Irritability through Research Domain Criteria: an opportunity for transdiagnostic conceptualisation

An evaluation of the Ultimatum Game as a measure of irritability and anger

The Ultimatum Game is an effective tool for understanding how social decision-making is influenced by emotions in both research and clinical settings. Previous findings have shown that the Ultimatum Game can evoke negative emotions, especially anger and aggression. In a sample of non-clinical adults (N = 143) we evaluated the sensitivity of an anger-infused version of the Ultimatum Game to individual differences in anger and irritability. Findings showed significant relationships between anger and aggressive behaviors in the Ultimatum game, but no association between irritability and aggressive behavior were observed. This indicates that the anger-infused Ultimatum Game is a promising method for studying individual differences in trait anger and anger expression. However, the relationship between decision-making in the anger-infused Ultimatum Game and irritability is less straight forward and needs further investigation. Therefore, when studying the behavioral responses of irritability, it would be beneficial to capture other behaviors beyond aggressive responses.

A network approach to the investigation of childhood irritability: probing frustration using social stimuli

BACKGROUND

Self-regulation in early childhood develops within a social context. Variations in such development can be attributed to inter-individual behavioral differences, which can be captured both as facets of temperament and across a normal:abnormal dimensional spectrum. With increasing emphasis on irritability as a robust early-life transdiagnostic indicator of broad psychopathological risk, linkage to neural mechanisms is imperative. Currently, there is inconsistency in the identification of neural circuits that underlie irritability in children, especially in social contexts. This study aimed to address this gap by utilizing a functional magnetic resonance imaging (fMRI) paradigm to investigate pediatric anger/frustration using social stimuli.

METHODS

Seventy-three children (M = 6 years, SD = 0.565) were recruited from a larger longitudinal study on irritability development. Caregivers completed questionnaires assessing irritable temperament and clinical symptoms of irritability. Children participated in a frustration task during fMRI scanning that was designed to induce frustration through loss of a desired prize to an animated character. Data were analyzed using both general linear modeling (GLM) and independent components analysis (ICA) and examined from the temperament and clinical perspectives.

RESULTS

ICA results uncovered an overarching network structure above and beyond what was revealed by traditional GLM analyses. Results showed that greater temperamental irritability was associated with significantly diminished spatial extent of activation and low-frequency power in a network comprised of the posterior superior temporal sulcus (pSTS) and the precuneus (p < .05, FDR-corrected). However, greater severity along the spectrum of clinical expression of irritability was associated with significantly increased extent and intensity of spatial activation as well as low- and high-frequency neural signal power in the right caudate (p < .05, FDR-corrected).

CONCLUSIONS

Our findings point to specific neural circuitry underlying pediatric irritability in the context of frustration using social stimuli. Results suggest that a deliberate focus on the construction of network-based neurodevelopmental profiles and social interaction along the normal:abnormal irritability spectrum is warranted to further identify comprehensive transdiagnostic substrates of the irritability.

Mediating effect of amygdala activity on response to fear vs. happiness in youth with significant levels of irritability and disruptive mood and behavior disorders

Introduction

Irritability, characterized by a tendency to exhibit increased anger, is a common clinical problem in youth. Irritability is a significant clinical issue in youth with various psychiatric diagnoses, especially disruptive behavior, and mood disorders (Attention-Deficit/Hyperactivity Disorder, Oppositional Defiant Disorder, Conduct Disorder, and Disruptive Mood Dysregulation Disorder). Although there have been previous studies focusing on functional alteration in the amygdala related to irritability, there is no comprehensive model between emotional, neuronal, and behavioral characteristics.

Methods

Using an functional magnetic resonance imaging (fMRI) procedure, we investigated the relationships between behavioral irritability, selective impairments in processing facial emotions and the amygdala neural response in youth with increased irritability. Fifty-nine youth with disruptive mood and behavior disorder completed a facial expression processing task with an event-related fMRI paradigm. The severity of irritability was evaluated using the Affective Reactivity Index.

Results

In the result of behavioral data, irritability, and reaction time (RT) differences between interpreting negative (fear) and positive (happiness) facial expressions were positively correlated. In the fMRI result, youth showed higher activation in the right cingulate gyrus, bilateral cerebellum, right amygdala, right precuneus, right superior frontal gyrus, right middle occipital gyrus, and middle temporal gyrus, during the happiness condition vs. fear condition. No brain region exhibited greater activation in the fear than in the happiness conditions. In the result of the mediator analysis, increased irritability was associated with a longer RT toward positive vs. negative facial expressions. Irritability was also positively associated with the difference in amygdala blood oxygen level-dependent responses between the two emotional conditions (happiness > fear). This difference in amygdala activity mediated the interaction between irritability and the RT difference between negative and positive facial expressions.

Discussion

We suggest that impairment in the implicit processing of facial emotional expressions with different valences causes distinct patterns of amygdala response, which correlate with the level of irritability. These results broaden our understanding of the biological mechanism of irritability at the neural level and provide information for the future direction of the study.

