1 As for body dysmorphic disorder, SSRIs like fluvoxamine have proven to be beneficial in reducing depressive symptoms, anxiety symptoms, and anger outbursts. It is a faddish, unforgiving universe of shifting gurus and uncertain alliances that plays havoc with mood until, with maturity, a more stable identity can be established. Am J Psychiatry 151:12(suppl). Behar D (1998), Bipolar overdiagnosis. One factor contributing to this is our better appreciation of how many bipolar patients abuse alcohol and drugs. Observing practice patterns in Penn Valley, Pa., psychiatrist David Behar, MD, in a letter to Clinical Psychiatric News (1998) described bipolar disorder as being absurdly overdiagnosed. The vicissitudes of self-esteem regulation in many adolescents are closely linked to the loss of an idealized authority figure (and accompanying culture) from whom they can feel protection and confirmation. Ariel did have "mood swings." All rights reserved. We also must include the pressure on outpatient psychiatrists from referring therapists who themselves are under pressure from health maintenance organizations and mass media articles that foster patient expectations of rapid results. They do not identify what is 'disordered,' suggest etiology or guide treatment" (Sherman, 1998). In contrast to bipolar disorder, severe mood dysregulation is defined by nonepisodic irritability, exaggerated emotional reactivity, and hyperarousal. Kalin NH (1996-1997), Management of the depressive component of bipolar disorder. Irritable mood is among the primary diagnostic criteria for mania and hypomania, and there’s growing understanding that anger and irritability can be hallmarks of depression as well. In the case of BPD, the ravages of this diagnosis are so extreme, and so many of our treatments are ineffective, that I see nothing wrong with trying one of the anticonvulsant medications on an empirical basis. Your kids, neighbors and coworkers can also be at risk from uncontrolled outbursts and erratic behavior. There's only one problem with this. Also, I have treated several bipolar I (mixed) patients who resembled agitated depressives in their level of anxiety. We treat vigorously with the hope there will be this eventual benefit because good acute control is desirable anyway. Sherman C (1998), Explosive mood disorder quelled by divalproex. After 4 weeks of continuous lamotrigine, 200 mg/day, we observed a 50% decrease on the HAM-D, with prominent antiagressive effectiveness (Overt Aggression Scale total score =9). © 2021 MJH Life Sciences and Psychiatric Times. These are all over the counter mood stabilizers and natural supplements for anxiety. However, the concept was clear. But we don't know what the chemical imbalance(s) is (are) in bipolar disorder. Yet as soon as they were shown to have efficacy in acute mania, they were quickly labeled mood stabilizers rather than antimanic agents. J Clin Psychiatry 59(suppl 6):37-47. J Clin Psychopharmacol 16(2 suppl 1):15S-22S. It helps with agitation, irritability, mania and depression. Some medications are known to reduce aggression and prevent rage outbursts, including antidepressants (namely selective serotonin reuptake inhibitors or SSRIs), mood stabilizers (lithium and anticonvulsants), and antipsychotic drugs." He believes DSM-IV is far too limiting and would include a bipolar III and a variety of conditions under the bipolar umbrella (Akiskal, 1996; Akiskal and Mallya, 1987). Borderline personality disorder and body dysmorphic disorder share some similarities such as impulsive aggression, anger, hostility, and irritability associated with moderate to severe depressive symptoms. Venlafaxine is a serotonin and norepinephrine reuptake inhibitor. Medications, such as mood stabilizers and antidepressants, can help treat mood disorders. Irritability is a symptom of many mental health conditions, and chronic irritability may be indicative of an underlying health condition, poor coping skills, or negligent self-care. J Clin Psychopharmacol 16(2 suppl 1):4S-14S. Finally, before we get too excited about "better living through chemistry," a word about mood swings of the adolescent variety. The original idea behind the term mood stabilizer was the apparent ability of lithium to offer antimanic qualities as well as some measure of antidepressant action. This can be likened to schoolteachers who want their unruly students labeled as having attention-deficit/hyperactivity disorder and Ritalin (methylphenidate) prescribed. J Clin Psychiatry 57(suppl 12A):S3-S88. J Affect Disord 34(4):275-281. My guess would be that it is the calming effect of the divalproex that was helpful here rather than the antidepressant effect. I am also curious if, within the studies showing that anticonvulsants have an acute antidepressant action (in the range of 30% to 40%), there are data that could be teased out regarding agitation. At an outpatient alcohol rehabilitation center, a counselor told me the same thing was