However, the concept was clear. Lithium is one of the most common bipolar disorder medication prescribed, and it does not list anger or irritability among the possible side effects. During our interview we also diagnosed presence of body dysmorphic disorder. 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. 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. The American Psychiatric Association's Practice Guideline for Treatment of Patients With Bipolar Disorder (1994) defines mood stabilizers as "medications with both antimanic and antidepressive actions." 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 Affect Disord 34(4):275-281. Frequently, mood stabilizers are used as the sole antidepressant. Uncontrolled anger can affect your relationships, your job and your health. To the Editor: Many psychiatric disorders are characterized by impulsive auto-hetero-aggression and violence which are manifested as suicide attempts, self-injurious behavior, or physician-directed violence or domestic violence. It could have been considered prior to a mood stabilizer given the severity of the aggression, but impulsivity and irritability were felt to be the primary underpinnings of the aggressive behaviors. Dixon JF, Hokin LE (1998), Lithium acutely inhibits and chronically up-regulates and stabilizes glutamate uptake by presynaptic nerve endings in mouse cerebral cortex. Ariel, a 16-year-old girl, had a history of repeated severe suicidal depressions punctuated by periods of a few hours, sometimes a day or two (definitely not four days as specified in the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition for hypomania), in which she felt a bit giddy as well as more social, energetic and creative. We initiated treatment with lamotrigine, 200 mg/day, in order to reduce both symptom domains. There were no treatment-emergent adverse events. 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. From time to time, various benzodiazepines have been claimed to have antidepressant efficacy. In addition to "mood swings" being used as the basis for diagnosis, irritability has gained new status. Severe mood dysregulation and bipolar disorder differ with regard to familial aggregation ( 6 ), physiological responses to frustration ( 7 ), and neural responses to social stimuli ( 8 ). Pharmacol Biochem Behav 52(2):329-333. Eliminate calling the patients bipolar and not that much harm is done. J Affect Disord 5(2):115-128. Originally coined by the FDA, mood stabilizer was a term that referenced drugs prescribed specifically for the purposes of treating psychiatric illnesses. Or, it might be an indirect result of their tranquilizing function. 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. To summarize, there are three important questions:1) Are rapidly shifting moods (now mislabeled as mood swings) particularly diagnostic of bipolar disorder?2) Are mood-stabilizing medications useful in patients with rapidly shifting moods whether or not they are truly bipolar?3) What is the mechanism of action of the anticonvulsant medications that make them useful in psychiatric conditions? There is little if any clear-cut evidence that valproate (Depakote, Depakene), carbamazepine (Tegretol) (Kalin, 1996-1997) or gabapentin (Neurontin) are effective antidepressant agents. Natural mood stabilizers: Although the results are mixed, they commonly use herbal mood stabilizers such as St. John’s wort and SAMe. In this case, the issue is not whether anticonvulsant, antimanic medications deserve to be called mood stabilizers in bipolar disorder, but rather that the termmood stabilizers conveys the impression that they are a perfect fit for volatile, overemotional patients. Ariel did have "mood swings." 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. it wo (depakote, act. Am J Psychiatry 151:12(suppl). Ariel's parents and friends, as well as Ariel herself, considered her good moods entirely normal and delighted in them. Rather, the patients' improvement might be the result of these agents' tranquilizing function. It helps with agitation, irritability, mania and depression. Quetiapine was successfully combined with mood stabilizers, particularly gabapentin, in patients with prominent affective instability. 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." J Clin Psychopharmacol 16(2 suppl 1):4S-14S. 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. Pressure also comes from the occasional therapist who doesn't like their diagnostic acumen questioned and will refer elsewhere if the patient doesn't receive medication for mood swings. As described in the Privacy Policy and Terms of Use, this website utilizes cookies, including for the purpose of offering an optimal online experience and services tailored to your preferences. 