Elsevier

Behavior Therapy

Volume 52, Issue 4, July 2021, Pages 883-896
Behavior Therapy

Irritability in Children and Adolescents With OCD

https://doi.org/10.1016/j.beth.2020.11.001Get rights and content

Highlights

  • Irritability was directly associated with depression, defiance, and impairment.

  • Irritability was significantly and positively associated with family accommodation.

  • Irritability was not significantly associated with OCD severity or anxiety.

  • Clinically significant improvement in irritability was found in 54% of youth.

  • Improvement in irritability was not related to OCD symptom reduction.

Abstract

Irritability is a common, impairing transdiagnostic symptom in childhood psychopathology, though it has not been comprehensively studied in pediatric obsessive-compulsive disorder (OCD). Further, the central cognitive behavioral treatment component for OCD, exposure and response prevention therapy (ERP), has been recently proposed as a treatment for irritability. This study aimed to evaluate whether certain clinical characteristics are associated with irritability in pediatric OCD and whether irritability reduces following ERP. Participants were 161 youth (ages 7–17) with OCD and a caregiver participating in a randomized controlled trial of D-cycloserine or pill placebo augmented ERP. Participants completed validated assessments during treatment. Irritability was significantly and positively associated with depressive symptoms, defiance, functional impairment, and family accommodation, but was not associated with pretreatment OCD severity, symptom dimensions, obsessive beliefs. Irritability significantly declined following treatment, with over half of youth with any pretreatment irritability experiencing clinically significant change, though this change was not related to OCD improvement. Results suggest that irritability may be a marker of psychiatric comorbidity, parental accommodation, and impairment in youth with OCD. Implications for the exposure-based treatment of irritability are discussed.

Section snippets

procedures

This study was a secondary analysis from a randomized controlled trial of D-cycloserine or pill placebo augmented ERP (Storch et al., 2016). The institutional review boards at each participating site (Massachusetts General Hospital and University of South Florida) approved the trial. Written parental consent and child assent were obtained at an initial screening visit at which the Schedule for Affective Disorders and Schizophrenia for School-Age Children–Present and Lifetime Version (K-SADS-PL;

sample characteristics

Two-hundred and six parent-child dyads consented to participate in the study, with 161 being eligible for pretreatment analyses. Of those, 142 were randomized to D-cycloserine or pill placebo plus ERP and were included in treatment outcome analyses with CY-BOCS as a dependent variable. Follow-up irritability measures were not completed with the first 29 children who were randomized; thus, analyses using the irritability measure as an outcome included 113 participants. No significant differences

Discussion

The goal of this study was to investigate irritability in the clinical presentation and treatment of youth with OCD. Results replicate the broader literature (e.g., Brandes et al., 2019, Copeland et al., 2013, Evans et al., 2019, Shimshoni et al., 2020), finding that irritability was significantly associated with greater functional impairment, depressive symptoms, and defiant behavior, and extend these findings to youth with OCD. It was also found that families accommodated obsessive-compulsive

Conclusions

This study was the first to investigate irritability among children and adolescents with OCD. In line with the broader literature, irritable youth with OCD appear to experience more severe depressive symptoms, defiant behaviors, and functional impairment, supporting irritability as a marker of greater negative affectivity and psychopathology. Families also described more accommodation among irritable youth, highlighting the importance of caregiver involvement in CBT for this population.

Conflict of Interest Statement

Dr. Geller has received grant or research support from the Eunice Kennedy Shriver National Institute of Child Health and Human Development subcontract with Duke Clinical Research Center Pediatric Trials Network, the National Institute of Mental Health, Biohaven Pharmaceuticals, Boehringer Ingelheim, Eli Lilly and Co., Forest Pharmaceuticals, GlaxoSmithKline, the International OCD Foundation, Neurocrine Biosciences, Nuvelution Pharma, Peace of Mind Foundation, Pfizer, Solvay, Syneos Health, Teva

References (58)

  • J. Savage et al.

    A genetically informed study of the longitudinal relation between irritability and anxious/depressed symptoms

    Journal of Clinical Child & Adolescent Psychology

    (2015)
  • L. Scahill et al.

    Children's Yale-Brown obsessive compulsive scale: Reliability and validity

    Journal of Clinical Child & Adolescent Psychology

    (1997)
  • Y. Shimshoni et al.

