Irrritabilidad 2

Accepted Manuscript
Defining and measuring irritability: Clarification and

differentiation of the construct
Michael J. Toohey, Raymond DiGiuseppe
PII: S0272-7358(15)30145-8
DOI: doi: 10.1016/j.cpr.2017.01.009
Reference: CPR 1585
To appear in: Clinical Psychology Review
Received date: 21 October 2015
Revised date: 23 December 2016
Accepted date: 30 January 2017
Please cite this article as: Michael J. Toohey, Raymond DiGiuseppe , Defining and
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Running Head: DEFINING AND MEASURING IRRITABILITY
Defining and Measuring Irritability:
Clarification and Differentiation of the Construct
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Michael J. Tooheya
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Raymond DiGiuseppeb,c
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Authors Note
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a
Antioch University Seattle: 2400 3rd Avenue, Seattle, WA, Suite 200, 98121;
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mtoohey1@antioch.edu
b
St. John’s University: 8000 Utopia Parkway, St. Johns University, MAR 113, Queens, NY
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11439; digiuser@stjohns.edu
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c
Albert Ellis Institute: 45 East 32nd Street, New York, NY 10016
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Correspondence concerning this article at all stages of publication should be addressed to
Michael J. Toohey: Antioch University Seattle: 2400 3rd Avenue, Seattle, WA, Suite 200,
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98121; mtoohey1@antioch.edu; (929) 266-8997

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DEFINING AND MEASURING IRRITABILITY 2
Abstract
Irritability is a symptom of 15 disorders in the DSM-5 and is included in Mood
Disorders, Addictive Disorders, Personality Disorders, and more (American Psychiatric
Association, 2013). However, the term irritability is defined and measured inconsistently in the
scholarly literature. In this article, we reviewed the scholarly definitions of irritability and the
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item content of irritability measures. Components of definitions and items measuring irritability
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were divided into three categories: a) causes, b) experience, and c) consequences. We also
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reviewed potential causes and biomarkers of irritability. We found much overlap between
definitions and measures of irritability and related constructs such as anger and aggression.
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Consequently, the validity of research on irritability needs to be questioned including the role of
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irritability in psychopathology and the presence of irritability as a symptom in any disorder.
Research on irritability’s role in behavioral disorders needs to be repeated after more well
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defined measures are developed. We proposed a more precise definition of irritability that clearly
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differentiates it from related constructs. Suggested items for measuring irritability are also
provided.
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Key Words: Irritability, Anger, Aggression, Definition, Assessment

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Defining and Measuring Irritability: Clarification and Differentiation of the Construct

Introduction
Irritability is one of the most transdiagnostic constructs in the Diagnostic and Statistical
Manual of Mental Disorders, 5th edition (DSM-5), ranging across 15 disorders including Mood
Disorders; Trauma- and Stressor-Related Disorders; Disruptive, Impulse-Control, and Conduct
Disorders; Substance-Related and Addictive Disorders; and Personality Disorders (American
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Psychiatric Association, 2013). Although irritability is one of the precursors for anger and
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aggression (Craig, 2008; DiGiuseppe, Tafrate, 2007; Ekman, 2007; Holtzman, O’Connor,
Barata, & Stewart, 2015; Kassinove & Tafrate, 2002), considerable confusion has existed in
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distinguishing irritability from anger, aggression, and other related constructs amongst the
public, researchers, practitioners, and theoreticians (DiGiuseppe & Tafrate, 2007; Holtzman et
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al., 2015).
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This overlap in the conceptualizations of irritability, anger, and aggression is apparent in

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the DSM-5. A list of the disorders that include irritability, anger, and aggression as a symptom
appears in Table 1. It is not immediately clear what distinguishes anger from irritability. Also,
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the DSM-5 often provides descriptive qualifiers to specify the nature of constructs; however,
these qualifiers add further conceptual confusion. For example, the terms irritable mood,
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irritability, mood [that] can be irritable, unexplained irritability, and irritable behavior
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represent the various ways irritability is described across DSM-5 disorders. It is unclear what
discriminates unexplained irritability from irritability, or irritability from irritable mood or
irritable behavior. Further, it is unclear what discriminates irritable mood from anger, or
irritable behavior from aggression or angry behavior. Researchers and clinicians will find it
difficult to make diagnostic judgments and treatment decisions given this lack of clarity.
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Our goal is to enhance the diagnostic accuracy and treatment efficacy of disorders related
to irritability, anger, and aggression by forming clearer, more precise conceptualizations of each
of these constructs. Once these conceptualizations are clarified, the field can progress to examine
how the constructs are related to any given psychiatric disorder.
Some literature exists addressing the role of irritability in the context of psychopathology
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throughout the lifespan. Irritability has been detected as early as infanthood (Keefe, Froese-Fretz,
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1991; Keefe, Kotzer, Froese-Fretz, & Curtin, 1996; Snaith & Taylor, 1985), and is potentially
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predicted by sensitivity to stimuli in the first few days of life (Keefe, et al., 1998). Irritability is
higher in childhood and gradually decreases through adolescence (Copeland, Brotman &
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Costello 2014; Wiggins, Mitchell, Stringaris, & Leibenluft, 2014). Despite this gradual
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reduction, early irritability predicts future psychopathology and behavioral problems. For
instance, infant irritability at 1 month predicted increased crying, sleep disruption, and decreased
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parent-child interaction at 4 months (Keefe, Kotzer, Froese-Fretz, & Curtin, 1996). Irritability at
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age 3 predicted depression, Oppositional Defiant Disorder (ODD), and functional impairment at
6 years old (Dougherty et al., 2015). Childhood irritability has also been linked to disruptive
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behavior, and anxiety and depressive symptoms and diagnoses in young adulthood (Althoff,
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Verhulst, Rettew, Hudziak, & van der Ende, 2010; Brotman, Schmajuk, & Rich, 2006;
Copeland, Shanahan, Egger, Angold, & Costello, 2014; Leibenluft, Cohen, Gorrindo, Brook, &
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Pine, 2006; Stringaris, Cohen, Pine, & Leibenluft, 2009). Specifically, Leibenluft and colleagues
(2006) found different diagnostic predictions for two different types of irritability: chronic
childhood irritability was linked to ADHD and MDD, while episodic irritability was linked to
specific phobias and mania. Stringaris and Goodman (2009) found that irritability in adolescence
predicted disorders of depression and anxiety, but not phobias. It is possible that Stringaris and
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Goodman (2009) captured chronic childhood irritability given that their questions referred to the
child’s mood over the past 6 months (p. 406). Paralleling the trajectory from childhood to
adolescence, Stringaris et al. (2009) found that irritability in adolescence predicted anxiety and
depressive disorders 20 years later in adulthood. Although recent studies have noted the presence
of increased irritability among older populations with dementia (Feast, Moniz-Cook, Stoner,
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Charlesworth, & Orrell, 2016; Spector, Orrell, Charlesworth, & Marston, 2016) or cognitive
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impairment (Linde, Matthews, Dening, & Brayne, 2016), more research is needed. We could not
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find research on the relationship between irritability and psychopathology in older, nonclinical
populations.
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A lack of clarity exists in scholarly definitions and measures of irritability. In a recent
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study aimed to evaluate the item content overlap in measures of irritability, graduate students and
scholars who had published in the field of anger or irritability rated 67 items from irritability
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scales on the degree to which the items represented the definitions of irritability, trait anger,
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anger-in, and anger-out (Friedmutter, Soto, & DiGiuseppe, 2012). Definitions were provided for
each construct. Of the 67 items, participants rated only nine items to definitely assess the
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construct of irritability without also representing any other construct (see Table 2 for items).
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Most items designed to measure irritability were considered by the raters to assess anger-related
constructs other than irritability. These results demonstrate that measures of irritability
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potentially lack the most basic psychometric feature of content validity. Consequently, the
empirical data from studies using these measures could remain impossible to interpret because
the items reflect multiple, different constructs.
The failure to distinguish between irritability, anger, and aggression presents several
problems. First, it leads to the contamination of measures of irritability with items that represent
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other constructs. Second, it reduces the validity of research on these three constructs. Third, it
prevents us from identifying biological markers (biomarkers) of each construct. Fourth, it
impedes our understanding of the role of each construct in diagnosis and psychopathology.
Finally, it diminishes potential strategies for intervention for anger, irritability, aggression, and
other psychological disorders of which each construct is a symptom. In order to successfully
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identify, measure, research, and treat irritability, and to understand the relationship between
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irritability and other forms of psychopathology, a precise, clear, and universal definition of
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irritability is needed that distinguishes it from related, yet separate, psychological constructs.
Although many definitions exist for anger and aggression, we use the established
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definition of aggression asserted by Dollard, Doob, Miller, Mowrer, and Sears (1939), that
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aggression is a “sequence of behavior, the goal-response to which is the injury of the person
toward whom it is directed” (p. 9). We conceptualize anger based on themes of a number of
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prominent anger definitions as organized by the anger episode model posited by Kassinove and
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Tafrate (2002). Although this conceptualization is not exhaustive, we aim to briefly highlight a
number of aspects of anger. According to Kassinove and Tafrate (2002), a typical anger episode
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contains five components. First, anger is provoked by a trigger, such as an attack or threat to
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one’s person, resources, or public image (Darwin, 1965). Second, a cognitive appraisal of the
trigger occurs that might include exaggerated or distorted cognitions concerning negative,
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catastrophizing evaluations of the threat and demandingness that it not occur (Beck, 1976; Ellis,
1994). Third, a distorted appraisal leads to the experience of anger, including subjective feelings
of various intensities (Spielberger, Jacobs, Russell, & Crane, 1963) and changes in physiology
such as tension and certain facial expressions (Darwin, 1965; Ekman, 2007). Fourth, the
experience of anger is followed by the desire or actual expression of anger such as aggression
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(Dollard et al., 1939). Finally, there is a consequence to the behavior; however, such outcomes
are not typically included in definitions of anger. According to Novaco (2003), anger could have
positive outcomes due to its “considerable adaptive value for coping with life’s adversities” (p.
1). Kassinove and Tafrate (2002) noted outcomes of anger often include interpersonal and legal
difficulties. Although the constructs of annoyance, hatred, and hostility are often used
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interchangeably with the above terms, those constructs will not be defined here due to their low
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frequency of occurrence in current definitions of irritability.
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In this article, we aim to clarify and distinguish the construct of irritability. We begin by
reviewing public and medical conceptualizations of irritability. Then, we examine
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psychological/psychiatric definitions and measures of irritability. After, we present a review of
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our findings and discuss new and remaining questions regarding the conceptualization of
irritability. Finally, we propose a definition of irritability and recommend items for measuring
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irritability. We hope to produce a number of questions and future directions that will inspire
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further research and, ultimately, increase our understanding of irritability.
Definitions and Measures of Irritability

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Public Conceptualization
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Patients and the lay public are often unaware of the professional or scientific distinction
between irritability and anger. Barata, Holtzman, Cunningham, O’Connor, and Stewart (2016)
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indicated that the public’s most common synonyms used to describe irritability were anger,
frustration, and annoyance. Satchell and Toohey (2016) examined the public perceptions of the
relationship between irritability and anger from 10 countries around the world (U.S., U.K., India,
China, Singapore, Malaysia, New Zealand, Australia, South Africa, and Ireland). Participants
were 161 men and 207 women. Half of the participants did not differentiate between irritability
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and anger. Some considered irritability to be a milder form of anger. About one-third of the
participants distinguished between anger and irritability: the majority of these considered
irritability to be a precursor for anger. Although specific distinctions were inconsistent,
differences occurred in terms of the experience (e.g., “irritability doesn't last as long”),
expressions (e.g., “you will not hurt people if you are irritable where else [sic] you will hurt
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people around you when you are angry”), and triggers (e.g., “Often irritability does not have a
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specific reason behind it - it’s just small things that bother you. Being angry usually suggests that
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someone wronged you and you need to express your hurt in some way”). This variability in the
lay public’s meaning of irritability will likely result in people responding differently and
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unreliably to survey and interview items that ask whether the participant or patient is “irritable.”
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A brief review of definitions of irritability from public dictionaries (i.e., Dictionary.com,
Macmillan, Merriam Webster, Oxford English, and Wikipedia) indicated that these sources
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better distinguished between irritability and anger. For example, the most comprehensive public
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definition, from the Oxford English Dictionary (n.d.), defines irritability as a state (“The quality
or state of being easily annoyed or excited to anger or impatience; proneness to vexation or

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annoyance; petulance”), pathology (“…The condition of being excessively or morbidly excitable

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or sensitive to the contact or action of anything”), and as change in physiology and biology
(“The capacity of being excited to vital action…by the application of an external stimulus…”).
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Overall, the dictionary definitions characterized irritability as having an increased likelihood for
annoyance and anger due to an increased sensitivity to stimuli. In sum, colloquial discriminations
between irritability and anger exist but are minimal and not necessarily followed by the general
public.
Medical.
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Conceptualizations of irritability are dependent upon the context in which they are
discussed. Although irritability in the psychological literature refers to a psychological state or
disposition, irritability in the medical literature is more commonly used to denote changes in
physiology. For example, when defining irritability as a change in biology and physiology, the
English Oxford Dictionary (n.d.) also included at the end of its definition that irritability is “a
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property of living matter or protoplasm in general, and characteristic in a special degree of
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certain organs or tissues of animals and plants, esp. muscles and nerves…” Similarly, Cabıoğlu
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and Ergene (2006) discussed the “irritability of the satiety center” (p. 7) to describe the changes
in food intake due to the increased sensitivity of the satiety center, which influences satiation
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(i.e., feeling full). Kuan et al. (2015) used the phrase “irritability of myofascial trigger spot” to
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describe the site that they refer to as “hypersensitive” (p. 1). Irritable bowel syndrome refers to
an increased sensitivity in the intestines causing them to contract, creating a number of

