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Irritability, Irritable Mood, and Aggressive Behavior
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The phenomenon of irritability, or an irritable mood, must be familiar to almost everyone, exposed as we are to all of the noise, niggling inconveniences, and annoyances of daily life It is, nevertheless, a dif cult symptom to interpret in the context of psychopathology Freud used the term Reisbarkeit in a restricted sense to denote an undue sensitivity to noise and considered it a manifestation of anxiety, but obviously this symptom has a much broader connotation and signi cance For one thing, some people are by nature irritable throughout life Also, irritability is an almost expected reaction in overworked, overwrought individuals, who become irritable by force of circumstances An irritable mood or feeling may be present without observed manifestations (inward irritability), or there may be an overt loss of control of temper, with irascible verbal and behavioral outbursts, provoked by trivial but frustrating events Irritability in the foregoing circumstances can hardly be considered a departure from normal However, when it becomes a recurrent event in a person of normally placid temperament, it assumes signi cance, for it may then signify an ongoing anxiety state or depression Irritability is also a common symptom of obsessional neurosis Here the irritability tends to be directed inward, indicating perhaps a sense of frustration with personal disability (Snaith and Taylor) Depressed patients are frequently irritable; as a corollary, this symptom should always be sought in patients suspected of being depressed, since it is so readily recognized by both patients and their families The days preceding menses and the mother s common postnatal mood disorder are characterized by high levels of outwardly directed irritability Short-temperedness and irritability are also common features of the manic state The most extreme degrees of irritability, exempli ed by repeated quarrelsome and assaultive behavior (irritable aggression), are rarely observed in anxiety neurosis and endogenous depression but are usually the mark of sociopathy and brain disease Such irritable aggression is also observed in some patients with Alzheimer disease and other types of dementia and following traumatic contusions of the temporal and frontal lobes
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Stress and Stress Syndromes
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The psychologic phenomenon of stress is closely allied to nervousness, fatigue, and anxiety, and all of them are pervasive features of modern life In general terms, stress has been de ned as a feeling of self-doubt about being able to cope with some situation over a period of time The term stress syndrome refers to perturbations of behavior and accompanying physiologic changes that are ascribable to environmental challenges of such intensity and duration as to overwhelm the individual s adaptive capacity The biologic effects of this phenomenon can be recognized in many species chickens laying fewer eggs when moved to a new coop and cows giving less milk when put in a new barn, or monkeys going berserk
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CARDINAL MANIFESTATIONS OF NEUROLOGIC DISEASE
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DEPRESSIVE REACTIONS
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There are few persons who do not at some time experience periods of discouragement and despair As with nervousness, irritability, and anxiety, depression of mood that is appropriate to a given situation in life (eg, grief reaction) is seldom the basis of medical concern Persons in these situations tend to seek help only when their grief or unhappiness is persistent and beyond control However, there are numerous instances in which the symptoms of depression assert themselves for reasons that are not apparent Often the symptoms are interpreted as a medical illness, bringing the patient rst to the internist or neurologist Sometimes another disease is found (such as chronic hepatitis or other infection or postinfectious asthenia) in which chronic fatigue is confused with depression; more often the opposite pertains, ie, an endogenous depression is the essential problem even when there has been evidence earlier of a viral or bacterial infection Since the risk of suicide is not inconsiderable in the depressed patient, an error in diagnosis may be life-threatening From the patient and the family it is learned that the patient has been feeling unwell, low in spirits, blue, glum, unhappy, or morbid There has been a change in his emotional reactions of which the patient may not be fully aware Activities that he formerly found pleasurable are no longer so Often, however, change in mood is less conspicuous than reduction in psychic and physical energy, and it is this type of case that is so often misdiagnosed by internists and neurologists A complaint of fatigue is almost invariable; not uncommonly, it is worse in the morning after a night of restless sleep The patient complains of a loss of pep, weakness, tiredness, having no energy, and/or that his job has become more dif cult His outlook is pessimistic The patient is irritable and preoccupied with uncontrollable worry over trivialities With excessive worry, the ability to think with accustomed ef ciency is reduced; the patient complains that his mind is not functioning properly and he is forgetful and unable to concentrate If the patient is naturally of suspicious nature, paranoid tendencies may assert themselves Particularly troublesome is the patient s tendency to hypochondriasis Indeed, most cases formerly diagnosed as hypochondriasis are now regarded as depression Pain from whatever cause a stiff joint, a toothache, eeting chest or abdominal pains, muscle cramps, or other disturbances such as constipation, frequency of urination, insomnia, pruritus, burning tongue, weight loss may lead to obsessive complaints The patient passes from doctor to doctor seeking relief from symptoms that
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would not trouble the normal person, and no amount of reassurance relieves his state of mind The anxiety and depressed mood of these persons may be obscured by their preoccupation with visceral functions When the patient is examined, his facial expression is often plaintive, troubled, pained, or anguished The patient s attitude and manner betray a prevailing mood of depression, hopelessness, and despondency In other words, the affect, which is the outward expression of feeling, is consistent with the depressed mood During the interview the patient may sigh frequently or be tearful and may cry openly In some, there is a kind of immobility of the face that mimics parkinsonism, though others are restless and agitated (pacing, wringing their hands, etc) Occasionally the patient will smile, but the smile impresses one as more a social gesture than a genuine expression of feeling The stream of speech is slow Sighing is frequent There may be long pauses between questions and answers The latter are brief and may be monosyllabic There is a paucity of ideas The retardation extends to all topics of conversation and affects movement of the limbs as well (anergic depression) The most extreme forms of decreased motor activity, rarely seen in the of ce or clinic, border on muteness and stupor ( anergic depression ) Conversation is replete with pessimistic thoughts, fears, and expressions of unworthiness, inadequacy, inferiority, hopelessness, and sometimes guilt In severe depressions, bizarre ideas and bodily delusions ( blood drying up, bowels are blocked with cement, I am half dead ) may be expressed Three theories have emerged concerning the cause of the pathologic depressive state: (1) that the endogenous form is hereditary, (2) that a biochemical abnormality results in a periodic depletion in the brain of serotonin and norepinephrine, and (3) that a basic fault in character development exists These theories are elaborated in Chap 57 It is the authors belief that depressive states are among the most commonly overlooked diagnoses in clinical medicine Part of the trouble is with the word itself, which implies being unhappy about something Endogenous depression should be suspected in all states of chronic ill health, hypochondriasis, disability that exceeds the manifest signs of a medical disease, neurasthenia and ongoing fatigue, chronic pain syndromes all of which may be termed masked depressions Inasmuch as recovery is the rule, suicide is a tragedy for which the medical profession must often share responsibility Depressive illnesses and theories of their causation and management are considered further in Chap 57
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