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. However, DSM-IV is not a true collection of illnesses defined by etiologies. Both valproate and carbamazepine did little better than placebo in the studies they cited, but if I understand them correctly, they considered bringing relief from the torment of depression as quickly as possible a less important priority than not iatrogenically causing mood instability. While the concern about antidepressants causing rapid cycling is based on an indisputable clinical possibility, these experts have no illusions about the effectiveness (or indisputable evidence for the effectiveness) of anticonvulsant medications as treatment for acute bipolar depression. Mood stabilizers may also be an effective treatment of irritability in HD. provides accurate and independent information on more than 24,000 prescription drugs, over-the-counter medicines and natural products. Proc Natl Acad Sci U S A 95(14):8363-8368. The latest speculations about lithium are that it is affecting G-proteins, that it exerts a push/pull effect on the neurotransmitter glutamate (Dixon and Hokin, 1998; Lenox et al., 1998), or that it alters sodium transport in nerve and muscle cells and effects a shift toward intraneuronal metabolism of catecholamines (Physicians' Desk Reference, 1999). J Clin Psychiatry 59(suppl 6):37-47. She would be in a perfectly good mood and then suddenly, with relatively minor provocation, switch to sadness, irritability or an outburst of anger. Kramlinger KG, Post RM (1996), Ultra-rapid and ultradian cycling in bipolar affective illness. As far as they were concerned, their behavior was totally incomprehensible and beyond their control. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. Strober M, Carlson G (1982), Bipolar illness in adolescents with major depression: clinical, genetic and psychopharmacologic predictors in a three- to four-year prospective follow-up investigation. Although there was an improvement in self-esteem, it was not inflated or grandiose. Similarly, rapid cycling-defined in the DSM-IV as four or more switches in a year-not infrequently appears in clinical summaries when what is being described are labile moods. Indeed, if we picture seizures as "a massive discharge of neurons," it is not much of a stretch to think of the various psychiatric conditions where anticonvulsant mechanisms are finding particular usefulness-explosive disorder, mania, panic disorder, borderline personality disorder-as conditions that may possibly have analogous massive discharges of nerve impulses. Valproate may deserve its widespread usage. J Clin Psychopharmacol 16(2 suppl 1):48S-55S. Both valproate and carbamazepine were effective in a case report of a patient with irritability and anger outbursts, although the treatment with valproate was compromised by an increase in liver transaminase and transferase ( Dujmovic et al., 2014 ). Then my father would say something, and I'd go stomping off to my room." Abilify is an atypical, and is my top ranked mood stabilizer. In any case, until recently, the term, mood swings, did not refer to volatile moods. Eleuthero From this vantage point, if a patient such as Ariel does not have symptoms that she, her family and friends, or any layperson, would consider symptoms, what are we treating? Or, "I would be doing fine shopping at the supermarket. My clinical impression, after close to 30 years of practice, is that they are not uncommon, both before other symptoms have become manifest and afterward. But we don't know what the chemical imbalance(s) is (are) in bipolar disorder. For example, Stephen J. Donovan, M.D., has proposed that a new diagnosis-explosive mood disorder (EMD)-be created and replace the diagnoses of conduct disorder or oppositional defiant disorder in one subset of patients-children with irritable mood swings-"because these are sociological not psychological constructs. This includes natural mood stabilizers. Yet as soon as they were shown to have efficacy in acute mania, they were quickly labeled mood stabilizers rather than antimanic agents. A huge number of patients whom I have followed after inpatient stays with an equivocal diagnosis are sleeping 14 hours a day. It is a collection of disorders about which committees decide certain symptoms should be clustered with the hope that someday, true etiological understanding will correlate with these clusters or future clusters as the evidence indicates. Each of these medications are prescribed for mood swings. Question 1: I do not know if rapidly shifting moods are a typical feature of manic-depressive illness. When the diagnosis is based on looser criteria, it is a more complicated issue. Our case report suggests that lamotrigine might be an appropriate bimodal-action drug, targeting simultaneously impulsive aggression and depressive symptoms. J Clin Psychiatry 57(suppl 12A):S3-S88. 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. Clinical Psychiatry News November, p 20 [letter]. Diverse research hypotheses are a good thing, but they are not the same as hard knowledge. By closing this message, browsing this website, continuing the navigation, or otherwise continuing to use the APA's websites, you confirm that you understand and accept the terms of the Privacy Policy and Terms of Use, including the utilization of cookies. 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. 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. Psychopharmacology (Berl) 128(4):380-397. de Angelis L (1995), Effects of valproate and lorazepam on experimental anxiety: tolerance, withdrawal and role of clonidine. Mood & Cognition in MS: [What you can do] Learn why and how people with MS experience changes in mood and cognitive functioning, and the latest information on how these symptoms can be addressed—from physical activity, medications and counseling to self-management strategies. 