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gastrointestinal symptoms ("Irritable bowel syndrome," 2013). Mullin, Kleitman, and

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Cooperman (1937) used the phrase “irritability to auditory stimuli during sleep” (p. 88) to
convey the likelihood of waking up because of an increased sensitivity to sound. Further,

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Maitland (2005) defined the irritability of a disorder (e.g., lower back pain irritability) as the
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“susceptibility” to experience pain (i.e., sensitivity to stimuli) and the intensity and duration of
the pain (p. viii). On a slightly different note, the Oxford English Dictionary also uses the phrase
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“irritability of plants” to describe the degree to which plants are affected by (i.e., sensitive to) the
surrounding climate (Bose, 1913). Thus, the term irritability in medicine typically denotes an
increased sensitivity to stimuli.
Psychological/Psychiatric.
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We uncovered 21 definitions of irritability in the psychiatric and psychological literature,
which appear in Table 3, and eleven measures of irritability, which appear in Table 4. Table 4
also includes the items of the measures and the construct we believe each item actually
measured. All of the irritability measures were pencil-and-paper surveys except for one (Acri &
Grunberg, 1992). Measures ranged from five items to thirty. Three of them included parent or
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care provider-rater forms.
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In our review, we found that definitions and survey items of irritability fit into three
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categories: 1) the causes of irritability, 2) the experience of irritability, and 3) the consequences
of irritability. The causes of irritability refer to any biological factors or stimuli that evoke
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irritability (e.g., hunger). The experience of irritability refers to the physiological, psychological,
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and phenomenological sensations of irritability (e.g., tension). The consequences of irritability
refer to emotions and behaviors that occur because of or after the experience of irritability (e.g.,
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anger, aggression). Separating these three components of irritability could result in more precise
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explorations within each category and could lead to a more thorough and distinguishable
conceptualization of irritability. Thus, we have organized the remainder of the manuscript into
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sections using the above three components. Within each component (e.g., causes of irritability)
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we first review the definitions of irritability: We highlight aspects of definitions that could be
categorized within the current component (e.g., as a cause) and note themes found among those
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categorizations. Second, we review the items found in measures of irritability: We highlight
aspects of items that could be categorized within the current component (e.g., as a cause) and
note themes found among those categorizations. Finally, we provide a commentary in which we
discuss strengths, limitations, and implications of the above findings. We also review further
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information in the commentary section concerning the causes of irritability, specifically, given
the gap in coverage of that component in definitions and measures.
Causes of irritability
Definitions. Few definitions of irritability included information about the causes or
precursors of irritability. Rich and Leibenluft (2006) discussed potential sources of frustration
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(e.g., social and academic difficulties) as triggers for irritability. They also discussed the
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importance of “[c]onnecting environmental triggers” (p. 213) to irritability for treatment
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planning. Snaith and Taylor (1985) and Craig et al. (2008) contrasted irritability to anger,
describing anger as being “justified” (p. 128) and having “recognizable antecedents” (p. 368),
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respectively. Thus, irritability becomes aroused without any “justifiable” triggers and can occur
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without any clear antecedents.
Measures. The causes of irritability appear the least often in questionnaires when
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compared to the number of items that reflect the experiences and consequences of irritability.
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Nevertheless, causes were included in some items. Examples included experiencing irritability or
a related construct when teased or mocked (Buss & Durkee, 1957; Craig et al., 2008; Kazdin et
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al., 1987), by being around other people (Buss & Durkee, 1957; Craig et al., 2008; Kazdin et al.,
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1987), by one’s own self (Born et al., 2008; Craig et al., 2008; Snaith et al., 1978), and by
recalling “past insults or injuries” and “when under pressure” (Craig et al., 2008, p. 372). A few
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items targeted the increased sensitivity to sensory stimuli as a cause of irritability, including
“Noises have seemed louder” and “I have been irritable when someone touched me” (Born et al.,
2008, p. 346), and “At times I find everyday noises irksome” (Craig et al., 2008, p. 372). Using a
more novel method of measuring irritability, Acri and Grunberg (1992) designed the Reactive
Irritability Scale in which smokers who recently abstained from smoking and nonsmokers rated
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how irritated they were by various noises presented to them in the moment. The authors found
that having participants rate their irritability when they were exposed to current noises was a
more sensitive measure than rating the general presence of irritability.
Commentary. In definitions and measures of irritability, causes often seem
interchangeable with the causes of other constructs, especially anger (e.g., social and academic
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difficulties) and depression (e.g., oneself). Including such causes in the definition of irritability
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makes it difficult to distinguish between causes of irritability and causes of anger when feeling
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irritable (i.e., irritable anger). For example, frustration from a goal (e.g., academic difficulties) is
considered a universal trigger for anger (Dollard et al., 1939; Ekman, 2007). Perhaps it is not
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that frustration from a goal triggers irritability itself but that frustrations have an increased
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likelihood to trigger anger when one is irritable. This was included in definitions stating that
when a person is irritable, anger will be triggered by typically less vexing triggers (Buss &
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Durkee, 1957; Caprara, Renzi, Alcini, Imperio, & Travaglia, 1983), and has been supported in
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studies that found that children with chronic irritability have a reduced tolerance to frustration
(Deveney et al., 2013, Leibenluft, Charney, Towbin, Bhangoo, & Pine, 2003; Leibenluft, 2011).
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Snaith and Taylor (1985) and Craig et al. (2008)’s conceptualizations provided more
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clarification between causes of anger and irritability. Craig et al.’s (2008) description of anger as
having recognizable antecedents posits that anger is triggered by a specific cue, whereas
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irritability is not. This parallels Moyer’s (1976) conceptualization of irritable aggression. He
stated that, although some types of aggression (i.e., predatory, inter-male, fear-induced, maternal,
and sex-related) are geared toward specific triggers, irritable aggression is differentiated by its
“inclusiveness” (p. 187): it occurs in response to a wide range and almost any sort of provoking
stimuli. The view of non-specific triggers for irritability is partially congruent with the findings
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that irritability has physiological causes affecting biological processes (e.g., changes in eating
that affect glucose levels) as opposed to more acute, salient external triggers (e.g., getting cut-off
in traffic) associated with anger. Although irritability might not be triggered by specific,
immediate cues (e.g., difficult people, failing an assignment), it seems likely that there are
specific biological processes that trigger irritability.
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Snaith and Taylor (1985)’s description of irritability maintains that it “lacks the cathartic
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effect of justified outbursts of anger” (p. 128). This definition posits that the expression of anger
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occurs in response to some appraisal of a moral or social injustice that deserves a retaliatory or
protective response (i.e., is justified), whereas irritability is considered to not have a specific
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trigger and would be unjustified if expressed toward a specific person or object. It is possible that
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the authors meant that given irritability’s association with a lowered threshold for anger, when
people are irritable, their angry reactions seem out of proportion to the trigger. For example, in
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an expansion of Snaith and Taylor’s (1985) definition, Barata and colleagues (2016) stated that
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irritability “often includes a feeling that one’s emotional responses are unjustified or
disproportionate to the immediate source” (p. 170). In these cases, their definition is not referring
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to the causes of irritability but to the causes of irritable anger. Barata and colleagues highlight
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this by noting that the emotional response of irritability (e.g., irritable anger) is unjustified.
Some of the causes of irritability are not included in definitions but have been supported
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by research findings. Although irritability has been linked to both inadequate sleep (Fernández-
Mendoza et al., 2009; Franzen, Buysse, Rabinovitz, Pollock, & Lotrich, 2010; Robinson &
Richardson-Robinson, 1922; Tamura & Tanaka, 2014) and fatigue (Lamers, Hickie, &
Merikangas, 2013), it has also been linked to other causes such as caffeine use and withdrawal
(Hughes & Boland, 1992; Juliano & Griffiths, 2004; Küçer, 2010), nicotine withdrawal (Awaisu
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et al., 2010; Zhan, Dierker, Rose, Selya, & Mermelstein, 2012), tobacco withdrawal (Hughes,
1992), dieting (Laessle, Platte, Schweiger, & Pirke, 1996), traumatic brain injury (Yang, Hua,
Lin, Tsai, & Huang, 2012), and pain (Fava, 1987; Fishbain et al., 2015; Malara et al., 2016).
Irritability has been especially linked to low glucose levels, also known as hypoglycemia – or
neuroglycopenia when it affects the brain (Ahrén, 2013; Slater & Roth, 1969; Wilson, 2010),
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especially when in combination with a cognitively demanding task (Benton, 2002). For example,
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glucose tablets reduce the irritability of smokers in withdrawal (McRobbie & Hajek, 2004). The
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impact of low glucose can also be clearly seen in people with diabetes who typically struggle
with irritability (Walsh & Roberts, 2005).
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A number of items also addressed the changes in sensory sensitivity (e.g., noises being
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louder) noted in the component of DiGiuseppe and Tafrate’s (2007) proposal that irritability
“involves increased sensitivity to environmental stimulation that causes physiological arousal

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and tension, without cognitive mediation…” (p. 29). Rather than being caused by non-
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specific/unjustified events, irritability might have causes related to sensory input without the
cognitive appraisal of injustice. However, it remains unclear whether changes in sensory

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sensitivity would best be considered part of the causes or experience of irritability. Thus, we
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propose the following conclusion given the present state of research: Although anger is more
situationally or cognitively determined, irritability is caused by physiological/biological changes

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and is associated with increased sensory sensitivity.
Experience of Irritability
Definitions. Surprisingly, few definitions include descriptions of the experience of
irritability. Most definitions refer to irritability by its consequences – as an ambiguous type of
state that leads to anger or aggression – with little description of the experience itself. When the
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experience of irritability is included, it is referred to as a mood (Craig et al., 2008; Dickstein et
al., 2008; Stringaris, 2011), an emotion (Leibenluft, Blair, Charney, & Pine, 2003), “emotional
process” (Barata et al., 2016, p. 169), or a behavior such as “temper outbursts” (Leibenluft, 2011,
p. 128; Stringaris & Goodman, 2009, p. 405). Some definitions describe the experience of
irritability itself more generally, as a “temporary psychological state” (Snaith, Constantopoulos,
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Jardine, & McGuffin, 1978, p. 164), “inner tension” (Deckersbach et al., 2004, p. 228), or “inner
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psychic tension” (Benazzi, Koukopoulos, & Akiskal, 2004, p. 85). In some cases, the term
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irritable is a descriptor, used as an adjective to describe a mood state (i.e., irritable mood; Snaith
& Taylor, 1985) or a behavior (i.e., irritable behavior; Rich & Leibenluft, 2006).
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Some definitions of the irritability experience significant overlap with anger or
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aggression. Spielberger, Reheiser, and Sydeman (1995) defined irritability as a less extreme form
of anger. While describing irritability in the context of Severe Mood Dysregulation Disorder
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(SMD), Dickstein et al. (2008) described irritability as including an “abnormal mood (anger or
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sadness)” (p. 31), and Leibenluft (2011) defined irritability as including “1) temper outbursts that
are developmentally inappropriate, frequent, and extreme; and 2) negatively valenced mood
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(anger or sadness) between outbursts” (p. 131). According to these two definitions, irritability is
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always experienced with feelings of sadness or anger at some point.
Two definitions differentiated the experience of irritability from anger. Snaith and Taylor
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(1985) defined irritability as non-cathartic, meaning that after its expression a person will not
experience a decrease in tension, as opposed to anger, which can lead to a decrease in energy
after its expression. DiGiuseppe and Tafrate (2007) described irritability as “a partially aroused
physiological state without the thoughts that usually occur with anger” (p. 31). In a separate,
working definition of irritability, they note that the arousal occurs “without cognitive mediation”
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(p. 29). They imply that a) irritability does not have the full or same level of physiological
arousal or tension (i.e., agitation) that appears with anger, and b) the role of cognition for
irritability is different from the role of cognition in traditional conceptualizations of anger in
which anger is thought to be a result of distorted and rigid cognitions (Beck, 1976; Ellis, 1994).
Measures. Although few definitions described the experience of irritability, all measures
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operationalized irritability using potential synonyms such as “mad,” “frustrated,” “bothered,”
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and “hot-headed” (Born et al., 2008, p. 346; Craig et al., 2008, p. 343; Kazdin et al., 1987, p.
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323; Stringaris et al., 2009, p. 1050). The majority of descriptions of irritability appeared
interchangeable with anger. It was sometimes difficult to discern whether an item (e.g., being
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mad) attempts to measure being mad as part of the experience of irritability or as an emotional
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consequence of feeling irritable.
A few items were more specific to irritability, highlighting the agitated nature of
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irritability with words such as “sensitive,” “grouchy,” “jumpy,” and “touchy,” (Born et al., 2008,
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p. 348; Buss & Durkee, 1957, p. 346; Caprara et al., 1983, p. 673). Some also addressed the
physiological arousal associated with irritability. For example, “I have been feeling relaxed”
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(reverse scored; Craig et al., 2008, p. 373), and “There has been a flood of tension through my
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body” and “[I] often felt very tense” (Born et al., 2008, pp. 348-349). There were no items that
directly addressed the partial arousal and tension included in the definition by DiGiuseppe and
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Tafrate (2007).
Commentary. The experience of irritability is rarely included in definitions and is
mostly measured using synonyms. Most measures fail to differentiate between the experiences of
irritability with anger and sadness. In order to fully understand irritability as an independent
construct, we need to ask: a) what occurs during the experience of irritability, b) what
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differentiates the experience of irritability from anger and sadness, and c) how does the
experience of irritability lower the threshold for anger, aggression, or sadness?
Irritability defined as a behavior was most commonly found in the literature regarding
children, especially when discussing childhood disorders such as Pediatric Bipolar Disorder
(PBD), Reactive Attachment Disorder (RAC), Oppositional Defiant Disorder (ODD), and
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Disruptive Mood Dysregulation Disorder (DMDD). However, in DMDD, PBD, and ODD, the
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symptom of irritability is specified as a mood and not as a behavior (see Table 1). It is possible
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that, given the higher likelihood that children who are both angry and aggressive are referred for
treatment primarily due to their aggression, irritability in children is more associated with
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aggression. Accordingly, much overlap occurs between irritability and aggression in the pediatric
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literature and diagnostic criteria for children.
Some strong arguments have been made to conceptualize irritability as a mood. Snaith
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and Taylor (1985) stated that, even when definitions are not provided, most authors use the term
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irritability to describe a mood associated with poor temper control. They continued that the
mood could be experienced without overt manifestation, and that it might be experienced briefly
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or chronically. Craig et al. (2008) also stated that, given its duration, irritability should be
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considered a mood while anger should be considered an emotion. According to Juslin and
Västfjäll (2008), moods are “Affective states that feature a lower felt intensity than emotions,
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that do not have a clear object, and that last much longer than emotions (several hours to days)”
(p. 561). Because irritability is also posited to be a “partially aroused physiological state”
(DiGiuseppe & Tafrate, 2007, p. 31), lack an identifiable trigger, (Snaith & Taylor, 1985), and
have a longer duration than anger (Craig et al., 2008), we echo Snaith and Taylor’s (1985) notion
that irritability is best conceptualized as a mood.