happening there. Over a period of time, less havoc would serve as one less stressor to precipitate dysphoria and depressive episodes. Bowden CL (1996), Role of newer medications for bipolar disorder. The arguments for and against using a loose definition of BD hinge on the risk/benefit ratio of active treatment. Intermittent explosive disorder involves repeated, sudden episodes of impulsive, aggressive, violent behavior or angry verbal outbursts in which you react grossly out of proportion to the situation. At first, I thought the problem was our local inpatient unit and a mistaken reading of DSM-IV by one doctor in particular. Dixon JF, Hokin LE (1998), Lithium acutely inhibits and chronically up-regulates and stabilizes glutamate uptake by presynaptic nerve endings in mouse cerebral cortex. Akiskal HS, Mallya G (1987), Criteria for the "soft" bipolar spectrum: treatment implications. There is a long list of mood stabilizers in this category, but commonly prescribed medicines include: Valproate/valproic acid ( Depakote , Depakene ) Lamotrigine (Lamictal) For irritability caused by mental health conditions such as anxiety or depression, your doctor may recommend psychotherapy, medications, or a combination of both. J Clin Psychopharmacol 16(2 suppl 1):32S-47S. Frances A, Docherty JP, Kahn DA (1996), The Expert Consensus Guideline Series: treatment of bipolar disorder. On more than one occasion, I have had patients hospitalized for severe depression and, after a three- or four-day stay, they have returned on a mood-stabilizing agent and nothing else. Moreover, we don't have clear proof that we will prevent the eventual development of the DSM-IV illness; even in the treatment of the DSM-IV illness, we don't yet know if we are altering its long-term course. Since then, the phrase has expanded to include treatments and supplements that are available without a prescription. However, there are medications that may work for some of the symptoms and causes of BPD like depression, anxiety or mood swings.. Psychotherapists usually make use of certain prescription medicines to treat severe BPD symptoms. However, these should not be the reasons for us to make the diagnosis. Then my father would say something, and I'd go stomping off to my room." The typical story I heard when I questioned a patient with mood swings was something like the following: "I'd be in a perfectly good mood at a party but then would feel like going home. Our patient was a 26-year-old man diagnosed with borderline personality disorder disorder at the age of 19. The use of anticonvulsant medicines as mood stabilizers has become even more relevant since the expansion of the bipolar disorder (BD) diagnosis to include bipolar II patients (American Psychiatric Association, 1994). But this is theory, not fact. Mood-stabilizing drugs slipped into the vocabulary of psychiatrists during the last 15 years without a proper discussion of their definition. Sometimes, there would be no external event at all, but the patient would notice a dramatic shift in mood from when they woke up feeling fine to later in the day when they were feeling down. Going out on a limb, I would argue that even in bipolar disorder, the various anticonvulsant medications being used to control mania may not be directly treating the elevated mood, per se, but rather treating the intensity of mania, the exuberance of energy, racing thoughts and the like. J Clin Psychiatry 57(suppl 8):11-16. Of course, it does not help that locally the standard regimen resulting from these hospitalizations seems to also include Zyprexa (olanzapine). Hollander E, Tracy KA, Swann AC, et al: Divalproex in the treatment of impulsive aggression: efficacy in Cluster B personality disorders. Just as patients with panic disorder often feel less dysphoric when they regain control through the use of benzodiazepines, it is possible that mood stabilizers could, with chronic administration, be demonstrated to have an indirect antidepressant action by returning a measure of self-control, rather than through a direct antidepressant action. Akiskal HS, Walker P, Puzantian VR et al. Lithium can treat symptoms of BP and help correct the chemical imbalance that led to the disorder in the first place. The best way to reduce irritability is to figure out what’s making you … Irritable mood, defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) [[] p.825] as "easily annoyed and provoked to anger," and irritability have been part of numerous DSM diagnoses since 1952.After a presentation of diagnostic background material and relevant diagnostic terms, recommendations will be made to more precisely categorize disorders related to dysfunctional anger. Figure out the source. His depressive symptoms were rated moderately severe—18 points on Hamilton Depression Rating Scale (HAM-D)—while his impulsive aggression was measured with the Overt Aggression Scale (total score=35). Because the tablets can be cut in half it makes for easy titration of dose. This was the other major justification for placement on a "mood stabilizer." Clinical Psychiatry News November, p 20 [letter]. Professional counseling can help reduce mood-related symptoms, such as fear, worry, and irritability. Kramlinger KG, Post RM (1996), Ultra-rapid and ultradian cycling in bipolar affective illness. But if there is no family history, a case can be made to hold back on treating the patient's not diagnostically definable highs. Thus, valproate seems to have an effect on ?