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. Off helps depression, mania, manic or mixed states, which can make people feel agitated,-4 weeks to work. Moreover, the new use of the term mood swings had been embraced by the other psychiatrists in town who were doing strictly outpatient work. We don't really know what mood stabilizers do for the illness. Treating Anger Disorders: Anger Management Treatment Program Options. Medications, such as mood stabilizers and antidepressants, can help treat mood disorders. Petty F (1995), GABA and mood disorders: a brief review and hypothesis. Lenox RH, McNamara RK, Papke RL, Manji HK (1998), Neurobiology of lithium: an update. © 2021 MJH Life Sciences and Psychiatric Times. Currently, there are no specific medications approved by the FDA for borderline personality disorder. They may represent the long-sought effective, nonaddicting tranquilizers. Of course, it does not help that locally the standard regimen resulting from these hospitalizations seems to also include Zyprexa (olanzapine). is also FDA-herpetic neuralgia) rks can break cycles of mood swings by stabilizing below:. Generally, in all of these cases the patients had almost no introspective capacity. The term would legitimately apply to these anticonvulsant medications in its traditional sense. While medications are used to help reduce anger, for many patients, it will not stop anger completely. At an outpatient alcohol rehabilitation center, a counselor told me the same thing was happening there. (It should be emphasized that Kramlinger and Post's ultradian cycling referred to ratings of mood systematically made every two hours and not sudden mood shifts.). The problem is, if my observation of local practice patterns hold elsewhere, such hunches have become routine, especially in the rapid-turnover inpatient wards that now characterize our mental health system. Otherwise, from pure chance, I would have seen more cases in which the divalproex worked as an antidepressant. Social workers and psychologists were asking, as never before, for medication evaluations for bipolar disorder on the basis of mood swings, and many patients were self-referring themselves for mood swings, having read about them on the Internet. There is another contributing issue to what I believe is the overdiagnosis of BD. 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. There was no family history of manic-depressive illness. The arguments for and against using a loose definition of BD hinge on the risk/benefit ratio of active treatment. Although the considerations above regarding risk/benefit ratio still apply, ordinarily I would have no difficulty with a clinician following a clinical intuition and diagnosing atypical BD now and again when full criteria were not met. In both cases LTG was started to treat the depressive episode. Companion book also available for download. But I would hope that psychiatrists have the wisdom to guide parents and children appropriately through this difficult time, and not confuse matters with scary diagnoses such as bipolar disorder and the use of chemicals that work in ways that are poorly understood. If we believe that we are somehow correcting a fundamental chemical imbalance, there would be a rationale. 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. Others include vitamins B and D, Kava, ginseng, L-treonine, bergamot, ylang-ylang and lavender. 2. There was no pressured speech, flight of ideas or a sense that her mind was racing. Did the responding patients have greater amounts of agitation than other depressed patients? 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. I'm not referring to the prophylactic use of mood-stabilizing agents when it is expected that antidepressants will later be necessary so that protection against a potential manic episode seems judicious. November, p 29. Kalin NH (1996-1997), Management of the depressive component of bipolar disorder. All rights reserved. Some experts such as Bowden (1996) and Keck and McElroy (1996) are so concerned about the possibility of rapid cycling that they go still further, considering the use of antidepressants as a last resort in treating bipolar depression only after multiple mood stabilizers have been tried first. 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." Classic psychoanalytic concepts are more relevant than ever. ... Wayne C. … It usually starts helping the first day taken. If this is the case nationally and not just in the Northeast, it is reasonable to look for an explanation. Hagop S. Akiskal, MD, makes the strongest argument for a liberal view of a very broad bipolar spectrum of abnormalities. As noted, alcohol and drug abusers are now very often being diagnosed with bipolar disorder, once again because labile affect, a common finding in alcohol and drug abusers, is being called mood swings. Undoubtedly, over time, some of the impulsive and/or moody adolescents now being diagnosed bipolar II on the basis of their mood swings will later prove to be suffering from manic-depressive illness. If that were the case, there would be no reason for this article. Keck PE Jr, McElroy SI (1996), Outcome in the pharmacologic treatment of bipolar disorder. Part of a bipolar treatment plan typically includes mood stabilizers that are designed to help with the chemical imbalance that initially led to the onset of the disorder. 