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Although definitions were more likely to refer to irritability as some sort of state, it is not
clear whether irritability should be conceptualized as a state, a trait, or both. In 1999, Spielberger
conceptualized anger, anxiety, sadness, and happiness in both state and trait forms. State anger
referred to the momentary subjective feelings ranging from “mild irritation or annoyance to
intense fury,” and trait anger referred to the disposition/tendency to perceive situations as
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frustrating and feel angry (p. 1). Accordingly, state irritability would refer to the momentary
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feelings of irritability, whereas trait irritability would refer to one’s general predisposition
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toward feeling irritable over time. Thus, some authors have followed Spielberger’s tradition by
distinguishing between both types of irritability, using the terms “tonic” or “chronic” (i.e., trait)
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and “episodic” or “phasic” (i.e., state). This is especially common in literature regarding children
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(Avenevoli, Blader, & Leibenluft, 2015; Copeland, Brotman, & Costello, 2015).
Although the suffix “-ility” in irritability refers to a general disposition of feeling

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irritable – predisposing the construct to be a trait – some authors conceptualize irritability as a

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state (Born & Steiner, 1999; Craig et al., 2008; Holtzman et al., 2015). This linguistic
construction of irritability as a state supports conceptualizations of irritability as an episodic

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mood state or behavior; if state irritability is momentarily caused by hunger or lack of sleep, it
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would end when these physiological needs were met. Some studies have supported a distinction
between state (i.e., phasic and/or episodic) and trait (i.e., tonic and/or chronic) irritability
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(Avenevoli, Blader, & Leibenluft, 2015; Leibenluft et al., 2006). For example, Leibenluft and
colleagues (2006) found that for children and adolescents, episodic and chronic irritability were
stable, independent constructs. Correlations within episodic irritability over time were higher
than those between episodic and chronic irritability at the same time point. Further, both types of
irritability varied based on age. Last, these types of irritability predicted separate diagnostic
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outcomes. Conversely, Copeland and colleagues (2015) found high correlations in the
occurrence of phasic/state and tonic/trait episodes in a community sample of youth, conveying
much overlap between the two types. Further, tonic/trait episodes were only twice as long as
phasic/state episodes, and many reports of phasic episodes were reported in the absence of tonic
irritability. The authors noted that these findings run contrary to the assumption that tonic/trait
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irritability would be a background state underlying more acute, phasic occurrences of irritability
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(Copeland, Brotman, & Costello, 2015). Given mixed findings, the potential separation of
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state/phasic/episodic and trait/chronic/tonic conceptualizations of irritability requires further
examination. Thus, we propose that future measures of irritability gather information on both
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types of irritability. Presently, we would recommend not attempting to specify whether
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irritability is a state, trait, or both.
There is also a clear lack of information regarding the role of cognition in irritability.
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DiGiuseppe and Tafrate (2007) highlighted that, unlike anger, irritability occurs without
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cognitive mediation, and Craig et al. (2008) noted that irritability “predisposes towards certain
emotions (e.g. anger), certain cognitions (e.g. hostile appraisals), and certain actions (e.g.
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aggression)” (p. 368). In this definition, the cognitions referenced by Craig and colleagues would
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be a consequence of irritability, similar to anger and aggression. Thus, it seems likely that these
cognitions are likely a characteristic of anger when one is irritable (i.e., irritable anger) as
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opposed to irritability itself. Since we believe irritability is caused by physiological stimuli (e.g.,
hunger), we think it is unlikely that it can be caused by the content of specific cognitions such as
rigid, demanding thoughts. This is in direct contrast to modern cognitive-behavioral
conceptualizations of anger and all emotions. However, it is possible that cognitive processes
such as rumination or constant obsessions might indirectly cause irritability by decreasing energy
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and increasing fatigue and exhaustion. Thus, although more research is needed, we propose that,
while anger-related cognitions can occur during (or as a consequence of) irritability
(specifically, when irritable anger is present), irritability is not directly caused by the content of
certain cognitions or appraisals.
A difference also exists in perceptions of the physiological arousal associated with
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irritability when compared to anger. We believe that, as a chronic mood, irritability will have
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some physiological arousal and tension, but less than that of the acute emotion of anger. Thus,
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we agree with this aspect of the definition by DiGiuseppe and Tafrate (2007) in that irritability is
associated with partial arousal and tension (i.e., partial agitation). Thus, future measures should
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assess for the presence of partial or less arousal in irritability. Measures that solely measure
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arousal levels risk measuring the construct of anger.
Consequences of irritability
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Definitions. In most definitions, irritability serves as a catalyst that leads to some

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negative emotion or behavior. In other words, people respond more easily and strongly to
provoking stimuli when irritable. For example, irritability has been defined as a readiness (Buss
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& Durkee, 1957), tendency (Caprara et al., 1986), proneness (Barata et al., 2016; Holtzman,
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2014), or lowered threshold (DiGiuseppe & Tafrate, 2007) for some negative consequence.
Although most definitions referred to the negative consequences of irritability as anger and
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aggression, other negative consequences included impatience (Craig, Hietanen, Markova, &
Berrios, 2008), an offensive attitude (Caprara et al., 1986), and an abnormal mood of sadness
(Dickstein et al., 2008; Leibenluft, 2011). Definitions differed on whether they characterized
irritability as including a lowered threshold for anger and aggression (i.e., with minimal
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provocation), a high frequency (i.e., occurring many times) of anger or aggression, or the
presence (i.e., one occurrence) of anger or aggression.
Measures. All measures of irritability included items concerning its consequences.
Within those items, two categories emerge: items measuring the presence of or lowered
threshold for the negative consequences of irritability. Although the phrase lowered threshold
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implies both a reduced tolerance for stimuli and a reduced ability to inhibit responses, we
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included this phrase within the consequences section of the manuscript given its association with
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anger and aggression.
Items measuring the presence of a consequence included phrases such as: “I have been
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feeling mad” and “I have yelled at others” (Born et al., 2008), “Sometimes I shout, hit, and kick,
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and let off steam” (Caprara et al., 1983), “Does he/she get into arguments?” (Burns, Folstein,
Brandt, & Folstein, 1990), and “It makes him very upset to have someone make fun of him”
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(Kazdin, Rodgers, Colbus, & Siegel, 1987). Occasionally, items are phrased to imply that there is
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more to irritability than the sole presence of a negative consequence. For example, in the prompt,
“[I am] easily annoyed by others” (Stringaris et al., 2012), the word easily indicates an increased
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likelihood and lowered threshold for becoming annoyed.

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Some items emphasize the role of irritability as a lowered threshold, increasing the
likelihood of a negative consequence. For example, “It took very little for things to bother me”
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(Born et al., 2008), and “[I’m] feeling like a bomb or powder keg that is ‘ready to explode.”
(Buss & Durkee, 1957; Caprara et al., 1983; Craig et al., 2008; Kazdin et al., 1987).
Some items include conditions: for example, “When I am tired I easily lose control”
(Caprara et al., 1983), “[I am] jumpy when touched by someone” (Born et al., 2008), “It makes
my blood boil to have somebody make fun of me” (Buss & Durkee, 1957), and “If your teachers
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make you do something you do not want to do, you get real mad or throw things or run out of the
room” (Stringaris, Cohen, Pine, & Leibenluft, 2009). However, for these items it is difficult to
determine whether the item measures the consequence (e.g., throwing things) or the trigger (e.g.,
teachers making you do something you do not want to do).
Commentary. Most definitions and all measures captured the emotional and behavioral
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consequences of irritability. However, these items most frequently confounded irritability with
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other constructs. Specifically, definitions and measures that solely focus on the presence of anger
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are more likely to represent the constructs of anger and aggression than irritability. For example
the items, “I have been feeling mad” and “I have yelled at others” could appear in measures of
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anger and aggression respectively. If irritability cannot occur without the presence of anger or
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aggression, the distinction between these constructs becomes impractical and arbitrary. Thus, we
appreciate the note in the definition provided by Barata et al. (2016), that the negative affective
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states associated with irritability (e.g., anger) “may or may not be outwardly expressed” (p. 170).
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Additionally, an increased desire or urge to behave aggressively might represent anger:
aggression via irritability (i.e., irritable aggression) would not be premeditated.

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We encourage the distinction between higher frequencies of anger/aggression and a

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lowered threshold for anger/aggression. Although having a lowered threshold for
anger/aggression leads to an increased frequency of occurrence, a high frequency of

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anger/aggression does not necessarily indicate a lowered threshold. Many circumstances
unrelated to irritability might increase the frequency of anger or aggression (e.g., being frustrated
from meeting a goal multiple times, being around others that one dislikes, having a sense of
entitlement, having demanding thoughts, discussing a hot topic). For these reasons, we propose
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that the definition and measures of irritability should emphasize the characteristic of its lowered
threshold, specifically regarding stimuli that do not typically evoke anger or aggression.
Future Considerations
The items designed to measure irritability are so confounded with – and often identical to
– those designed to measure anger and aggression that we seriously question the validity of any
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findings using most current irritability measures. No meaningful research concerning the
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relationships between irritability with anger and aggression can be considered until this item
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content overlap is removed. Consequently, research exploring whether irritability is a key
symptom of any form of psychopathology could be misleading. Given this content overlap, no
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justification appears evident to specify whether anger, irritability, or aggression would be the
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most appropriate symptom of any DSM disorder. As a result, the treatment for any disorder with
one of these constructs as a symptom has likely been hindered. We understand that we are
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making a strong claim that questions the existing diagnostic system. Yet, this conclusion is
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drawn from the content of the items used to measure irritability rather than from the names of the
scales used in the research. Given this state of affairs, we propose the following:
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Construct clarification and measurement. The field needs to accept a definition of

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irritability that clearly differentiates it from anger and aggression. Once the field establishes such
a consensus, researchers should compare their items to the definition and develop instruments
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that can measure irritability independently from anger and aggression.
Diagnosis and Psychopathology. Given the overlap in conceptualizations of irritability,
we cannot yet identify the separate or combined roles of irritability, anger, and aggression in
psychopathology. It is possible that irritability is present for some disorders, which then leads to
anger. In such cases, irritability is the primary symptom. It is also possible that the use of the
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term irritability currently describes a behavioral issue – in which case the term aggression might
be the more appropriate symptom. Perhaps irritability, anger, and aggression represent one latent
variable. Thus, we recommend that future research focus on clarifying whether irritability,
anger, or aggression would be the most appropriate symptom(s) for mental and behavioral
disorders where any of these three appear. We also recommend reducing overlapping
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descriptions among these symptoms such as “irritable behavior” and “physical anger.”
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Biomarkers. It is important to identify the degree to which irritability is influenced by
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environmental or genetic factors. Identifying biomarkers of irritability could provide objective
data to understand the etiology, assessment, and treatment of irritability. For example,
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identifying biomarkers could lead to more effective pharmacological and other treatments. Also,
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if lowered glucose is a biomarker of irritability, we can safely assume that lack of eating can
cause irritability since a lack of eating affects glucose. Identifying biomarkers of irritability
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would additionally help distinguish irritable anger from non-irritable anger (i.e., evoked through
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cognitive means).
Insel et al. (2010) promulgated a Research Domain Criteria (RDoC) for classifying
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mental disorders using a neurological framework – specifically as dysfunctional neural circuits.