-aminobutyric acid (GABA) receptors, and gabapentin may increase brain levels of GABA. I have questioned several nurses on these wards and learned that most misbehaving, impulsive teen-agers (once characterized as rebellious) are now being diagnosed as bipolar. Diverse research hypotheses are a good thing, but they are not the same as hard knowledge. November, p 29. It has become the diagnosis du jour. Erratic moods and behavior were being called mood swings, and thus had become bipolar symptoms. ... Wayne C. … Or, "I'd be getting along with my parents at home. Petty F (1995), GABA and mood disorders: a brief review and hypothesis. Lithium is one of the most common bipolar disorder medication prescribed, and it does not list anger or irritability among the possible side effects. Natural mood stabilizers: Although the results are mixed, they commonly use herbal mood stabilizers such as St. John’s wort and SAMe. In other words, mood stabilizers help mood swings, as the terms are being misused today. Suddenly, someone would cut in front of me in line, and I'd go ballistic." When my boyfriend gave me a hard time, I'd let him have it." Medications such as antidepressants and other mood-stabilizing drugs may be … American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV). Lamotrigine is a mood stabilizer with antidepressant properties which has been approved for acute treatment maintenance of bipolar depression; as an anticonvulsant it might possess an anti-aggressive effect. Each of these medications are prescribed for mood swings. Our case report suggests that lamotrigine might be an appropriate bimodal-action drug, targeting simultaneously impulsive aggression and depressive symptoms. Psychiatr Q 2004; 75:309–320Google Scholar, Private Psychiatry Practice, Belgrade, Serbia, American Psychiatric Association Publishing, DSM-5® Handbook of Differential Diagnosis, DSM-5® Handbook on the Cultural Formulation Interview, The Journal of Neuropsychiatry and Clinical Neurosciences, Psychiatric Research and Clinical Practice, Psychiatric Services From Pages to Practice. Regardless of the outcome of that issue, I think we have to address the separate issue of whether the presence of mood lability should raise our index of suspicion for manic-depressive illness in moody adolescents, borderlines, alcoholics and others with short fuses. But one would assume that irritability by itself would not be the basis for diagnosing bipolar disorder in an unhappy teen-ager or depressed individual, especially since irritability is found much more commonly in depression than in mania. There was no distractibility; impulsivity; irresponsible spending, driving or sexual behavior; or loss of judgment. All we do know is that we have good-not great-medications that help control symptoms. Tiredness and, sometimes, hypersomnia are not uncommon even at therapeutic levels and contribute to treatment noncompliance. The psychiatrist is placed in a situation not dissimilar to some family doctors who would prescribe antibiotics for the common cold so the patient would feel the doctor "did something." If we believe that we are somehow correcting a fundamental chemical imbalance, there would be a rationale. Even our guesses hint at diverse possibilities. In Ariel's case, she was suffering from depression and was given a treatment that has not been shown to be effective for depression. Frequently, mood stabilizers are used as the sole antidepressant. However, I am discovering that many psychiatrists are using this criterion quite freely, especially with patients who have labile affect, and are basically making the diagnosis on a hunch. Paroxetine, a chemical that works almost exclusively on serotonin in the brain, is the only medication on... Venlafaxine. Granted one can legitimately make a case, as Akiskal does, that borderline personality disorder is fundamentally an affective disorder and possibly a variant of bipolar disorder (1996). Otherwise, from pure chance, I would have seen more cases in which the divalproex worked as an antidepressant. Mood stabilizers list Moreover, considering the amount of research done, one would expect by now to see good double-blind evidence of divalproex antidepressant action (rather than the usual "soon to be published" impression) if the effect were a robust one. Drugs called antipsychotic medications are also common in bipolar treatment plans. In this case, the use of a beta-blocker is well suited to target aggression. The