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. However, in my experience, high doses of selective serotonin reuptake inhibitors seem to work far better for labile affect, probably because of their ability to alleviate frustration and dull passions rather than from an antidepressant action, per se. Despite this lack of proof, when a bipolar diagnosis is unequivocal, treatment is a no-brainer. Behar D (1998), Bipolar overdiagnosis. Figure out the source. After all, patients with panic disorder often develop depression secondary to their lost sense of control and have an improvement in mood once benzodiazepines have put out the fires. On the benefit side, at least theoretically, is the kindling model for bipolar disorder. Because the tablets can be cut in half it makes for easy titration of dose. Since then, the phrase has expanded to include treatments and supplements that are available without a prescription. Mood-stabilizing drugs slipped into the vocabulary of psychiatrists during the last 15 years without a proper discussion of their definition. 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. 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. Suddenly, someone would cut in front of me in line, and I'd go ballistic." Results: Case 1 manifested with anger and murderous impulse when taking 125 mg/day of LTG. This position is not absurd in the sense that when we eventually understand the genetics and biology of manic-depressive illness, we may discover fundamental relationships. Mood lability is also an important component of borderline personality disorder (BPD) and here, too, an unusual number of patients are being diagnosed bipolar on the basis of their mood swings. 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. We made this decision as the patient responded poorly to the treatment with SSRI and serotonin-norepinephrine reuptake inhibitor antidepressants and second generation antipsychotics. Mental Health and Irritability . The use of the term mood swingsin bipolar disorder has usually referred not to labile affect, but to relatively long stretches of depression or mania lasting weeks or months-although occasionally days-which would then swing to the opposite. 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). 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. Or, "I'd be getting along with my parents at home. Kramlinger and Post (1996) described clear-cut bipolar patients who were followed on a ward and rated for mood every two hours during the course of a day. Our patient was a 26-year-old man diagnosed with borderline personality disorder disorder at the age of 19. American Psychiatric Association (1994), Practice Guideline for Treatment of Patients with Bipolar Disorder. Ultimately, the problem may be language itself. Mood-stabilizing drugs slipped into the vocabulary of psychiatrists during the last 15 years without a proper discussion of their definition. Psychopharmacol Bull 23(1):68-73. © 2021 MJH Life Sciences™ and Psychiatric Times. Petty F, Davis LL, Kabel D, Kramer GL (1996), Serotonin dysfunction disorders: a behavioral neurochemistry perspective. 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). There's only one problem with this. But this is theory, not fact. This question is of some relevance because of the kind of backward reasoning that seems to accompany the effective use of anticonvulsant medications. These are all over the counter mood stabilizers and natural supplements for anxiety. In contrast to bipolar disorder, severe mood dysregulation is defined by nonepisodic irritability, exaggerated emotional reactivity, and hyperarousal. Enter your email address below and we will send you the reset instructions, If the address matches an existing account you will receive an email with instructions to reset your password, Enter your email address below and we will send you your username, If the address matches an existing account you will receive an email with instructions to retrieve your username. J Clin Psychopharmacol 16(2 suppl 1):15S-22S. 1 As for body dysmorphic disorder, SSRIs like fluvoxamine have proven to be beneficial in reducing depressive symptoms, anxiety symptoms, and anger outbursts. Like genetic theories of alcoholism, it shifts blame and gives an external enemy to fight against. She did not feel that her "up" times were a problem. This can be likened to schoolteachers who want their unruly students labeled as having attention-deficit/hyperactivity disorder and Ritalin (methylphenidate) prescribed. You can take them alone or with mood stabilizers to … Clearly in this situation, it is advisable to monitor patients with serious depression closely for early signs, even more so when there are soft signs of hypomania. Our patient was a 26-year-old man diagnosed with borderline personality disorder disorder at the age of 19.