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Although there is a clear lack of literature on the neurobiology of irritability ("Childhood
Chronic Irritability and the Pathophysiology," 2014), some potential biomarkers have been
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examined. First, irritability has a moderate degree of heritability. Based on different findings
from twin studies, irritability has a heritability correlation ranging from .31 to .51 – potentially
the strongest in early adolescence (.37, Coccaro, Bergeman, Kavoussi, & Seroczynski, 1997; .31,
Stringaris et al., 2012; .51 Savage et al., 2015). Potential sex and age differences exist in
heritability. Roberson-Nay et al. (2015) found that genetic influences increase as men age but
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decline as women age. Additionally, the heritability of irritability is linked to carriers of the
Huntington’s disease gene (Kirkwood et al., 2002; Berrios et al., 2002).
Second, irritability is associated with changes in brain regions. For example, some fMRI
studies have examined differences in the brains of irritable versus healthy individuals (typically
youth). Two studies examined differences in chronically irritable children when given a
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frustrating task. Perlman et al. (2015) found decreased activation in their anterior cingulate
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cortex and striatum. Deveney et al. (2013) found decreased activation in the striatum as well as
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in the left amygdala and parietal cortex. Although Deveney and colleagues (2013) found
decreased activation in the posterior cingulate cortex, Perlman and colleagues (2015) found
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increased activation. However, Perlman and colleagues (2015) noted that an increased activation
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in the PCC for their participants might be driven by the stimulant medications taken by their
irritable participants. A few studies examined brain differences in the facial emotion processing
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of irritable samples. The majority of studies measured changes in brain activation when showing
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participants a facial expression that is either happy, angry, or fearful. Tseng et al. (2016) and
Thomas et al. (2012, 2013, 2014) examined differences between children with Severe Mood
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Dysregulation Disorder (SMD) and healthy participants. When viewing happy faces, children
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with SMD showed increased activation in the right amygdala (Thomas et al., 2013) and the right
inferior parietal lobe, left middle occipital/fusiform gyrus, right middle occipital gyrus, and left
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middle/superior frontal gyrus (Thomas et al., 2012), and decreased activation in the insula,
parahippocampal gyrus (PHG), and thalamus. When shown angry faces, children with SMD also
showed increased activation in the right amygdala (Thomas et al., 2013) and the occipital
regions, right posterior cingulate cortex, right middle occipital gyrus (Thomas et al., 2014), the
PHG (Tseng et al., 2016), and the superior temporal gyrus (Thomas et al., 2014; Tseng et al.,
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2016), and decreased activation in the left amygdala (Thomas et al., 2012). Two studies also
examined differences at resting state. When examining brain changes in people with Bipolar
Disorder, of which irritability is a symptom, Stoddard et al. (2016) found hyperconnectivity in
two networks: the temporal and parietal network for visual processing and a corticostriatal
network for attention and response generation processes. When examining the neuro-metabolites
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of children with and without irritability and hyper-arousal symptoms, Dickstein et al. (2008),
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found that children with irritability and hyper-arousal symptoms had significantly lower myo-
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inositol (an intra-cellular second-messenger marker associated with bipolar disorder) in the
temporal lobe than those without irritability. Significant differences were not found in intensities
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of combined glutamate and glutamine (a major excitatory neurotransmitter).
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It is likely that dysregulation in the above brain regions reflects behavioral changes found
for children with chronic irritability. For example, the ACC is associated with error monitoring,
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deviation from a potential reward, and emotion regulation (Amiez, Joseph, & Procyk, 2005;
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Bush, Luu, & Posner, 2000; Carter et al., 1998; Perlman, 2015); the amygdala is associated with
emotion labeling and the evaluation of the emotional salience of negative stimuli (Deveney et al,
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2013; Perlman, 2015; Rich et al., 2008); and the striatum is associated with general reward
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response (Deveney et al., 2013; Perlman, 2015). Irritable children have also been found to
perform poorly in tasks that require cognitive flexibility and adaptability, possibly because of the
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corticostriatal network (Adleman et al., 2011; Leibenluft, 2011; Stoddard et al., 2016).
Third, irritability is associated with changes in hormones, neurotransmitters, and the
hypothalamic-pituitary-adrenal axis (HPA). For example, suggested markers for irritability
include changes in hormones and neurotransmitters such as increased norepinephrine and
cortisol (Gerra et al., 1996), increased testosterone (Gerra et al., 1996; Rabkin, Rabkin, &
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Wagner, 1997), decreased testosterone, (Sternbach, 1998; Tenover, 1997; Vermeulen, 1993),
reduced serotonin (Coccaro, Harvey, Kupsaw-Lawrence, Herbert, & Bernstein, 1991; Landén,
Erlandsson, Bengtsson, Andersch, & Eriksson, 2009), and increased central α2-adrenergic
receptor responsivity in the limbic-hypothalamic-pituitary axis clonidine, which is associated
with increased norepinephrine (Coccaro, Lawrence, et al., 1991).
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Although some biomarkers have been identified, it remains unclear whether these are part
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of the experience or causes of irritability. If they are part of the experience, it is unclear whether
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these identified biomarkers are direct manifestations of irritability. It is possible that these
biomarkers are only indirect manifestations of irritability, or are actually manifestations of anger
or aggression.
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Causes. Physiological causes such as a lack of sleep, hunger, pain, and caffeine
withdrawal all have a clear, direct link to biological changes that impact irritability. Thus, we
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believe these are excellent examples of causes of irritability. However, feeling some emotions
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such as depression, anxiety, embarrassment, guilt, disgust, resentment, stress, fatigue, and even
anger might cause irritability due to their impact on physiology (e.g., depleting energy).
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Similarly, environmental stressors that lead to a depletion of energy or other physiological

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changes (e.g., working hard for many hours) might cause irritability. Thus disorders that include
high arousal and/or lowered energy (as a symptom or as a result of attempting to manage
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symptoms) might cause rather than consist of irritability. For example, the reduced energy
associated with Major Depressive Disorder might cause irritability and the persistent worrying in
Generalized Anxiety Disorder might reduce energy. This could be the case for disorders such as
OCD, Tourette’s Syndrome, and Tic Disorders in which patients spend much energy coping with
and controlling their thoughts and behaviors. Thus, we propose that the causes of irritability are
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physiological in nature and directly linked to changes in biological processes. By
conceptualizing the causes of irritability as biological, directions for the treatment of irritability
become clear.
Treatment. Because the causes of irritability affect physiological/biological processes
(e.g., hunger, pain, fatigue), the best treatments will as well (e.g., eating, icing, resting). This is
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important when treating irritable anger versus non-irritable anger. For example, many anger
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interventions teach patients new responses to specific people or situations (e.g., forgiving your
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partner, problem solving about conflicts, and assertively responding to a challenging person).
However, if a patient is experiencing irritable anger (e.g., a new parent who lacks sleep), he or
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she will become angry at many people or situations, and targeting specific triggers of their anger
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will be ineffective.
Not all anger results from irritability, and not all anger should be treated via irritability.
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Although the notion of getting sleep when needed seems obvious, the notion of getting sleep (or
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eating, relaxing, or meeting any physiological need) if you are angry (specifically, via irritability)
is rarely – if at all – addressed in current treatments for anger. Maslow’s (1943) hierarchy of
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basic needs includes physiological concerns for the treatment of irritability and irritable anger.
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Knowing which physiological variables increase irritability could lead to more effective
psychosocial interventions for irritability such as the use of stimulus-control procedures (e.g.,
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“don’t over exercise,” “avoid situations that lead to fatigue”) and relapse-prevention strategies
(e.g., “This is a situation that requires a lot of self-control. I need to stay focused and deal with
the possibility that I can get irritable”). Thus, we propose that treatments for irritability should
target physiological and biological processes (or coping with unchangeable biological process as
in done in therapy for pain).

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Sensory Sensitivity. It remains unclear whether increased sensitivity to sensory stimuli is
a cause or manifestation (i.e., part of the experience) of irritability. In other words, we do not
know whether experiencing our senses strongly increases irritability, or whether a biological
change leads to irritability which includes making sensory stimuli more salient. Increased
sensitivity, common sensations (e.g., lights and or noises) might become overwhelming and lead
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to irritable anger. Similar to the disorders in the “Causes” section above, Autism Spectrum
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Disorder might be a cause irritability due to its heightened sensory sensitivity (Adelaide, 2010;
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Stringaris & Taylor, 2015). It is also possible that irritability plays a key role in misophonia, or a
strong dislike or hatred of specific sounds such as chewing or breathing (Cavanna, & Seri, 2015).
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Cognition. We propose that, unlike anger, irritability is not mediated by cognition.
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Although cognitions (e.g., hostile attributions, revenge-seeking) are associated with irritability, it
is currently unclear whether those cognitions are part of the experience or consequence of
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irritability. It is also unclear whether irritable anger is cognitively mediated. Because irritability
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is driven by biological changes, anger due to irritability might also be driven physiologically and,
consequently, might not be cognitively mediated (and impulsive/not premeditated). On the other
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hand, irritability might be physiologically based but irritable anger might have the same
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cognitive mechanisms as non-irritable anger. More empirical evidence concerning the role of
cognitions in irritability is needed.

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Culture. It will be important to highlight differences and similarities in people across
cultures when researching irritability. We hypothesize that, as a biologically-based construct,
there will be more cross-cultural similarities than differences for the causes and experience of
irritability. However, cultural differences in the causes of irritability might lead to differences in
prevalence rates of irritability. For example, it is likely that locations with less financial
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resources will have less access to meeting their physiological needs and, consequently, more
irritability. Irritability could also vary in cultures with different dietary habits or sleep schedules
(e.g., Spanish siestas). In terms of consequences, it would be worth examining cultural
differences in irritable anger and aggression as well as whether those differences parallel the
cultural differences of non-irritable anger. For example, are there gender differences in the
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expression of irritable anger and, if so, are they the same as those for traditional anger? Whether
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reviewing biomarkers, cognitions, causes, experiences, or consequences, what represents
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irritability might not the same for different cultures. Even when the construct is defined and
assessed clearly, individual, contextual, and group differences are likely to emerge.
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Pathways to Aggression. The development of independent measures of irritability,
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anger, and aggression might lead to better predictions of aggression. We can postulate at least
three paths to aggression, each with different implications for treatment. First, irritability leads to
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irritable aggression: A patient might go from irritability directly to aggression without anger. For
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such patients, directly targeting the irritability and its causes (i.e., physiological/biological
disturbances) would be the best treatment; anger management would be irrelevant. Second,
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irritability leads to irritable anger which leads to irritable aggression: A patient might go from
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irritability directly to anger, at which point the anger might lead to aggression. In this instance,
anger mediates the relationship between irritability and aggression. For such patients, treating the
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irritability might be the most successful strategy to prevent and reduce both anger and
aggression. Anger interventions (e.g., cognitive restructuring) might be more helpful in targeting
the anger, but not necessarily the irritability. Third, non-irritable anger leads to non-irritable
aggression: A patient might feel anger that leads to aggression without irritability. For such
patients, anger interventions would be the treatment of choice. It is possible and, in our opinion
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most likely, that all three of these pathways exist. It is also possible that the pathways will differ
by disorder. It seems important to explore these pathways within disorders that have irritability,
anger, or aggression as a symptom.
Definition and Assessment Recommendations
Proposed Definition
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Given the importance of establishing a precise, universal definition of irritability that
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distinguishes it from anger, aggression, and related constructs, we propose the following
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definition of irritability based upon our review of the literature above:
Irritability is a mood of partial physiological agitation characterized by an
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increased sensitivity to sensory stimuli and a non-cognitively mediated lowered
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threshold for responding with anger and/or aggression to typically less vexing
stimuli; it is caused by factors that directly affect physiology and/or biology such
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as hunger, lack of sleep, pain, and fatigue.

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The above definition incorporates elements from each reviewed category (i.e., causes,
experience, consequences) and refines and expands upon the definitions provided by DiGiuseppe
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and Tafrate (2007) given their inclusion of many common themes found. The above definition
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emphasizes the found themes that irritability is: a) a mood, b) associated with partial agitation, c)
associated with an increased sensitivity to sensory stimuli, d) non-cognitively mediated (thus, is

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reactive and not premeditated), e) a lowered threshold for provoking stimuli, f) followed by
anger and aggression, and g) physiologically based and directly linked to
physiological/biological changes. A few potential components of irritability were not included
due to the need for further research. For example: a) the specific biological mechanisms which
play a role in irritability, b) whether to include non-physical conditions (e.g., emotions, chronic
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environmental stressors) as causes of irritability, c) the role and/or presence of cognitions in the
experience of irritability, d) whether irritable aggression is mediated by anger, and e) whether
irritability is a state, trait, or both.
Proposed Measurement
Many items from irritability scales assess components of anger that are also measured by
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widely used anger scales such as the Anger Disorders Scale (DiGiuseppe & Tafrate, 2004), the
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Novaco Anger Scale (Novaco, 2003), and the State Trait Anger Expression Inventory 2
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(Spielberger, 1999). Similarly, irritability observer forms (i.e., for parents and care providers)
risk capturing aggression by their reliance on external behavior. This was shown to occur for
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anger observer forms. Fives, Kong, Fuller, and DiGiuseppe (2010) found that peer ratings of
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children’s anger were so highly correlated with the peer rating of the children’s aggression that
the anger ratings were redundant. Although there might be some differences in parent and child
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reports of irritability for children with severe mood disorders (Stoddard et al, 2014), further
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research is needed to determine the usefulness of cross informant forms of irritability measures.
Of the existing irritability scales, the BITe scale developed by Holtzman, et al. (2015)
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appears to be the best. This short scale of five items assesses the feeling of irritability, agitation,
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and a lowered threshold for arousal. However, it risks underrepresenting the construct of
irritability by representing it through five items, one of its items overlaps with anger, and it
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includes items that could measure irritability as both a state and a trait. Removing items that
potentially measure anger, and exploring the distinction between state and trait irritability would
be the next logical step in developing a measure of irritability. We recommend that measures
incorporate items that represent all aspects of irritability as we define it above (i.e., including
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aspects from the causes, experience, and consequences) without measuring anger, aggression, or
related constructs.
Although including eliciting stimuli (i.e., causes) of a construct is less common in
measures for emotions, it occurs often for anger (Novaco, 2003) and could help to identify
patients with irritability – especially given the more direct relationship between the
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physiological causes and biological changes of irritability. For example, if a person becomes
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angry while hungry, it increases the likelihood that likely he or she is experiencing irritable anger
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instead of non-irritable anger. Items addressing the causes of irritability should also include the
notion of stimuli being more vexing than usual. Thus, the prompts, “I am feeling bothered by
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things” would not capture irritability as well as a prompt such as “I have been feeling more
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bothered toward things that usually don’t bother me.”
It is possible that, given the physiological nature of irritability, the experience of

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irritability could be best measured using neurological equipment (e.g., electromyograph, blood
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chemistry analyzer, urine analyzer) once biomarkers are more clearly identified. However,
survey items measuring the experience of irritability would best include synonyms for
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irritability, taking caution that such synonyms do not overly reflect anger or other emotions. The
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most precise synonyms will reflect a generally negative mood associated with long-lasting slight
physiological agitation such as “crabbiness,” “grouchiness,” or “grumpiness.” Items might also

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address physiological agitation explicitly, although it will ideally measure a partial physiological
agitation. Ideally, measures would include items that capture an increased sensitivity to sensory
stimuli. Items should avoid capturing cognitive aspects of irritability given our current difficulty
in distinguishing between the cognitions of irritability in anger.

