated. Regardless, the concept of a cycling mood disease was accepted before the end of the 19th century. Kraepelin then described “manic depressive insanity” and presented his description of a full spectrum of mood dysfunction which could be exhibited through single episodes of mania or depression or a complement of many episodes of each. It was this concept which was incorporated into the first DSM and carried out until DSM-III, in which the description of episodic mood dysfunction was used to build a diagnosis of bipolar disorder. Criticism of this approach is explored through discussion of the bipolar spectrum concept and some recent examinations of the clinical validity of these DSM diagnoses are presented. The concept of bipolar disorder in children is also explored.
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Affiliation(s)
- Brittany L Mason
- Department of Psychiatry, University of Texas Southwestern Medical Center; Dallas, TX 75390, USA.
| | - E Sherwood Brown
- Department of Psychiatry, University of Texas Southwestern Medical Center; Dallas, TX 75390, USA.
| | - Paul E Croarkin
- Department of Psychiatry and Psychology, Mayo Clinic, Rochester, MN 55901, USA.
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Vidal-Ribas P, Brotman MA, Valdivieso I, Leibenluft E, Stringaris A. The Status of Irritability in Psychiatry: A Conceptual and Quantitative Review. J Am Acad Child Adolesc Psychiatry 2016; 55:556-70. [PMID: 27343883 PMCID: PMC4927461 DOI: 10.1016/j.jaac.2016.04.014] [Citation(s) in RCA: 298] [Impact Index Per Article: 37.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/27/2016] [Accepted: 04/29/2016] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Research and clinical interest in irritability have been on the rise in recent years. Yet several questions remain about the status of irritability in psychiatry, including whether irritability can be differentiated from other symptoms, whether it forms a distinct disorder, and whether it is a meaningful predictor of clinical outcomes. In this article, we try to answer these questions by reviewing the evidence on how reliably irritability can be measured and its validity. METHOD We combine a narrative and systematic review and meta-analysis of studies. For the systematic review and meta-analysis, we searched studies in PubMed and Web of Science based on preselected criteria. A total of 163 articles were reviewed, and 24 were included. RESULTS We found that irritability forms a distinct dimension with substantial stability across time, and that it is specifically associated with depression and anxiety in longitudinal studies. Evidence from genetic studies reveals that irritability is moderately heritable, and its overlap with depression is explained mainly by genetic factors. Behavioral and neuroimaging studies show that youth with persistent irritability exhibit altered activations in the amygdala, striatum, and frontal regions compared with age-matched healthy volunteers. Most knowledge about the treatment of irritability is based on effects of treatment on related conditions or post hoc analyses of trial data. CONCLUSION We identify a number of research priorities including innovative experimental designs and priorities for treatment studies, and conclude with recommendations for the assessment of irritability for researchers and clinicians.
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Affiliation(s)
- Pablo Vidal-Ribas
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom.
| | - Melissa A Brotman
- Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Isabel Valdivieso
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
| | - Ellen Leibenluft
- Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health, National Institutes of Health, Department of Health and Human Services, Bethesda, MD
| | - Argyris Stringaris
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, United Kingdom
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Birmaher B. The Risks of Persistent Irritability. J Am Acad Child Adolesc Psychiatry 2016; 55:538-9. [PMID: 27343879 DOI: 10.1016/j.jaac.2016.04.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Accepted: 05/02/2016] [Indexed: 11/19/2022]
Affiliation(s)
- Boris Birmaher
- Western Psychiatric Institute and Clinic/University of Pittsburgh Medical Center, Pittsburgh.