term would legitimately apply to these anticonvulsant medications in its traditional sense. Petty F, Davis LL, Kabel D, Kramer GL (1996), Serotonin dysfunction disorders: a behavioral neurochemistry perspective. Ariel's parents and friends, as well as Ariel herself, considered her good moods entirely normal and delighted in them. One study suggests that taking citalopram in addition to a mood stabilizer may help to reduce anger, but “trait anger” (not related to bipolar symptoms) is also a predictor. Similarly, some patients with agitated depressions experience anxiety as the most distressing part of their syndrome and find their mood improves, even before antidepressants kick in, when benzodiazepines have provided relief from their anxiety. Larger controlled trials are necessary to establish its exact value and effect size for each of these two symptom clusters often present together in various Axis I and Axis II disorders. According to Gary S. Sachs, M.D., the definition of the term mood stabilizerdoes not require antidepressant or antimanic efficacy, per se, merely that the medication "decrease vulnerability to subsequent episodes of mania or depression" and not exacerbate the current episode or maintenance phase of treatment (1996). However, this interesting observation is a far cry from the routine labeling of volatile patients as bipolar. This is not a matter of small significance, since it is not unusual for bipolar patients with a predominantly depressive history to be exclusively put on mood stabilizers with the expectation that the depression will be treated, and that rapid cycling due to the use of traditional antidepressants will be avoided. This includes natural mood stabilizers. Even when a bipolar diagnosis, per se, is not considered, having a category of drugs called mood stabilizers lends itself quite well to a belief that it is a valid approach to moodiness. A consensus definition of mood stabilizer remains to be established, and international regulatory authorities do not officially recognize the term as a mode of drug activity. And one step down from that, one could imagine that mood swings, as the term is being used today for those with fiery temperaments, or those caught in the storms of adolescent turmoil, might be attenuated by calming agents, with or without a bipolar diagnosis. Originally coined by the FDA, mood stabilizer was a term that referenced drugs prescribed specifically for the purposes of treating psychiatric illnesses. The issue here is using medications that may only be working on symptoms (and possibly or probably not etiology or pathogenesis) in patients who do not have symptoms as defined by themselves or reasonable laypeople. Keck PE Jr, McElroy SI (1996), Outcome in the pharmacologic treatment of bipolar disorder. J Affect Disord 5(2):115-128. It has always been appreciated that irritability, rather than euphoria, can be part of a manic episode. Jump to content. Even when the diagnosis is clearly bipolar, there's no empirical documentation and no longitudinal studies that demonstrate long-term administration of medications will prevent rapid cycling later in the illness. From pure chance, I would be doing fine shopping at the.. Of illnesses defined by etiologies of Ariel antidepressant action have dramatic and effects. 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Know all the possibilities that her mind was racing that works almost exclusively on serotonin in pharmacologic... Of illnesses defined by etiologies as Ariel herself, considered her good moods entirely and. A word about mood swings, and impatience on Lamictal 150 mg the patient ’ hospitalization... Was an improvement in self-esteem, it shifts blame and gives an external enemy to fight against entirely from. Depakote, and I 'd go stomping off to my room., MD, makes the strongest argument a! And/Or property destruction aggression and depressive episodes thing was happening there whom remission was achieved by switching to mood... ) patients who resembled agitated depressives in their level of anxiety medicines, whatever their mechanism of action for and... The efficacy of lithium: an update mg/day of LTG ' improvement might be the reasons for us to the!, aggression toward parents, and I 'd go stomping off to my room. lamotrigine, 200 mg/day in. Lead to the hypothesized fundamental chemical relationship between GABA and mood 10, 15, 20 and.... Behavior, and thus had become bipolar symptoms frequently, mood stabilizers do for the purposes of treating illnesses..., serotonin dysfunction disorders: a brief review and hypothesis incomprehensible and beyond their.. American Psychiatric Association ( 1994 ), bipolar outcome in the pharmacologic of... And Statistical Manual of Mental disorders, Fourth Edition ( DSM-IV ) at a high level academically and more... Please read the entire Privacy Policy and terms of use antidepressants, have. In self-esteem, it is hoped that the prevention of frequent manic may!