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Items measuring consequences would ideally capture a lowered threshold for anger and
aggression. Given the risk of measuring the constructs of anger and aggression, caution should
be taken to not measure a high frequency or presence of anger or aggression. Specifically, we
recommend an item such as “I have been more easily angered” over an item such as “I am
feeling angry” or “I often feel angry.”
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The lack of clarity regarding the construct of irritability is clear. We need to isolate
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irritability from anger, aggression, and related constructs for a better understanding of the
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individual roles of each in psychopathology. We hope that the above proposed definition is a step
toward creating a more unified and precise understanding of irritability that will lead to more
powerful diagnoses and treatment efficacy.

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References:
Acri, J. B., & Grunberg, N. E. (1992). A psychophysical task to quantify smoking cessation-
induced irritability: the reactive irritability scale (RIS). Addictive Behaviors, 17(6), 587-
601.
Adleman, N.E., Kayser, R., Dickstein, D., Blair, R.J.R., Pine, D., & Leibenluft, E. (2011). Neural
T
correlates of reversal learning in severe mood dysregulation and pediatric bipolar
IP
disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 50,1173–
CR
1185.
Aebi M, van Donkelaar MM, Poelmans G, Buitelaar JK, Sonuga-Barke EJ,Stringaris A; IMAGE
US
consortium, Faraone SV, Franke B, Steinhausen HC, van Hulzen KJ (2015). Gene-set
AN
and multivariate genome-wide association analysis of oppositional defiant behavior
subtypes in attention-deficit/hyperactivity disorder American Journal of Medical

M
Genetics Part B. doi: 10.1002/ajmg.b.32346.

ED
Ahrén, B. (2013). Avoiding hypoglycemia: a key to success for glucose-lowering therapy in type
2 diabetes. Vascular health and risk management, 9, 155-163.

PT
Althoff, R.R, Verhulst, F.C., Rettew, D.C., Hudziak, J.J., van der Ende, J. (2010). Adult
CE
outcomes of childhood dysregulation: a 14-year follow-up study. Journal of the American
Academy of Child & Adolescent Psychiatry, 49(11), 1105-1116.

AC
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental
Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Amiez, C., Joseph, J. P., & Procyk, E. (2005). Anterior cingulate error‐related activity is
modulated by predicted reward. European Journal of Neuroscience, 21(12), 3447-3452.

ACCEPTED MANUSCRIPT
Avenevoli, S., Blader, J.C., Leibenluft, E. (2015). Irritability in youth: An update. Journal of the
American Academy of Child & Adolescent Psychiatry, 54(11):881-883.
Awaisu, A., Samsudin, S., Amir, N. A., Omar, C. G., Hashim, M. I., Mohamad, M. H., ... &
Hassali, M. A. (2010). Measurement of nicotine withdrawal symptoms: linguistic
validation of the Wisconsin Smoking Withdrawal Scale (WSWS) in Malay. BMC
T
medical research methodology, 10(1), 46.
IP
Barata, P.C., Holtzman, S., Cunningham, S., O'Connor, B.P., & Stewart, D.E. (2016). Building a
CR
Definition of Irritability From Academic Definitions and Lay Descriptions. Emotion
Review 8(2), 164-172.
US
Beck, A.T. (1976). Cognitive therapy and the emotional disorders. New York: International
AN
University Press.
Benazzi, F., Koukopoulos, A., & Akiskal, H. (2004). Toward a validation of a new definition of
M
agitated depression as a bipolar mixed state (mixed depression). European Psychiatry,

ED
19(2), 85-90.
Benton, D. (2002). Carbohydrate ingestion, blood glucose and mood. Neuroscience &
PT
Biobehavioral Reviews, 26(3), 293-308.

CE
Berrios, G. E., Wagle, A. C., Markova, I. S., Wagle, S. A., Rosser, A., & Hodges, J. R. (2002).
Psychiatric symptoms in neurologically asymptomatic Huntington's disease gene carriers:

AC
a comparison with gene negative at risk subjects. Acta Psychiatrica Scandinavica,
105(3), 224-230.
Born, L., Koren, G., Lin, E., & Steiner, M. (2008). A new, female-specific irritability rating
scale. Journal of Psychiatry & Neuroscience: JPN, 33(4), 344.
Bose, J. C. (1913). Researches on irritability of plants. Longmans, Green, and Company.

ACCEPTED MANUSCRIPT
Brotman, M. A., Schmajuk, M., Rich, B. A., Dickstein, D. P., Guyer, A. E., Costello, E. J., ... &
Leibenluft, E. (2006). Prevalence, clinical correlates, and longitudinal course of severe
mood dysregulation in children. Biological psychiatry, 60(9), 991-997.
Burns, A., Folstein, S., Brandt, J., & Folstein, M. (1990). Clinical assessment of irritability,
aggression, and apathy in Huntington and Alzheimer disease. The Journal of Nervous and
T
Mental Disease, 178(1), 20-26.
IP
Bush, G., Luu, P., & Posner, M. I. (2000). Cognitive and emotional influences in anterior
CR
cingulate cortex. Trends in cognitive sciences, 4(6), 215-222.
Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of hostility.
Journal Of Consulting Psychology, 21(4), 343.

US
AN
Cabıoğlu, M. T., & Ergene, N. (2006). Changes in serum leptin and beta endorphin levels with
weight loss by electroacupuncture and diet restriction in obesity treatment. The American
M
Journal Of Chinese Medicine, 34(01), 1-11.

ED
Caprara, G. V., Cinanni, V., D'Imperio, G., Passerini, S., Renzi, P., & Travaglia, G. (1985).
Indicators of impulsive aggression: Present status of research on irritability and emotional

PT
susceptibility scales. Personality and Individual Differences, 6(6), 665-674.

CE
Caprara, G. V., Renzi, P., Alcini, P., Imperio, G. D., & Travaglia, G. (1983). Instigation to
aggress and escalation of aggression examined from a personological perspective: The

AC
role of irritability and of emotional susceptibility. Aggressive Behavior, 9(4), 345-351.
Caprara, G. V., Renzi, P., D'Augello, D., D'Imperio, G., Rielli, I., & Travaglia, G. (1986).
Interpolating physical exercise between instigation to aggress and aggression: The role of
irritability and emotional susceptibility. Aggressive Behavior, 12(2), 83-91.

ACCEPTED MANUSCRIPT
Carter, C. S., Braver, T. S., Barch, D. M., Botvinick, M. M., Noll, D., & Cohen, J. D. (1998).
Anterior cingulate cortex, error detection, and the online monitoring of performance.
Science, 280(5364), 747-749.
Cavanna, A. E., & Seri, S. (2015). Misophonia: current perspectives. Neuropsychiatric Disease
And Treatment, 11, 2117-2123. doi:10.2147/NDT.S81438
T
Childhood Chronic Irritability and the Pathophysiology of Mental Illness. (2014). Retrieved
IP
April 5, 2016, from National Institute of Mental Health website:
CR
http://www.nimh.nih.gov/research-priorities/scientific-meetings/2014/childhood-chronic-
irritability/childhood-chronic-irritability-and-the-pathophysiology-of-mental-illness.shtml
US
Coccaro, E. F., Bergeman, C. S., Kavoussi, R. J., & Seroczynski, A. D. (1997). Heritability of
AN
aggression and irritability: a twin study of the Buss—Durkee Aggression Scales in adult
male subjects. Biological Psychiatry, 41(3), 273-284.

M
Coccaro, E. F., Harvey, P. D., Kupsaw-Lawrence, E., Herbert, J. L., & Bernstein, D. (1991).
ED
Development of neuropharmacologically based behavioral assessments of impulsive
aggressive behavior. The Journal of Neuropsychiatry and Clinical Neurosciences.

PT
Coccaro, E. F., Lawrence, T., Trestman, R., Gabriel, S., Klar, H. M., & Siever, L. J. (1991).
CE
Growth hormone responses to intravenous clonidine challenge correlate with behavioral
irritability in psychiatric patients and healthy volunteers. Psychiatry Research, 39(2),

AC
129-139.
Copeland, W. E., Brotman, M. A., & Costello, E. J. (2015). Normative irritability in youth:
developmental findings from the Great Smoky Mountains Study. Journal of the American

ACCEPTED MANUSCRIPT
Copeland, W. E., Shanahan, L., Egger, H., Angold, A., & Costello, E. J. (2014). Adult diagnostic
and functional outcomes of DSM-5 disruptive mood dysregulation disorder. American
Journal of Psychiatry, 171(6), 668-674.
Craig, K. J., Hietanen, H., Markova, I. S., & Berrios, G. E. (2008). The Irritability Questionnaire:
a new scale for the measurement of irritability. Psychiatry Research, 159(3), 367-375.
T
Darwin, C. (1965). The expression of emotions in man and animals. Chicago: University of
IP
Chicago Press.
CR
Deckersbach, T., Perlis, R. H., Frankle, W. G., Gray, S. M., Grandin, L., Dougherty, D. D., . . .
Sachs, G. S. (2004). Presence of irritability during depressive episodes in bipolar
disorder. CNS Spectrums, 9, 227-227.

US
AN
Denson, T. F., von Hippel, W., Kemp, R. I., & Teo, L. S. (2010). Glucose consumption
decreases impulsive aggression in response to provocation in aggressive individuals.

M
Journal of Experimental Social Psychology, 46(6), 1023-1028.

ED
Deveney, C. M., Connolly, M. E., Haring, C. T., Bones, B. L., Reynolds, R. C., Kim, P., . . .
Leibenluft, E. (2013). Neural mechanisms of frustration in chronically irritable children.

PT
American Journal of Psychiatry, 170(10), 1186-1194.

CE
Dickstein, D. P., van der Veen, J. W., Knopf, L., Towbin, K. E., Pine, D. S., & Leibenluft, E.
(2008). Proton magnetic resonance spectroscopy in youth with severe mood

AC
dysregulation. Psychiatry Research: Neuroimaging, 163(1), 30-39.
Dictionary.com (Accessed September 2015) http://dictionary.reference.com/
DiGiuseppe, R., & Tafrate, R. C. (2004). Anger Disorders Scale. Multi Health Systems: Toronto,
Ontario, Canada
ACCEPTED MANUSCRIPT
DiGiuseppe, R., & Tafrate, R. C. (2007). Understanding Anger Disorders. New York, NY, US:
Oxford University Press.
Dollard, J., Doob, L., Miller, N., Mowrer, O., & Sears, R. (1939). Frustration and aggression.
New Haven, CT: Yale University Press.
Ekman, P. (2007). Emotions revealed: Recognizing faces and feelings to improve communication
T
and emotional life. Macmillan.
IP
Ellis, A. (1994). Reason and emotion in psychotherapy: Revised and updated. New York: Carol
CR
Publishing.
Evans, I. M., Heriot, S. A., & Friedman, A. G. (2002). A behavioural pattern of irritability,
US
hostility and inhibited empathy in children. Clinical Child Psychology and Psychiatry,
AN
7(2), 211-224.
Fernández-Mendoza, J., Vela-Bueno, A., Vgontzas, A. N., Olavarrieta-Bernardino, S., Ramos-

M
Platón, M. J., Bixler, E. O., & De la Cruz-Troca, J. J. (2009). Nighttime sleep and
ED
daytime functioning correlates of the insomnia complaint in young adults. Journal of
Adolescence, 32(5), 1059-1074.