    Anxious-Irritable Children: A distinct subtype of childhood anxiety?

    Behavior Therapy

    (2020)
  • E.A. Storch et al.

    Rage attacks in pediatric obsessive-compulsive disorder: Phenomenology and clinical correlates

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2012)
  • E.A. Storch et al.

    Impact of comorbidity on cognitive-behavioral therapy response in pediatric obsessive-compulsive disorder

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2008)
  • A. Stringaris et al.

    Pediatric bipolar disorder versus severe mood dysregulation: Risk for manic episodes on follow-up

    Journal of the American Academy of Child & Adolescent Psychiatry

    (2010)
  • D.F. Tolin et al.

    Are “obsessive” beliefs specific to OCD? A comparison across anxiety disorders

    Behaviour Research and Therapy

    (2006)
  • W.L. Tseng et al.

    Test-retest reliability and validity of a frustration paradigm and irritability measures

    Journal of Affective Disorders

    (2017)
  • A.M. Waters et al.

    Towards a cognitive-learning formulation of youth anxiety: A narrative review of theory and evidence and implications for treatment

    Clinical Psychology Review

    (2016)
  • T.M. Achenbach et al.

    Manual for the ASEBA school-age forms & profiles: An integrated system of multi-informant assessment

    (2001)
  • C.M. Ale et al.

    Components of cognitive behavioral therapy related to outcome in childhood anxiety disorders

    Clinical Child and Family Psychology Review

    (2015)
  • R.R. Althoff et al.

    Classes of oppositional-defiant behavior: Concurrent and predictive validity

    Journal of Child Psychology and Psychiatry

    (2014)
  • American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (DSM-5®). American...
  • H.R. Bird et al.

    The Columbia Impairment Scale (CIS): Pilot findings on a measure of global impairment for children and adolescents

    International Journal of Methods in Psychiatric Research

    (1993)
  • C.M. Brandes et al.

    The p factor and the n factor: Associations between the general factors of psychopathology and neuroticism in children

    Clinical Psychological Science

    (2019)
  • M.A. Brotman et al.

    Irritability in youths: A translational model

    American Journal of Psychiatry

    (2017)
  • J.D. Burke et al.

    Identifying the irritability dimension of ODD: Application of a modified bifactor model across five large community samples of children

    Journal of Abnormal Psychology

    (2014)
  • L. Calvocoressi et al.

    Family accommodation of obsessive-compulsive symptoms: Instrument development and assessment of family behavior

    The Journal of Nervous and Mental Disease

    (1999)
  • M.E. Coles et al.

    Development and initial validation of the obsessive belief questionnaire-child version (OBQ-CV)

    Depression and Anxiety

    (2010)
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    We gratefully acknowledge the contributions of the following individuals to the original trial: Susan Sprich, Ph.D., Aude Henin, Ph.D., Jamie Micco, Ph.D., Joseph McGuire, Ph.D., P Jane Mutch, Ph.D., Monica Wu, Ph.D., Robert Selles, Ph.D., Adam B Lewin, Ph.D., ABPP, Allison Kennel, ARNP, Nicole McBride, Ph.D., Alyssa Faro, Ph.D., Kelsey Ramsay, Ashley Brown, Andrew MIttelman, Abigail Stark, Ph.D., Allison Cooperman, Angelina Gomez, Chelsea Ale, Ph.D., Kathleen Trainor, Ph.D., Cary Jordan, Ph.D., Christine Cooper-Vince, Ph.D., Anne Chosak, Ph.D., Noah Berman, Ph.D., Marco Grados, MD, Gary Geffken, Ph.D., Rebecca Betensky, Ph.D., Barbara Coffey, MD, Martin Franklin, Ph.D., Jennifer Britton, Ph.D., David Greenblatt, MD, and David Pauls, Ph.D. This study was funded by grants 1R01MH093381 (Dr. Storch) and 5R01MH093402 (Dr. Geller) from the National Institute of Mental Health (NIMH). The NIMH had no involvement in the study design, data collection, analysis and interpretation of data, the writing of this report, or in the decision to submit this article for publication. clinicaltrials.govIdentifier: NCT00864123.

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