"RESURRECTING IRRITABILITY"

Date: Friday, April 9, 1999
Presented by: Leslie Born, MSc Women's Health Concerns Clinic St. Joseph's Hospital

The idea of resurrecting irritability as a phenomenon is an appropriate concept, as for the most part, the literature on irritability, reaching back to antiquity, lies buried and forgotten.

The term "irritability", traced to its Latin root, appeared in Plato's doctrine of physical and mental health some 2400 years ago. According to Plato, the human soul, then considered the source of human vitality, and not the religious entity, was comprised of 3 parts: reason, fits of passion or irritability, and appetite or desire. The soul was located in the head, chest and stomach.

Several centuries after Plato, Claudius Galen, picking up on aspects of Plato's doctrine and of the Hippocratic writings, ascribed changes in health to a physical correspondence with nature. For example, a prominence of yellow bile corresponded with a choleric (hot tempered) temperament (here denoting a physical tendency) and the warm, dry summer or fire season.

This view of human proneness to anger, or irritability, as an essential aspect of human physiological function remained in the medical literature until the mid-nineteenth century. Along the way, new ideas about the nature of irritability were written about, and in later centuries, these ideas were widely adopted into medical thinking.

The general historical conceptualization of irritability, extending from around 500 B.C. to the mid-nineteenth century A.D., includes several notable points: first and foremost, that "irritability" as a phenomenon had a positive connotation. It was necessary for us to live and breathe; second, that irritability has state and trait aspects; and third, that excessive irritability signaled physiological imbalance which manifested as disturbance in mood.

Our current conceptualization of irritability might be traced to the "disease model" of mental illness prevalent in medicine in the late nineteenth and early twentieth centuries. Irritability signaled, not merely health status or the changing seasons, but disease. In the medical (and later psychologic) literature since the 1860s, irritability has represented a symptom of some other mental or physical condition with the emphasis on behavioural disturbance. This perspective is exemplified by our standard diagnostic schema, the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV). It is speculated that interest in irritability as a phenomenon has been subverted by attention to the topics of anxiety and, in particular, depression.

In the late 1970s, however, the topic of irritability resurfaced in the medical literature. Articles on its definition and measurement appeared, followed in the 1990s, by a pair of articles on its heritability. The 1990s has also included the introduction, in the DSM-IV, of a mood disturbance, specific to women, called Premenstrual Dysphoric Disorder (PMDD). PMDD is distinct as its primary syptoms include irritability, tension, and dysphoria, and the diagnostic criteria exclude other emotional disturbances, such as depression or anxiety or psychoses. Recently, investigators in Canada, the United States and Sweden together have determined that PMDD is a distinct clinical entity, and not a form of "masked depression" as was previously thought.

The benefit of a reliable and valid instrument to assess irritable mood emerges from clinical presentations where irritability, and not depression or anxiety, is the primary presenting complaint. At the Women's Health Concerns Clinic, such presentations are frequent in women not only with premenstrual complaints, but also those with perinatal, and perimenopausal mood disturbances. Controversy surrounds the measurement of irritabilty. Four self-report rating scales of irritablity have been published since 1957, however, a number of problematic issues pertaining to content and construct validity have been elucidated. Moreover, the writings on irritability and women are scant.

Thus, we carried out a pilot study (n=30) to collect patients' own descriptions of irritability using a survey which explored emotional changes, physical reactions, sensory changes, changes in behaviour, and effects of irritability on daily function. Our results underscore that the key aspects which comprise irritability as a phenomenon may be more specific and more extensive than those encompased by the existing scales, and that the responses suggest a very different type of mood disturbance compared with the criteria for DSM-IV depressive or anxiety disorders.

In summary, the historical writings, a body of clinical evidence, the studies on PMDD, recently published case reports, and our early research results, taken together, suggest congruence with the notion of severe irritability as a distinct mood condition. This idea, a group of us posit, represents not an introduction, but rather a resurrection of a longstanding and familiar, yet elusive, phenomenon.

Author's note: This presentation was excerpted from her Master's thesis entitled: "Irritability as a Phenomenon: Historical Overview and Recent Research" (1998); and from a recent poster presentation entitled: "A Gender-Specific Measure of Irritability" (1999).