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Correction to "The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder across Home and School". J Child Adolesc Psychopharmacol 2016:cap.2015.0053.cxn. [PMID: 26938370 DOI: 10.1089/cap.2015.0053.cxn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Seymour KE, Jones RN, Cushman GK, Galvan T, Puzia ME, Kim KL, Spirito A, Dickstein DP. Emotional face recognition in adolescent suicide attempters and adolescents engaging in non-suicidal self-injury. Eur Child Adolesc Psychiatry 2016; 25:247-59. [PMID: 26048103 PMCID: PMC6642805 DOI: 10.1007/s00787-015-0733-1] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/30/2015] [Indexed: 01/09/2023]
Abstract
Little is known about the bio-behavioral mechanisms underlying and differentiating suicide attempts from non-suicidal self-injury (NSSI) in adolescents. Adolescents who attempt suicide or engage in NSSI often report significant interpersonal and social difficulties. Emotional face recognition ability is a fundamental skill required for successful social interactions, and deficits in this ability may provide insight into the unique brain-behavior interactions underlying suicide attempts versus NSSI in adolescents. Therefore, we examined emotional face recognition ability among three mutually exclusive groups: (1) inpatient adolescents who attempted suicide (SA, n = 30); (2) inpatient adolescents engaged in NSSI (NSSI, n = 30); and (3) typically developing controls (TDC, n = 30) without psychiatric illness. Participants included adolescents aged 13-17 years, matched on age, gender and full-scale IQ. Emotional face recognition was evaluated using the diagnostic assessment of nonverbal accuracy (DANVA-2). Compared to TDC youth, adolescents with NSSI made more errors on child fearful and adult sad face recognition while controlling for psychopathology and medication status (ps < 0.05). No differences were found on emotional face recognition between NSSI and SA groups. Secondary analyses showed that compared to inpatients without major depression, those with major depression made fewer errors on adult sad face recognition even when controlling for group status (p < 0.05). Further, compared to inpatients without generalized anxiety, those with generalized anxiety made fewer recognition errors on adult happy faces even when controlling for group status (p < 0.05). Adolescent inpatients engaged in NSSI showed greater deficits in emotional face recognition than TDC, but not inpatient adolescents who attempted suicide. Further results suggest the importance of psychopathology in emotional face recognition. Replication of these preliminary results and examination of the role of context-dependent emotional processing are needed moving forward.
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Affiliation(s)
- Karen E Seymour
- Division of Child and Adolescent Psychiatry, Johns Hopkins University School of Medicine, 550 North Broadway, Suite 943, Baltimore, MD, 21205, USA.
| | - Richard N Jones
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, USA
| | - Grace K Cushman
- Bradley Hospital's Pediatric, Mood, Imaging and NeuroDevelopment (PediMIND) Program, Alpert Medical School of Brown University, Providence, USA
| | - Thania Galvan
- Bradley Hospital's Pediatric, Mood, Imaging and NeuroDevelopment (PediMIND) Program, Alpert Medical School of Brown University, Providence, USA
| | - Megan E Puzia
- Bradley Hospital's Pediatric, Mood, Imaging and NeuroDevelopment (PediMIND) Program, Alpert Medical School of Brown University, Providence, USA
| | - Kerri L Kim
- Bradley Hospital's Pediatric, Mood, Imaging and NeuroDevelopment (PediMIND) Program, Alpert Medical School of Brown University, Providence, USA
| | - Anthony Spirito
- Department of Psychiatry and Human Behavior, Alpert Medical School of Brown University, Providence, USA
| | - Daniel P Dickstein
- Bradley Hospital's Pediatric, Mood, Imaging and NeuroDevelopment (PediMIND) Program, Alpert Medical School of Brown University, Providence, USA
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Baweja R, Belin PJ, Humphrey HH, Babocsai L, Pariseau ME, Waschbusch DA, Hoffman MT, Akinnusi OO, Haak JL, Pelham WE, Waxmonsky JG. The Effectiveness and Tolerability of Central Nervous System Stimulants in School-Age Children with Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder Across Home and School. J Child Adolesc Psychopharmacol 2016; 26:154-63. [PMID: 26771437 PMCID: PMC4800382 DOI: 10.1089/cap.2015.0053] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE This study examines the effectiveness and tolerability of stimulants in children with attention-deficit/hyperactivity disorder (ADHD) and disruptive mood dysregulation disorder (DMDD). METHODS To be eligible, participants had to meet Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision (DSM-IV) criteria for the combined subtype of ADHD and National Institute of Mental Health (NIMH) severe mood dysregulation criteria. The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-V) DMDD criteria were retrospectively assessed after the study was completed. An open-label medication trial lasting