PT
Fishbain, D. A., Gao, J., Lewis, J. E., Bruns, D., Meyer, L. J., & Disorbio, J. M. (2015).
CE
Prevalence comparisons of somatic and psychiatric symptoms between community
nonpatients without pain, acute pain patients, and chronic pain patients. Pain Medicine,
AC
16(1), 37-50. doi:10.1111/pme.12527
Fives, C. J., Kong, G., Fuller, J. R., & DiGiuseppe, R. (2010). Anger, aggression, and irrational
beliefs in adolescents. Cognitive Therapy and Research. 35(3), 199-208. DOI:
10.1007/s10608-009-9293-3.
ACCEPTED MANUSCRIPT
Friedmutter, R., Soto, B., & DiGiuseppe, R. The content validity of irritability items. Poster
presented at the Association for Behavioral and Cognitive Therapies, 46th Annual
Convention of Behavioral and Cognitive Therapies (ABCT), November 15-18, 2012,
National Harbor, MD.
Franzen, P. L., Buysse, D. J., Rabinovitz, M., Pollock, B. G., & Lotrich, F. E. (2010). Poor sleep
T
quality predicts onset of either major depression or subsyndromal depression with
IP
irritability during interferon-alpha treatment. Psychiatry research, 177(1), 240-245.
CR
Gerra, G., Avanzini, P., Zaimovic, A., Fertonani, G., Caccavari, R., Delsignore, R., . . . Maestri,
D. (1996). Neurotransmitter and endocrine modulation of aggressive behavior and its
US
components in normal humans. Behavioural Brain Research, 81(1), 19-24.
AN
Holtzman, S., O'Connor, B. P., Barata, P. C., & Stewart, D. E. (2015). The Brief Irritability Test
(BITe): A Measure of Irritability for Use Among Men and Women. Assessment. doi:
M
10.1177/1073191114533814
ED
Hughes, G. V., & Boland, F. J. (1992). The effects of caffeine and nicotine consumption on
mood and somatic variables in a penitentiary inmate population. Addictive Behaviors,

PT
17(5), 447-457.
CE
Insel, T., Cuthbert, B., Garvey, M., Heinssen, R., Pine, D. S., Quinn, K., ... & Wang, P. (2010).
Research domain criteria (RDoC): toward a new classification framework for research on
AC
mental disorders. American Journal of Psychiatry, 167(7), 748-51
Irritable bowel syndrome. (2013). from
http://www.nlm.nih.gov/medlineplus/ency/article/000246.htm
Irritability. (n.d.). In OED Online: Oxford English Dictionary. Retrieved from
http://www.oed.com.
ACCEPTED MANUSCRIPT
Juliano, L. M., & Griffiths, R. R. (2004). A critical review of caffeine withdrawal: empirical
validation of symptoms and signs, incidence, severity, and associated features.
Psychopharmacology, 176(1), 1-29.
Juslin, P. N., & Västfjäll, D. (2008). Emotional responses to music: The need to consider
underlying mechanisms. Behavioral and Brain Sciences, 31(05), 559-575.
T
Kazdin, A. E., Rodgers, A., Colbus, D., & Siegel, T. (1987). Children's Hostility Inventory:
IP
Measurement of aggression and hostility in psychiatric inpatient children. Journal of
CR
Clinical Child Psychology, 16(4), 320-328.
US
Keefe, M. R., Froese‐Fretz, A., & Kotzer, A. M. (1998). Newborn predictors of infant irritability.
Journal of Obstetric, Gynecologic, & Neonatal Nursing, 27(5), 513-520.

AN
Keefe, M. R., & Froese-Fretz, A. (1991). Living with an irritable infant: The maternal
perspective. Maternal Child Nursing, 16, 255-259.

M
Keefe, M. R., Kotzer, A. M., Froese-Fretz, A., & Curtin, M. (1996). A longitudinal comparison
ED
of irritable and nonirritable infants. Nursing Research, 45(1), 4-9.
Kirkwood, S. C., Siemers, E., Viken, R., Hodes, M. E., Conneally, P. M., Christian, J. C., &
PT
Foroud, T. (2002). Longitudinal personality changes among presymptomatic Huntington

CE
disease gene carriers. Cognitive and Behavioral Neurology, 15(3), 192-197.
Kuan, T. S., Lin, Y. C., Lien, W. C., Hsieh, P. C., Chung, Y. T., Lin, S. H., & Chou, L. W.
AC
(2015). The Effect of Monochromatic Infrared Photo Energy on the Irritability of
Myofascial Trigger Spot of Rabbit Skeletal Muscle. Evidence-Based Complementary and
Alternative Medicine, 2015, 1-7. DOI: 10.1155/2015/816956

ACCEPTED MANUSCRIPT
Küçer, N. (2010). The relationship between daily caffeine consumption and withdrawal
symptoms: a questionnaire-based study. Turkish Journal Of Medical Sciences, 40(1),
105-108. doi:10.3906/sag-0809-26
Laessle, R., Platte, P., Schweiger, U., & Pirke, K. (1996). Biological and psychological
correlates of intermittent dieting behavior in young women. A model for bulimia nervosa.
T
Physiology & Behavior, 60(1), 1-5.
IP
Lamers, F., Hickie, I., & Merikangas, K. R. (2013). Prevalence and correlates of prolonged
CR
fatigue in a US sample of adolescents. American Journal of Psychiatry, 170(5), 502-510.
Landén, M., Erlandsson, H., Bengtsson, F., Andersch, B., & Eriksson, E. (2009). Short onset of
US
action of a serotonin reuptake inhibitor when used to reduce premenstrual irritability.
AN
Neuropsychopharmacology, 34(3), 585-592.
Leibenluft, E. (2011). Severe mood dysregulation, irritability, and the diagnostic boundaries of
M
bipolar disorder in youths. American Journal of Psychiatry, 168(2), 129-142.

ED
Leibenluft, E., Blair, R. J. R., Charney, D. S., & Pine, D. S. (2003). Irritability in pediatric mania
and other childhood psychopathology. Annals of the New York Academy of Sciences,
PT
1008(1), 201-218.
CE
Leibenluft, E., Charney, D. S., & Pine, D. S. (2003). Researching the pathophysiology of
pediatric bipolar disorder. Biological Psychiatry, 53(11), 1009-1020.

AC
Leibenluft, E., Charney, D. S., Towbin, K. E., Bhangoo, R. K., & Pine, D. S. (2003). Defining
clinical phenotypes of juvenile mania. American Journal of Psychiatry, 160(3), 430-437.
Leibenluft, E., Cohen, P., Gorrindo, T., Brook, J. S., & Pine, D. S. (2006). Chronic Versus
Episodic Irritability in Youth: A Community-Based, Longitudinal Study of Clinical and

ACCEPTED MANUSCRIPT
Diagnostic Associations. Journal of Child & Adolescent Psychopharmacology, 16(4),
456-466.
MacMillian Dictionary. Accesessed Decemebr 2014). http://www.macmillandictionary.com/us
Maitland, G. D. (2005). Maitland's vertebral manipulation (Vol. 1). E. Hengeveld, K. Banks, &
K. English (Eds.). Butterworth-Heinemann.
T
Malara, A., De Biase, G. A., Bettarini, F., Ceravolo, F., Di Cello, S., Garo, M., & ... Rispoli, V.
IP
(2016). Pain Assessment in Elderly with Behavioral and Psychological Symptoms of
CR
Dementia. Journal Of Alzheimer's Disease, 50(4), 1217-1225 9p. doi:10.3233/JAD-
150808
US
Maslow, A.H. (1943). A theory of human motivation. Psychological Review, 50, 370-396.
AN
McRobbie, H., & Hajek, P. (2004). Effect of glucose on tobacco withdrawal symptoms in recent
quitters using bupropion or nicotine replacement. Human Psychopharmacology: Clinical

M
and Experimental, 19(1), 57-61.

ED
Merriam-Webster Dictionary. (accessesed December 2014). http://www.merriam-webster.com/
Moyer, K. E. (1976). The psychobiology of aggression: Harper & Row New York.
PT
Mullin, F. J., Kleitman, N., & Cooperman, N. (1937). Studies on the physiology of sleep changes
CE
in irritability to auditory stimuli during sleep. Journal Of Experimental Psychology,
21(1), 88.
AC
National Institute of Mental Health. (n.d.). RDoC constructs. Retrieved April 29, 2016, from
http://www.nimh.nih.gov/research-priorities/rdoc/rdoc-constructs.shtml
Novaco, R. W. (2003). Novaco Anger Scale and Provocation Inventory. Western Psychological
Services: Torrance, CA.

ACCEPTED MANUSCRIPT
Perlman, S. B., Jones, B. M., Wakschlag, L. S., Axelson, D., Birmaher, B., & Phillips, M. L.
(2015). Neural substrates of child irritability in typically developing and psychiatric
populations. Developmental Cognitive Neuroscience, 14, 71-80.
Rabkin, J. G., Rabkin, R., & Wagner, G. J. (1997). Testosterone treatment of clinical
hypogonadism in patients with HIV/AIDS. International Journal of STD & AIDS, 8(9),
T
537-545.
IP
Rich, B. A., Grimley, M. E., Schmajuk, M., Blair, K. S., Blair, R. J. R., & Leibenluft, E. (2008).
CR
Face emotion labeling deficits in children with bipolar disorder and severe mood
dysregulation. Development and psychopathology, 20(02), 529-546.
US
Rich, B. A., & Leibenluft, E. (2006). Irritability in pediatric mania. Clinical Neuropsychiatry,
AN
3(3), 205-218.
Robb, A. S. (2010). Managing irritability and aggression in autism spectrum disorders in

M
children and adolescents. Developmental Disabilities Research Reviews, 16(3), 258-264.

ED
Roberson-Nay, R., Leibenluft, E., Brotman, M.A., Myers, J., Larsson, H., Lichtenstein, P.,
Kendler, K.S. (2015). Longitudinal stability of genetic and environmental influences on

PT
irritability: From childhood to young adulthood. American Journal of Psychiatry, 172,

CE
657-664.
Robinson, E. S., & Richardson-Robinson, F. (1922). Effects of loss of sleep. II. Journal Of
AC
Experimental Psychology, 5(2), 93-100. doi:10.1037/h0071197
Rostrup, M., & Ekeberg, Ø. (1992). Awareness of high blood pressure influences on
psychological and sympathetic responses. Journal of Psychosomatic Research, 36(2),
117-123.
ACCEPTED MANUSCRIPT
Satchell, A. K. & Toohey, M.J. (2016). A Cross-Cultural Qualitative Examination of the
Relationship between Irritability and Anger. Poster presented at the 50th Annual
Convention of the Association of Behavioral and Cognitive Therapies (ABCT), October
27-30, New York.
Savage, J., Verhulst, B., Copeland, W., Althoff, R. R., Lichtenstein, P., & Roberson-Nay, R.
T
(2015). A genetically informed study of the longitudinal relation between irritability and
IP
anxious/depressed symptoms. Journal of the American Academy of Child & Adolescent
CR
Psychiatry, 54(5), 377-384.
Slater, E., & Roth, M. (1969). Mayer-Gross, Slater, and Roth: Clinical Psychiatry (3rd ed.).
London, Bailliere, Tindall and Cassell.

US
AN
Snaith, R., Constantopoulos, A., Jardine, M., & McGuffin, P. (1978). A clinical scale for the
self-assessment of irritability. The British Journal of Psychiatry, 132(2), 164-171.

M
Snaith, R., & Taylor, C. (1985). Irritability: definition, assessment and associated factors. The
ED
British Journal of Psychiatry, 147(2), 127-136.
Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-2. Psychological Assessment

PT
Resources, Inc.: Lutz, FL.

CE
Spielberger, C.D., Jacobs, G., Russell, S., Crane, R. (1983). Assessment of anger: the state-trait
anger scale. In J.N. Butcher & C.D. Spielberger (Eds.), Advances in personality
AC
assessment (Vol 2). Hillsdale, NJ: Erlbaum.
Spielberger, C. D., Reheiser, E. C., & Sydeman, S. J. (1995). Measuring the experience,
expression, and control of anger. Issues In Comprehensive Pediatric Nursing, 18(3), 207-
232. doi:10.3109/01460869509087271
ACCEPTED MANUSCRIPT
Sternbach, H. (1998). Age-associated testosterone decline in men: clinical issues for psychiatry.
American Journal of Psychiatry, 155(10), 1310-1318.
Stringaris, A. (2011). Irritability in children and adolescents: a challenge for DSM-5. European
Child & Adolescent Psychiatry, 20(2), 61-66.
Stringaris, A., Cohen, P., Pine, D., & Leibenluft, E. (2009). Adult outcomes of youth irritability:
T
a 20-year prospective community-based study. American Journal Of Psychiatry, 166(9),
IP
1048-1054.
CR
Stringaris, A., & Goodman, R. (2009). Longitudinal outcome of youth oppositionality: irritable,
headstrong, and hurtful behaviors have distinctive predictions. Journal of the American
US
AN
Stringaris, A., Goodman, R., Ferdinando, S., Razdan, V., Muhrer, E., Leibenluft, E., & Brotman,
M. A. (2012). The Affective Reactivity Index: a concise irritability scale for clinical and
M
research settings. Journal of Child Psychology and Psychiatry, 53(11), 1109-1117.

ED
Stringaris, A., & Taylor, E. (2015). Disruptive Mood: Irritability in Children and Adolescents.
Oxford University Press, USA.

PT
Stringaris, A., Zavos, H., Leibenluft, E., Maughan, B., & Eley, T. C. (2012). Adolescent
CE
irritability: phenotypic associations and genetic links with depressed mood. American
Journal of Psychiatry, 169(1), 47-54.

AC
Stoddard, J., Gotts, S. J., Brotman, M. A., Lever, S., Hsu, D., Zarate Jr, C., ... & Leibenluft, E.
(2016). Aberrant intrinsic functional connectivity within and between corticostriatal and
temporal-parietal networks in adults and youth with bipolar disorder. Psychological
Medicine, 46(7), 1509.

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Stoddard, J., Stringaris, A., Brotman, M. A., Montville, D., Pine, D. S., & Leibenluft, E. (2014).
Irritability in child and adolescent anxiety disorders. Depression and anxiety, 31(7), 566-
573.
Tamura, N., & Tanaka, H. (2014). Effects of sleep education with self‐help treatment for
elementary schoolchild with nocturnal lifestyle and irritability. Sleep and Biological
T
Rhythms, 12(3), 169-179.
IP
Tarter, R. E., Blackson, T., Brigham, J., Moss, H., & Caprara, G. V. (1995). The association
CR
between childhood irritability and liability to substance use in early adolescence: a 2-year
US
follow-up study of boys at risk for substance abuse. Drug and Alcohol Dependence,
39(3), 253-261.
AN
Tenover, J. (1997). Testosterone and the aging male. Journal of Andrology, 18(2), 103-106.
Thomas, L.A., Brotman, M.A., Bones, B.L., Chen, G., Rosen, B.H., Pine, D.S., Leibenluft, E.
M
(2014). Neural circuitry of masked emotional face processing in youth with bipolar
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disorder, severe mood dysregulation, and healthy volunteers. Developmental Cognitive
Neuroscience, 8, 110-120.
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Thomas, L. A., Kim, P., Bones, B. L., Hinton, K. E., Milch, H. S., Reynolds, R. C., ... &
CE
Leibenluft, E. (2013). Elevated amygdala responses to emotional faces in youths with
chronic irritability or bipolar disorder. NeuroImage: Clinical, 2, 637-645.