The diagnosis of bipolar disorder in children and adolescents: Past, present and future

AIMS

This article examines the ongoing debate concerning the diagnosis of bipolar disorder in children and adolescents. This contentious issue has generated robust discussion over the past two decades without consensus, and as such the true prevalence of so-called paediatric bipolar disorder (PBD) remains unknown. In this article we offer a solution to break this deadlock.

METHODS

Recent meta-analyses and additional literature concerning the definition and prevalence of PBD was critically reviewed with a view to understanding the perspectives of those developing the taxonomy of PBD, and those engaged in research and clinical practice.

RESULTS

A key finding is the lack of iteration and meaningful communication between the various groups interested in PBD that stems from deep-seated problems within our classificatory systems. This undermines our research efforts and complicates clinical practice. These problems make the already difficult diagnosis of bipolar disorder in adults even more challenging to transpose to younger populations, and additional complexities arise when parsing clinical phenomenology from normative developmental changes in youth. Therefore, in those manifesting bipolar symptoms post-puberty, we argue for the use of adolescent bipolar disorder to describe bipolar symptoms whereas in pre-pubertal children, we propose a reconceptualisation that allows symptomatic treatment to be advanced whilst requiring critical review of these symptoms over time.

CONCLUSION

Significant changes in our current taxonomy are necessary and to be clinically meaningful, these revisions to our diagnoses need to be developmentally-informed.

Early reduction in irritability is associated with improved outcomes among youth with depression: Findings from the AMOD study

OBJECTIVES

Evaluate whether early improvement in irritability predicts improvement in depression severity in a naturalistic sample of adolescents undergoing pharmacologic treatment for major depressive disorder.

METHODS

Adolescents (N = 161) aged 13-18 years with a moderate to severe depressive episode were enrolled. Outcome measures included the Children's Depression Rating Scale-Revised (CDRS-R), Quick Inventory of Depressive Symptomatology (QIDS-A₁₇), and Clinical Global Impression scale (CGI). Paired t-tests were used to estimate the change in irritability items from baseline to week-4, and Cohen's d effect sizes were computed. Separate linear regression analyses with CDRS-R, QIDS-A₁₇, and CGI at week-8 as the dependent variables and baseline levels of irritability and baseline-to-week-4 changes in irritability as independent variables of interest were conducted. These analyses were repeated after controlling for overall depression severity (minus the irritability item) at baseline and baseline to week-4 change.

RESULTS

Greater baseline to week-4 reduction in irritability was associated with lower levels of CDRS-R, QIDS-A₁₇, and CGI at week-8. These findings were significant for QIDS-A₁₇ and CGI even after controlling for baseline-to-week-4 changes in other depressive symptoms.

LIMITATIONS

The single item evaluation of irritability reduced assessment reliability in the absence of validated measures of irritability.

CONCLUSIONS

Early reduction in irritability is strongly associated with better outcomes in depressed youths, regardless of baseline depression severity. Further research is needed to quantify the burden of irritability, explore it as a tool for measurement-based care, and to develop targeted treatments for irritability.

Dissecting the depressed mood criterion in adult depression: The heterogeneity of mood disturbances in major depressive episodes

BACKGROUND

Mood disturbances have historically remained a core criterion in diagnosing major depressive episode. DSMs have illustrated this criterion with depressed, hopeless, discouraged, cheerless, and irritable mood, suggesting interchangeability. Extant research has examined individual forms of mood disturbance to depression severity. Less examined is the heterogeneity in mood disturbances and its implication to their association to depression presentations and outcomes.

METHOD

The current study used a nationally representative sample of U.S. adults with unipolar major depressive disorder to study the association between specific forms of mood disturbances to depression severity, chronicity, or symptoms, above and beyond other forms, as well as their relations to functional impairment, suicidal outcomes, and psychiatric comorbidity via generalized linear models.

RESULTS

Cheerless and hopeless mood were associated with depression severity. Hopeless and irritable mood were associated with depression chronicity. Different forms of mood disturbance showed differential relations to depressive symptoms. Cheerless, hopeless, and irritable mood were associated with depression-specific functional interference, incremental to depression severity. Cheerless, hopeless, and discouraged mood were associated with passive suicidal ideation. Hopeless mood was associated with active suicidal ideation. Hopeless and irritable mood were associated with both suicide plan and suicide attempt. Different forms of mood disturbance demonstrated differential associations to comorbid psychiatric conditions.

DISCUSSION

The relations between different forms of mood disturbances and various aspects of depression are nuanced. Theoretically, these relations highlight the potential utility in acknowledging the complexity and heterogeneity in mood disturbances. Clinically, our results suggest potential utility in routinely monitoring mood disturbances.

