Aggression is a term used to describe a range of behaviors that result in physical and emotional harm to oneself, others, or objects in the environment. It is a problematic public health concern that can have a destructive impact on individuals, families, and communities. Aggression and aggressive tendencies are most commonly believed to be a result of environmental and psychosocial factors, including genetic influences, traumatic life experiences, and childhood violence.
While aggression presents as extreme behavior, irritability manifests more subtly. Irritability can loosely be defined as a state of hypersensitivity and reactivity, resulting in excessive and easily provoked anger, annoyance, or impatience.
Viewed as a milder form of aggression, irritability often produces an array of personal consequences, including academic problems, poverty, psychopathology, and suicidality. Considered a low-frequency behavior, there is currently no reliable marker, measure, or test, to diagnose irritability—similar to its kindred diagnosis of aggression.
In the following, we will examine a case that demonstrates just how disruptive “low frequency” manifestations of irritability can be for patients and those around them.
Allen did not come in for treatment willingly. I had been treating Allen’s stepson for ADHD when his live-in partner, Samantha, approached me with her concerns about Allen. She described the following incident to explain Allen’s typical behavior:
“We were driving to my parent’s house for dinner one Sunday when another driver cut in front of us. Allen began to curse and honk his horn excessively until the driver pulled over, allowing Allen to pass. Instead of driving away, Allen’s anger continued to escalate until he got out of his truck, grabbed a crowbar from the trunk and started charging towards the other driver. The driver sped off and fortunately nobody was hurt, but at that point I knew that Allen needed help.”
Allen did not believe he had an anger problem. He had been on several antidepressant medications in the past to control his mood, including Zoloft and Prozac. While these medications seemed to be effective in helping Allen control his depression, his uncontrolled levels of irritability remained.
After several repeated attempts, Samantha finally made Allen seek help. When he arrived at my office for his scheduled appointment, he proceeded to scream at my administrative assistant for “making” him fill out “so many stupid” forms. To make matters worse, I was running fifteen minutes behind schedule, which only intensified his anger.
Allen entered my office in the same belligerent state; he glared at me and shouted several expletives seemingly directed at no one in particular. Eventually, he was able to discuss his ongoing issues with anger but remained hostile throughout our session.
During my initial visit with Allen, I learned that he had lost several jobs earlier in his life and had a history of alcoholism, depression, and irritability. When asked about his family, he reported that his father and many uncles were alcoholics. He had left his childhood home at the age of eighteen and was not close with his family. At the time, however, Allen had been sober for more than ten years and functioned in a high-level sales job.
After Allen settled down and I was able to ask more detailed questions about his childhood, medical history, family history and past attempts of therapy and medications, I realized that he was caught in a mental health system that really didn’t know how to treat his problem.
Allen went to therapy as a teenager and had been on and off antidepressants since the age of 16. When the irritability persisted even after therapy and multiple medications, he found success in Alcoholics Anonymous (AA), which helped him quit drinking, but didn’t address his underlying irritability and anger. Allen had never hurt anyone, but he had experienced ‘road rage’ for years. Incidents, such as one his partner Samantha described, had been a consistent feature of Allen’s life.
I recommended he take 5mg of nutritional lithium daily for a month, and we scheduled a follow-up session.
When I met Allen for the second time approximately one month after our initial meeting, he came to the office with Samantha. Allen was calm and inquisitive about his lab tests. He reported no side effects on the 5 mg of lithium and described a week without any episodes of road rage. His wife thought Allen was less irritable at home and had, as an example, tolerated a long wait in a restaurant where they had a reservation—typically, she explained, these were the kinds of incidents that sent him “over the edge.”
During our second session, we mostly discussed laboratory tests for low levels of Vitamin D, and I prescribed 5,000 IU of Vitamin D and asked Allen to increase his nutritional lithium to 10 mg twice a day. When Allen returned for his second follow-up visit, after three months on the 10 mg of lithium and Vitamin D, he walked towards me, smiled and shook my hand.
The gratitude in his eyes was apparent. As we completed our session, he expressed his remorse over how his irritability and angry outbursts impacted his family and others.