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Thomas, L.A., Brotman, M.A., Rosen, B.A., Bones, B.L., Reynolds, R.C., Pine, D.S., Leibenluft,
E. (2012).Parametric modulation of amygdala activity by emotion in youth with bipolar
disorder, severe mood dysregulation, and controls. Archives of General Psychiatry, 69,
1257-1566.
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Tseng, W.-L., Thomas, L.A., Harkins, E., Pine, D.S., Leibenluft, E., Brotman, M.A. (2016).
Neural correlates of masked and unmasked face emotion processing in youth with severe
mood dysregulation. Social Cognitive and Affective Neuroscience, 11(1), 78-88
Vermeulen, A. (1993). The male climacterium. Annals of Medicine, 25(6), 531-534.
Walsh, J., & Roberts, R. (2005). How to handle anger during low blood sugars. Retrieved from
T
http://www.diabetesnet.com/diabetes-control/low-blood-sugars/emotion-control
IP
Wiggins, J. L., Mitchell, C., Stringaris, A., & Leibenluft, E. (2014). Developmental trajectories
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of irritability and bidirectional associations with maternal depression. Journal of the
American Academy of Child & Adolescent Psychiatry, 53(11), 1191-1205.
US
Wikipedia (accessed July 2015). http://en.wikipedia.org/wiki/Irritability
AN
Wilson, V. (2011). Non-diabetic hypoglycaemia: causes and pathophysiology. Nursing Standard,
25(46), 35-39.
M
Yang, C.-C., Hua, M.-S., Lin, W.-C., Tsai, Y.-H., & Huang, S.-J. (2012). Irritability following
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traumatic brain injury: divergent manifestations of annoyance and verbal aggression.
Brain Injury, 26(10), 1185-1191.

PT
Zhan, W., Dierker, L. C., Rose, J. S., Selya, A., & Mermelstein, R. J. (2012). The natural course
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of nicotine dependence symptoms among adolescent smokers. Nicotine & Tobacco
Research, 14(12), 1445-1452.

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Table 1
Disorders with symptoms of irritability, anger, and aggression in the DSM-5
Irritability Anger Aggression
Generalized Anxiety Disorder: “irritability” (p. Disruptive Mood Disruptive Mood Dysregulation
122) Dysregulation Disorder: Disorder: “physical aggression” (p.
Bipolar Disorder I and II: “irritable mood” (p. “persistently…angry” (p. 156) 156)
T
124-125; p. 132-133) Posttraumatic Stress Disorder: “verbal
IP
Premenstrual Dysphoric
Cyclothymic Disorder: “irritable mood” (p. 139) Disorder: “anger” (p. 177) or physical aggression” (p. 272)
CR
Disruptive Mood Dysregulation Disorder: Posttraumatic Stress Acute Stress Disorder: “verbal or
“persistently irritable” (p. 156) Disorder: “angry outbursts physical aggression” (p. 281)
US
Major Depressive Disorder: “irritable mood” (p. (with little or no Intermittent Explosive Disorder:
160) provocation)” (p. 272) “verbal or physical aggression” (p.

AN
Persistent Depressive Disorder: “mood can be Acute Stress Disorder: “angry 466)
irritable” (p. 168) outbursts (with little or no Conduct Disorder: “aggression” (p.
M
Premenstrual Dysphoric Disorder: ”marked provocation)” (p. 281) 469)
irritability“ (p. 172) Oppositional Defiant Alcohol Intoxication: “aggressive

ED
Reactive Attachment Disorder: “unexplained Disorder: “angry mood” (p. behavior” (p. 497)
irritability” (p. 265) 462) Cannabis Withdrawal: “aggression”

PT
Posttraumatic Stress Disorder: “irritable Cannabis Withdrawal: (p. 518)
behavior” (p. 273) “anger” (p. 518) Inhalant Intoxication: “assaultiveness”

CE
Acute Stress Disorder: “irritable behavior” (p. Stimulant Intoxication: (p. 538)
281) “anger” (p. 567) Sedative, Hypnotic, or Anxiolytic

AC
Oppositional Defiant Disorder: “irritable mood” Tobacco Withdrawal: Intoxication: “aggressive behavior”
(p. 461) “frustration or anger” (p. 575) (p. 550)
Cannabis Withdrawal: “irritability” (p. 506) Paranoid Personality Antisocial Personality Disorder:
Tobacco Withdrawal: “irritability” (p. 518) Disorder: “react angrily” (p. “aggressiveness” (p. 659)
Antisocial Personality Disorder: “irritability” (p. 649)
659) Borderline Personality
Borderline Personality Disorder: “irritability” Disorder: “anger” (p. 663)
(p. 663)
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Table 2
Items rated as assessing irritability and not the related constructs of anger or aggression.
I have been feeling ready to explode.

I have been irritable when someone touched me.
I have been rather sensitive.
Noises have seemed louder.
T
It took very little for things to bother me.
IP
Often, I feel easily annoyed or irritated.
CR
I become impatient easily when I feel under pressure.
At time, I find everyday noises irksome.
I am quite sensitive to others’ remarks.
US
He/she is easily frustrated.
Sometimes, people bug him just be being around.
AN
The patient may endorse a heightened awareness of noise or (physical) touch.
Sometimes, the smallest thing can put him/her in a bad mood.
M
ED
PT
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Table 3
Scholarly definitions of irritability
Author(s) Definition Consequence Type(s)
Benazzi et al. (2004, p. None

inner psychic tension
85)
Barata et al. (2016, pp. Irritability is an emotional process that is characterized by a proneness to experience Lowered Threshold
T
169-170). negative affective states, such as anger, annoyance, and frustration, which may or
IP
may not be outwardly expressed. Irritability often includes a feeling that one’s
CR
emotional responses are unjustified or disproportionate to the immediate source, but
difficult to control.
US
Buss and Durkee (1957, A readiness to explode with negative affect at the slightest provocation. This Lowered Threshold
p. 343) includes quick temper, grouchiness, exasperation, and rudeness
Caprara et al. (1986, p. the tendency to react impulsively, controversially, and offensively to the least Lowered Threshold
AN
84) provocation and at the slightest disagreement.
Caprara et al. (1983, p. Lowered Threshold

M
A stable tendency of the individual to react offensively to minimal provocation

346)
ED
Craig et al. (2008, p. A mood that predisposes towards certain emotions (e.g. anger), certain cognitions High Frequency
368) (e.g. hostile appraisals), and certain actions (e.g. aggression). It is subjectively
PT
unpleasant and objectively characterised by expressions of negative emotion in
interpersonal relationships
CE
Deckersbach et al. High Frequency

A state of inner tension that often leads to outbursts of anger
(2004, p. 228)
AC
Dickstein et al. (2008, p. (1) markedly increased reactivity to negative emotional stimuli manifest verbally or Lowered Threshold,
31) behaviorally at least three times weekly and (2) abnormal mood (anger or sadness), High Frequency,
present at least half of the day most days Presence
DiGiuseppe and Irritability is a physiological state characterized by a lowered threshold for Lowered Threshold
Tafrate (2007, p. 31) responding with anger or aggression to stimuli. It is a partially aroused physiological
Definition state without the thoughts that usually occur with anger
DiGiuseppe and a complex construct that involves increased sensitivity to environmental stimulation Lowered Threshold
Tafrate (2007, p. 29) that causes physiological arousal and tension, without cognitive mediation, and that
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Working definition results in a lowered threshold to experience anger, and/or impulsive, but not
premeditated, anger
Evans, Heriot, and Lowered Threshold

a lower threshold of stimulation necessary to elicit anger
Friedman (2002, p. 214)
Holtzman, O'Connor, is a mood characterized by a proneness to experience negative affective states, such Lowered Threshold
Barata, & Stewart, as anger, annoyance, and frustration upon little provocation, and may be outwardly
T
(2014) expressed in the form of aggressive behavior
IP
Leibenluft (2011, p. 1) temper outbursts that are developmentally inappropriate, frequent, and extreme; Presence
131) and 2) negatively valenced mood (anger or sadness) between outbursts
CR
Leibenluft, Blair, et al. An emotional state characterized by having a low threshold for experiencing anger in Lowered Threshold
(2003, p. 206) response to negative emotional events.
US
Leibenluft, Charney, Lowered Threshold
An increased reactivity to negative emotional stimuli
and Pine (2003, p. 1011)
AN
Rich and Leibenluft a multi-faceted emotional state characterized by a low threshold for experiencing Lowered Threshold
(2006, p. 206) anger in response to negative emotional events and stimuli; this anger produces
M
behavioral outbursts, often marked by aggression. Severe irritability is noted for its
rapid onset, substantial intensity, and prolonged duration

ED
Snaith and Taylor Feeling state characterised by reduced control over temper which usually results in High Frequency
(1985, p. 128) irascible verbal or behavioural outbursts, although the mood may be present without
PT
observed manifestation. It may be experienced as brief episodes, in particular
circumstances, or it may be prolonged and generalised. The experience of irritability

CE
is always unpleasant for the individual and overt manifestation lacks the cathartic
effect of justified outbursts of anger

AC
Snaith et al. (1978, p. a temporary psychological state characterized by impatience, intolerance and poorly High Frequency
164) controlled anger…irritability might be expressed outwardly toward others or
directed inwardly toward oneself
Stringaris (2011, p. 61) refers to easy annoyance and touchiness, is characterised by the emotion of anger, Lowered Threshold
and temper outbursts can be its behavioural manifestations
Stringaris and Lowered Threshold

the combination of temper outbursts, anger, and a low threshold for being annoyed
Goodman (2009, p. 405)
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Tarter, Blackson, High Frequency

the propensity to experience and express anger following actual or perceived
Brigham, Moss, and
provocation
Caprara (1995, p. 253)
Note: Italics added to highlight the basis for the categorization of the type of consequence included in the definition
T
IP
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AN
M
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Table 4
Irritability measures and construct(s) indicated by items
Scale/Measure Item Construct Measured
Acri and Grunberg (1992) – Participants were presented with various noises and used a magnitude Irritability
The Reactive Irritability estimation technique to depict level of irritability.
Scale (pp. 587-601)
T
Born et al. (2008) – Born (From “Not at all” to “Most or all of the time”)
IP
Anger
Steiner Irritability Scale (pp. 1. I have been feeling mad
CR
348-349) 2. I have been feeling ready to explode Irritability
3. I have yelled at others Verbal Aggression
US
4. I have been irritable when someone touched me Irritability
5. I have been easily flying off the handle Irritability
6. It feels like there has been a cloud of anger over me Anger

AN
7. I have been rather sensitive Irritability
8. I have been quick to criticize others Verbal aggression

M
9. Noises have seemed louder Irritability

ED
10. I have been getting annoyed with myself Causes of Anger
11. I have been so angry that I lost control Anger Expression

PT
12. There has been a flood of tension through my body Anger
13. I said nasty things to others that I did not mean Verbal Aggression
CE
14. It took very little for things to bother me Irritability
In the past week, how has feeling irritable affected your (from “not at all”
AC
to “extremely”):
Outcome of Irritability
15. Relationships with family?
16. Daily activities? Outcome of Irritability
17. Ability to deal with frustration? Outcome of Irritability
18. Self-esteem? Outcome of Irritability
19. Social relationships? Outcome of Irritability
(from “not at all irritable” to “extremely irritable”):

State Irritability
20. How would you rate yourself at this moment
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21. How would you rate your usual self Trait Irritability
1. ANNOYANCE: from “mostly patient and tolerant” to “It felt like

Irritability
everything was annoying all the time”
2. ANGER: from “Did not feel angry at all” to “Mostly felt full of Anger
rage”
3. TENSION: from “On most days felt quite relaxed” to “Often felt Physiological Arousal
very tense”
T
4. HOSTILE BEHAVIOR: from “For the most part was pleasant
IP
Anger
when talking to others” to “Often got into shouting fights”
CR
5a. SENSITIVITY: “Jumpy when touched by someone” (endorsed or Irritability/Anxiety
not endorsed)
US
5b. SENSITIVITY: “It seemed like people’s voices were much Irritability
louder than usual” (endorsed or not endorsed)

AN
Burns et al. (1990) – from 1(not at all irritable) to 5 (extremely irritable):
Irritability
Irritability Scale (p. 25) 1. How irritable would you say he/she was?
M
2. Does he/she sulk after he/she is angry? Anger Expression
3. Does he/she “pout” if he/she does not get his/her own way? Anger Expression
ED
4. Does he/she get into arguments? Verbal Aggression
5. Does he/she raise his/her voice in anger? Verbal Aggression

PT
Buss and Durkee (1957) – True or False:

Irritability
Hostility-Guilt Inventory (p. 1. I lose my temper easily but get over it quickly
CE
346) Irritability Subscale 2. I am always patient with others Anger/Irritability (Reversed)
3. I am irritated a great deal more than people are aware of Anger

AC
4. It makes my blood boil to have somebody make fun of me Causes of Anger
5. If someone doesn’t treat me right, I don’t let it annoy me Anger
6. Sometimes people bother me just by being around. Causes of Anger
7. I often feel like a powder keg ready to explode. Irritability
8. I sometimes carry a chip on my shoulder Resentment
9. I can’t help being a little rude to people I don’t like. Verbal Aggression
10. I don’t let a lot of unimportant things irritate me. Anger

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11. Lately, I have been kind of grouchy. Irritability
Caprara et al. (1985) – True or False: Causes of Irritable