Parent training for the treatment of irritability in children and adolescents: a multisite randomized controlled, 3-parallel-group, evaluator-blinded, superiority trial

Background

Irritability is common in children and adolescents with Attention Deficit Hyperactivity Disorder (ADHD), Oppositional Defiant Disorder (ODD) and with anxiety/depressive disorders. Although youth irritability is linked with psychiatric morbidity, little is known regarding its non-pharmacological treatments. Developing non-pharmacological treatments for children with severe, chronic irritability is an important target for clinical research. To achieve this goal, we will test the benefits of parent-focused therapies in reducing irritability. The aim of the study is to compare Parent Management Training (PMT) and Non-Violent Resistance Training (NVR) programs with treatment-as-usual (TAU) on the improvement of irritability in children and adolescents with a baseline Parent-rated Affective Reactivity Index of 4 or higher, in the context of ADHD and other emotional and behavioural disorders. Additionally, we will assess (i) improvement of irritability at different times and according to different informants (parents, children, clinicians); (ii) improvement of parental strategies; and (iii) acceptability of the interventions, exploring possible mechanisms of the therapeutic effect.

Methods

Two hundred and seventy participants between 6 and 15 years with ADHD and other emotional and behavioural disorders will be recruited and randomly assigned with their parents to the PMT, NVR, and TAU groups. PMT and NVR programs have 10 online sessions and two booster sessions at 1 and at 3 months. The primary outcome measure is the change from baseline at 3 months after completion of the program of the Clinician-rated Affective Rating Scale (CL-ARI) assessed by a blind evaluator. Secondary outcome measures include the change from baseline from those scales: the CL-ARI, the Clinical Global Impression Improvement scale, the Parenting and Familial Adjustment Scales, the Child-rated Cranky thermometers and the Parent-rated ARI. We will assess the parent’s expressed emotions and reflexivity during the online five-minute speech sample, clinical dimensions through the Child Behavior Checklist 6–18 and the Inventory of Callous Unemotional traits. Evaluations will be done remotely at baseline and at 1- and 3-months follow-up visits.

Discussion

We expect a benefit in controlling irritability in the treatment groups. This will constitute an important achievement in promoting parental support programs in the treatment of irritability in the context of emotional and behavioural disorders.

Clinicaltrials.gov. Number: NCT05528926. Registered on the 2nd of September, 2022.

Translating RDoC to Real-World Impact in Developmental Psychopathology: A Neurodevelopmental Framework for Application of Mental Health Risk Calculators

The National Institute of Mental Health Research Domain Criteria's (RDoC) has prompted a paradigm shift from categorical psychiatric disorders to considering multiple levels of vulnerability for probabilistic risk of disorder. However, the lack of neurodevelopmentally-based tools for clinical decision-making has limited RDoC's real-world impact. Integration with developmental psychopathology principles and statistical methods actualize the clinical implementation of RDoC to inform neurodevelopmental risk. In this conceptual paper, we introduce the probabilistic mental health risk calculator as an innovation for such translation and lay out a research agenda for generating an RDoC- and developmentally-informed paradigm that could be applied to predict a range of developmental psychopathologies from early childhood to young adulthood. We discuss methods that weigh the incremental utility for prediction based on intensity and burden of assessment, the addition of developmental change patterns, considerations for assessing outcomes, and integrative data approaches. Throughout, we illustrate the risk calculator approach with different neurodevelopmental pathways and phenotypes. Finally, we discuss real-world implementation of these methods for improving early identification and prevention of developmental psychopathology. We propose that mental health risk calculators can build a needed bridge between RDoC's multiple units of analysis and developmental science.

Novel insights into irritability: the relationship between subjective experience, age and mood

BACKGROUND

The relationship between irritability as a subjective experience and the behavioural indicators typically used to measure the construct are not known. Its links to mood, and contextual relationships, vary with age and are yet to be thoroughly examined.

AIMS

First, to interrogate the relationship between the subjective experience of irritability and mood, and that with its behavioural indicators. Second, to determine how these relationships vary with age and over time.

METHOD

This study examined data from a previous clinical trial of adolescents and young adults (N = 82) with bipolar disorder, who received a psychological intervention over 18 months. Participants completed a battery of questionnaires, which included assessments of irritability. Analyses of covariance were conducted to examine the interaction between mood symptoms, subjective measures of irritability, behavioural measures of irritability and age over time.

RESULTS

Subjective irritability scores differed significantly over time when controlling for manic, but not depressive, symptom scores. Further, subjective irritability significantly differed when controlling for behavioural measures of irritability (temper outbursts and argumentativeness). There were significant interactions between scores of depressive symptoms, temper outbursts and subjective irritability with age, wherein younger participants showed no correlation between depressive symptoms and temper outbursts. In addition, younger participants showed lower correlations between subjective irritability and both depressive and temper outburst scores, than older participants.

CONCLUSIONS

Subjective irritability is linked to mood morbidity and behavioural outbursts, and these relationships are contingent on age. Our novel findings suggest that subjective irritability should be assessed in greater detail in patients with mood disorders.

Irritability in Mood Disorders: Neurobiological Underpinnings and Implications for Pharmacological Intervention

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.