up to 6 weeks was completed to optimize the central nervous system (CNS) stimulant dose. Measures of affective symptoms, ADHD symptoms and other disruptive behaviors, impairment, and structured side effect ratings were collected before and after the medication trial. RESULTS Optimization of stimulant medication was associated with a significant decline in depressive symptoms on the Childhood Depression Rating Score-Revised Scale (p<0.05, Cohen's d=0.61) and Mood Severity Index score (p<0.05, Cohen's d=0.55), but not in manic-like symptoms on the Young Mania Rating Scale. There was a significant reduction in ADHD (p<0.05, Cohen's d=0.95), oppositional defiant disorder (ODD) (p<0.05, Cohen's d=0.5), and conduct disorder (CD) symptoms (p<0.05, Cohen's d=0.65) as rated by parents. There was also a significant reduction in teacher-rated ADHD (p<0.05, Cohen's d=0.33) but not in ODD symptoms. Medications were well tolerated and there was no increase in side effect ratings seen with dose optimization. Significant improvement in functioning was reported by clinicians and parents (all p's<0.05), but youth still manifested appreciable impairment at end-point. CONCLUSIONS CNS simulants were well tolerated by children with ADHD comorbid with a diagnosis of DMDD. CNS stimulants were associated with clinically significant reductions in externalizing symptoms, along with smaller improvements in mood. However, most participants still exhibited significant impairment, suggesting that additional treatments may be needed to optimize functioning.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Peter J. Belin
- Center for Children and Families, Florida International University, Miami, Florida
| | - Hugh H. Humphrey
- Department of Psychiatry, Herbert Wertheim College of Medicine, Florida International University, Miami, Florida
| | - Lysett Babocsai
- Center for Children and Families, Florida International University, Miami, Florida
| | - Meaghan E. Pariseau
- Department of School and Counseling Psychology, SUNY Buffalo, Buffalo, New York
| | - Daniel A. Waschbusch
- Department of Psychiatry, Penn State University College of Medicine, Hershey, Pennsylvania
| | - Martin T. Hoffman
- Department of Pediatrics, SUNY Buffalo School of Medicine, Buffalo, New York
| | | | - Jenifer L. Haak
- Department of Psychiatry, SUNY Buffalo School of Medicine, Buffalo, New York
| | - William E. Pelham
- Center for Children and Families, Florida International University, Miami, Florida
| | - James G. Waxmonsky
- Department of Psychiatry, Penn State University College of Medicine, Hershey, Pennsylvania
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A Randomized Clinical Trial of an Integrative Group Therapy for Children With Severe Mood Dysregulation. J Am Acad Child Adolesc Psychiatry 2016; 55:196-207. [PMID: 26903253 PMCID: PMC4764804 DOI: 10.1016/j.jaac.2015.12.011] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2015] [Revised: 12/18/2015] [Accepted: 12/22/2015] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Nonepisodic irritability is a common and impairing problem, leading to the development of the diagnoses severe mood dysregulation (SMD) and disruptive mood dysregulation disorder (DMDD). No psychosocial therapies have been formally evaluated for either, with medication being the most common treatment. This study examined the feasibility and efficacy of a joint parent-child intervention for SMD. METHOD A total of 68 participants aged 7 to 12 years with attention-deficit/hyperactivity disorder (ADHD) and SMD were randomly assigned to the 11-week therapy or community-based psychosocial treatment. All participants were first stabilized on psychostimulant medication by study physicians. Of the participants, 56 still manifested impairing SMD symptoms and entered the therapy phase. Masked evaluators assessed participants at baseline, midpoint, and endpoint, with therapy participants reassessed 6 weeks later. RESULTS All but 2 therapy participants attended the majority of sessions (n = 29), with families reporting high levels of satisfaction. The primary outcome of change in mood symptoms using the Mood Severity Index (MSI) did not reach significance except in the subset attending the majority of sessions (effect size = 0.53). Therapy was associated with significantly greater improvement in parent-rated irritability (effect size = 0.63). Treatment effects for irritability but not MSI diminished after therapy stopped. Little impact on ADHD symptoms was seen. Results may not be generalizable to youth with SMD and comorbidities different from those seen in this sample of children with ADHD, and are limited by the lack of a gold standard for measuring change in SMD symptoms. CONCLUSION While failing to significantly improve mood symptoms versus community treatment, the integrative therapy was found to be a feasible and efficacious treatment for irritability in participants with SMD and ADHD. CLINICAL TRIAL REGISTRATION INFORMATION Group-Based Behavioral Therapy Combined With Stimulant Medication for Treating Children With Attention Deficit Hyperactivity Disorder and Impaired Mood; http://clinicaltrials.gov/; NCT00632619.