Anger/Irritability
Irritability Scale (p. 673) 1. I easily fly off the handle with those who don’t listen or understand.
Originally in Caprara et al. 2. I am often in a bad mood. Negative Affect
(1983, pp. 122-123) 3. Usually when someone shows a lack of respect for me, I let it go by. Anger (Reversed)
4. I have never been touchy. Irritability/Anxiety (Reversed)
T
5. It makes my blood boil to have somebody make fun of me. Causes of Anger
IP
6. I think I have a lot of patience. Anger/Irritability (Reversed)
7. When I am irritated I need to vent my feelings immediately. Anger Expression
CR
8. When I am tired I easily lose control. Causes of Irritability
9. I think I am rather touchy. Irritability
US
10. When I am irritated I can’t tolerate discussions. Causes of Irritable Anger
11. I could not put anyone in his place, even if it were necessary. Assertiveness
AN
12. I can’t think of any good reason for resorting to violence. Anger (Reversed)
13. I often feel like a powder keg ready to explode. Irritability

M
14. I seldom strike back even if someone hits me first. Aggression (Reversed)
15. I can’t help being a little rude to people I don’t like. Verbal Aggression
ED
16. Sometimes when I am angry I lose control over my actions. Anger Expression
17. I do not know of anyone who would wish to harm me. Hostile-Attributions (Reversed)
PT
18. Sometimes I really want to pick a fight. Aggression
19. I do not like to make practical jokes. Not Applicable

CE
20. When I am right, I am right. Anger Cognition
21. I never get mad enough to throw things. Anger/Aggression (Reversed)

AC
22. When someone raises his voice I raise mine higher. Verbal Aggression
23. Sometimes people bother me just by being around. Irritability/Causes of Irritable

Anger
24. Some people irritate me if they just open their mouth. Irritability/Causes of Irritable
Anger
25. Sometimes I shout, hit and kick and let off steam. Aggression
26. I don’t think I am a very tolerant person. Trait Irritability
27. Even when I am very irritated I never swear. Verbal Aggression (Reversed)
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28. It is others who provoke my aggression. Anger Cognitions
29. Whoever insults me or my family is looking for trouble. Causes of Anger
30. It takes very little for things to bug me. Irritability
Craig et al. (2008) – The Rater form: Causes of Anger
Irritability Questionnaire (pp. (from 0 Never/Not at all to 3 Most of the time/Very much so):
372-374) 1. I find myself bothered by past insults or injuries.
How often? How much?
T
IP
2. I become impatient easily when I feel under pressure. Anger/Irritability/Causes of
Irritable Anger
CR
3. Things are going according to plan at the moment. Causes of Anger (Reversed)
US
4. I lose my temper and shout or snap at others. Verbal Aggression

AN
5. At times I find everyday noises irksome. Irritability

M
6. When I flare up, I get over it quickly. Anger Duration

ED
7. Arguments are a major cause of stress in my relationships. Anger Outcomes

PT
8. I have been fairly even tempered. Anger

CE
9. Lately I have felt frustrated. Anger

AC
10. I am quite sensitive to others' remarks. Insecurity
11. When I am irritated, I need to vent my feelings immediately. Anger Expression
12. I have been feeling relaxed. Irritability/Anger (Reversed)
13. I feel as if people make my life difficult on purpose. Hostile Attributions

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14. Lately I have felt bitter about things. Anger/Resentment
15. At times I can't bear to be around people. Irritability Causes of

Anger/Social Phobia
16. When I look back on how life treated me, I feel a bit disappointed and Resentment/Causes of Anger
angry.
T
IP
from 0 Never/Strongly Disagree to 3 Most of the time/Strongly Agree): Hostile Attributions
CR
17. Somehow I don't seem to be getting the things I actually deserve.
(from 0 Never/Not at all to 3 Most of the time/Very much so):
US
18. I've been feeling like a bomb, ready to explode.

Irritability
AN
(from 0 Never/Strongly Disagree to 3 Most of the time/Strongly Agree):
19. Other people always seem to get the breaks.

Hostile Attributions
M
(from 0 Never/Not at all to 3 Most of the time/Intensely):

ED
Causes of Anger
20. Lately I have been getting annoyed with myself.

PT
(from 0 Never/Not at all to 3 Most of the time/Very much so):
21. When I get angry, I use bad language or swear.

CE

Verbal Aggression
Carer form:
AC
(0 Never, 0 Not at all to 3 Most of the time, 3 Intensely)
1. He/she tends to sulk or ‘pout’.

Anger Expression
(0 Never, 0 Not at all to 3 Most of the time, 3 Very much so)

Irritability
2. Sometimes the smallest thing can put him/her in a bad mood.
(0 Never, 0 Not at all to 3 Most of the time, 3 Extensive Damage)
3. He/she has gotten so angry that he/she has broken things.

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Aggression
4. He/she loses his temper and snaps or shouts at others.

Verbal Aggression

Hostile Attributions
5. He/she is quite critical of others.
T
IP
(0 Never, 0 No injury to 3 Most of the time, 3 Severe injuries)
Aggression
CR
6. He/she has been so enraged that he/she has hit someone.
How often? How severe was the attack?
US
Depression/Anger Expression
7. He/she has become surly and withdrawn.

AN
(0 Never, 0 Not at all to 3 Most of the time, 3 Intensely)
Irritability
8. He/she is easily frustrated.
M

ED
(0 Never, 0 Not at all to 3 Most of the time, 3 Severely)

Aggression
9. He/she might lose control and hurt someone.

PT

Verbal Aggression
10. He/she has threatened violence against him/herself or others.
CE
Holtzman, O'Connor, Barata, 1. I have been grumpy Irritability

AC
& Stewart (2014) BITe 2. I have been feeling like I might snap Irritability
3. Other people have been getting on my nerves Causes of Anger
4. Things have been bothering me more than they normally do Irritability
5. I have been feeling irritable Irritability
Kazdin et al. (1987) – True or False:

Irritability/Anger Trigger
Children’s Hostility 1. Sometimes people bug him just by being around
Inventory (p. 323) Irritability 2. He is usually madder than most people realize Anger
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Subscale 3. He can always wait for others Anger (Reversed)
4. It makes him very upset to have someone make fun of him Causes of Anger
5. He often feels like a bomb is ready to explode inside Irritability
6. If someone doesn’t treat him right, he doesn’t let it bug him Causes of Anger (Reversed)
Snaith et al. (1978) – A Outward Irritability:

Verbal Aggression
Clinical Scale for the Self- 1. I lose my temper and shout or snap at others (from “Yes, definitely”
to “No, not at all”)
T
Assessment of Irritability (pp.
I am patient with other people (from “All of the time” to “Hardly
IP
170-171) 2. Anger (Reversed)/Irritability
(Reversed)
ever”)
CR
3. I feel I might lose control and hit or hurt someone (from Aggression
“Sometimes” to “Never”)
US
4. People upset me so that I feel like slamming doors or banging about Anger
(from “Yes, often” to “Not at all”)

AN
Inward Irritability:
Aggression/Depression/Borderl
1. I feel like harming myself (from “Yes, definitely” to “No, not at all”)
ine Personality Disorder
M
2. I get angry with myself or call myself names (from “Yes, definitely” Causes of Anger
to “No, not at all”)

ED
3. The thought of hurting myself occurs to me (from “Sometimes” to Aggression/Depression/Borderl

ine Personality Disorder
“Not at all”)
PT
4. Lately, I have been getting annoyed with myself (from “Very much Causes of Anger
so” to “Never”)
CE
Stringaris et al. (2009) – Parent observer report: Causes of Anger/Anger

Expression
Parent-rated and Child-rated 1. When parent makes [name of child] do things, does [name of
AC
irritability measures (pp. child] have tantrums? (“no,” “sometimes,” or “yes”)
1049-1050) 2. When teacher makes [name of child] do things, does [name of Causes of Anger/Anger
Expression
child] have tantrums? (“no,” “sometimes,”
3. How often is [name of child] angry on an average day? (“never,” Anger
“once in a while,” “often,” or “constantly”)
Child self-report Anger
4. I feel like losing my temper at people (“ true;” “mostly true, but

ACCEPTED MANUSCRIPT
not completely true;” “mostly false, but not completely false;” or
“false”)
5. Often have temper outbursts I cannot control (“not at all,” “a Anger Expression
little,” “somewhat,” “quite a bit,” or “extremely”)
6. I am often said to be hot-headed or bad tempered (“ true;” Anger
“mostly true, but not completely true;” “mostly false, but not
completely false;” or “false”)
T
Often feeling easily annoyed or irritated (“not at all,” “a little,”
IP
7. Irritability
“somewhat,” “quite a bit,” or “extremely”)
CR
8. When your parents make you do something you do not want to Causes of Anger/Anger
Expression
do, you get real mad or throw things or run out of the room
US
(“no,” “sometimes,” or “yes”)
9. If your teachers make you do something you do not want to do, Causes of Anger/Anger
AN
Expression
you get real mad or throw things or run out of the room (“no,”
“sometimes,” or “yes”)
M
Stringaris et al., (2012) “not true,” “somewhat true,” or “certainly true”
Affective Reactivity Index (p. In the last 6 months and compared to others of the same age, how well does
ED
each of the following statements describe the behavior/feelings of your

1111) Parent and Child-rated child (or your behavior/feelings by self-report)? Please try to answer all
questions.
Measure Irritability/Causes of Irritable
1. Easily annoyed by others
PT
Anger
2. Often lose temper Anger

CE
3. Stay angry for a long time Anger
4. Angry most of the time Anger

AC
5. Get angry frequently Anger
6. Lose temper easily Irritability
7. Overall, irritability causes him/her (or ‘‘me’’ by self-report) Irritability Outcome

problems’.
Note: Italics added to highlight the basis for the determination of the construct measured.
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Highlights
- Irritability is defined and measured inconsistently in scholarly literature

- We review and analyze scholarly definitions and measures of irritability
- There is much overlap among the constructs of irritability, anger, and aggression
- Themes of irritability were divided into causes, experience, and consequences
- We propose a definition of irritability and recommend items for measurement
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Irrritabilidad 2

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Defining and measuring irritability: Clarification and

Michael J. Toohey, Raymond DiGiuseppe

Running Head: DEFINING AND MEASURING IRRITABILITY

Defining and Measuring Irritability:

Clarification and Differentiation of the Construct

Correspondence concerning this article at all stages of publication should be addressed to

98121; mtoohey1@antioch.edu; (929) 266-8997

Irritability is a symptom of 15 disorders in the DSM-5 and is included in Mood

Disorders, Addictive Disorders, Personality Disorders, and more (American Psychiatric

Key Words: Irritability, Anger, Aggression, Definition, Assessment

Defining and Measuring Irritability: Clarification and Differentiation of the Construct

Disorders; Trauma- and Stressor-Related Disorders; Disruptive, Impulse-Control, and Conduct

Disorders; Substance-Related and Addictive Disorders; and Personality Disorders (American

This overlap in the conceptualizations of irritability, anger, and aggression is apparent in

discriminates unexplained irritability from irritability, or irritability from irritable mood or

how the constructs are related to any given psychiatric disorder.

the items reflect multiple, different constructs.

prevents us from identifying biological markers (biomarkers) of each construct. Fourth, it

other psychological disorders of which each construct is a symptom. In order to successfully

reviewing public and medical conceptualizations of irritability. Then, we examine

further research and, ultimately, increase our understanding of irritability.

Definitions and Measures of Irritability

irritability to be a precursor for anger. Although specific distinctions were inconsistent,

or state of being easily annoyed or excited to anger or impatience; proneness to vexation or

annoyance; petulance”), pathology (“…The condition of being excessively or morbidly excitable

discussed. Although irritability in the psychological literature refers to a psychological state or

an increased sensitivity in the intestines causing them to contract, creating a number of

gastrointestinal symptoms ("Irritable bowel syndrome," 2013). Mullin, Kleitman, and

convey the likelihood of waking up because of an increased sensitivity to sound. Further,

increased sensitivity to stimuli.

We uncovered 21 definitions of irritability in the psychiatric and psychological literature,

categorizations. Second, we review the items found in measures of irritability: We highlight

the gap in coverage of that component in definitions and measures.

Definitions. Few definitions of irritability included information about the causes or

more sensitive measure than rating the general presence of irritability.

Commentary. In definitions and measures of irritability, causes often seem

irritability is not. This parallels Moyer’s (1976) conceptualization of irritable aggression. He

specific biological processes that trigger irritability.

with irritability (Walsh & Roberts, 2005).

“involves increased sensitivity to environmental stimulation that causes physiological arousal

cognitive appraisal of injustice. However, it remains unclear whether changes in sensory

situationally or cognitively determined, irritability is caused by physiological/biological changes

and is associated with increased sensory sensitivity.

Definitions. Surprisingly, few definitions include descriptions of the experience of

irritability. Most definitions refer to irritability by its consequences – as an ambiguous type of

experience of irritability is included, it is referred to as a mood (Craig et al., 2008; Dickstein et

irritability itself more generally, as a “temporary psychological state” (Snaith, Constantopoulos,

always experienced with feelings of sadness or anger at some point.

irritability is different from the role of cognition in traditional conceptualizations of anger in

Commentary. The experience of irritability is rarely included in definitions and is

experience of irritability lower the threshold for anger, aggression, or sadness?

that irritability is best conceptualized as a mood.

Although the suffix “-ility” in irritability refers to a general disposition of feeling

irritable – predisposing the construct to be a trait – some authors conceptualize irritability as a

construction of irritability as a state supports conceptualizations of irritability as an episodic

occurrence of phasic/state and tonic/trait episodes in a community sample of youth, conveying

rigid, demanding thoughts. This is in direct contrast to modern cognitive-behavioral

certain cognitions or appraisals.

A difference also exists in perceptions of the physiological arousal associated with

Definitions. In most definitions, irritability serves as a catalyst that leads to some

presence (i.e., one occurrence) of anger or aggression.

Measures. All measures of irritability included items concerning its consequences.