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Carlson GA, Pataki C. Disruptive Mood Dysregulation Disorder Among Children and Adolescents. FOCUS: JOURNAL OF LIFE LONG LEARNING IN PSYCHIATRY 2016; 14:20-25. [PMID: 31975790 DOI: 10.1176/appi.focus.20150039] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Disruptive mood dysregulation disorder (DMDD) was introduced in the mood disorders section of DSM-5. Its primary symptoms are "severe, recurrent temper outbursts" (manifested verbally and/or physically) superimposed on and associated with chronic irritability. DMDD is a condition with an early age of onset (i.e., symptoms apparent by age 10, although the diagnosis cannot be made before age 6); however, nothing is known about the condition among adults in part because questions about temper outbursts (versus "often losing temper") are not consistently asked after 6 years of age. Other qualifiers are present so that better-known conditions are not overlooked. For instance, manic symptoms that are present for more than 1 day, symptoms that are not exclusively occurring during major depressive disorder, or symptoms that are better explained by autism, posttraumatic stress disorder, separation anxiety, and dysthymia are exclusionary. Although DMDD can co-occur with attention-deficit hyperactivity disorder (ADHD), conduct disorder, and substance use disorder, it preempts diagnoses of both oppositional defiant disorder and intermittent explosive disorder.
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Affiliation(s)
- Gabrielle A Carlson
- Dr. Carlson is professor of Psychiatry and Pediatrics and director emerita in the Division of Child and Adolescent Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York (e-mail: ). Dr. Pataki is clinical professor of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
| | - Caroly Pataki
- Dr. Carlson is professor of Psychiatry and Pediatrics and director emerita in the Division of Child and Adolescent Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York (e-mail: ). Dr. Pataki is clinical professor of Psychiatry and Biobehavioral Sciences, David Geffen School of Medicine at University of California, Los Angeles
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50
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Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation disorder: current insights. Neuropsychiatr Dis Treat 2016; 12:2115-24. [PMID: 27601906 PMCID: PMC5003560 DOI: 10.2147/ndt.s100312] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Disruptive mood dysregulation disorder (DMDD) was introduced as a new diagnostic entity under the category of depressive disorders in Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). It was included in DSM-5 primarily to address concerns about the misdiagnosis and consequent overtreatment of bipolar disorder in children and adolescents. DMDD does provide a home for a large percentage of referred children with severe persistent irritability that did not fit well into any DSM, Fourth Edition (DSM-IV) diagnostic category. However, it has been a controversial addition to the DSM-5 due to lack of published validity studies, leading to questions about its validity as a distinct disorder. In this article, the authors discuss the diagnostic criteria, assessment, epidemiology, criticism of the diagnosis, and pathophysiology, as well as treatment and future directions for DMDD. They also review the literature on severe mood dysregulation, as described by the National Institute of Mental Health, as the scientific support for DMDD is based primarily on studies of severe mood dysregulation.
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Affiliation(s)
- Raman Baweja
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - Susan D Mayes
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - Usman Hameed
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
| | - James G Waxmonsky
- Department of Psychiatry, Penn State University College of Medicine, Hershey, PA, USA
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