Irritability is a common complaint from persons with HD and their families. It is often
associated with a depressed mood, but may also result from a loss of the ability of the brain to regulate the experience and
expression of emotion.
Irritability in persons with HD may take the form of an increase in the patients' baseline
level of irritability, or there may be episodes of explosiveness as irritable responses to life
events become exaggerated in intensity and duration.
Other patients may not be irritable under most circumstances, but will develop a kind
of rigidity of thinking which will cause them to perseverate relentlessly on a particular desire or idea, becoming progressively
more irritable if their demands are not met.
One woman, for example, insists on having ten or twelve varieties of juice in the refrigerator
at all times and was markedly irritable during a recent visit to the clinic. Her husband had started the car to drive to the
clinic and had refused to go back into the house to get her another glass of juice. Hours later she was still dwelling on
it and kept interrupting the interview to say that she wanted to go home to have a drink.
Irritability in HD may have a variety of triggers and exacerbating causes. It is important to understand it in context
and avoid premature use of medications.
One must first understand exactly what the informant means by saying the patient is irritable or agitated.
- Does the patient appear restless?
- Is the patient yelling or verbally abusive?
- Is there potential for violence?
Many factors can precipitate an irritable episode, such as hunger, pain, inability to communicate, frustration with failing
capabilities, boredom, and changes in expected routine.
Family members and caregivers should learn to respond diplomatically, appreciating the patient's irritability as a symptom.
Confrontations and ultimatums should be avoided if the issue is not crucial.
The environment should be made as calm and structured as possible. Some families achieve this more easily than others.
Family settings in which there are children and adolescents, unpredictable working hours, noise, or general chaos may lead
to irritability and aggressiveness in persons with HD.
Caretaker and family support groups can provide emotional support and are a forum for sharing strategies that members have
found useful in their own households.
When irritability is severe, or enduring, or is expressed physically, patients are often described as agitated. A great
deal of overtreatment, particularly with neuroleptics, stems from continuous use of a drug for an episodic problem.
It is always necessary to revisit the situation and see whether the drug has actually reduced the frequency of outbursts.
For episodic outbursts, success often results from combining drug therapy with a careful analysis of the context and precipitants
of the outburst.
Nevertheless, we have found a number of medications helpful in treating enduring irritability. Patients may respond to
antidepressants, particularly the SSRIs (sertraline, fluoxetine, and paroxetine) even if they do not meet all the criteria
for major depression.
The optimal doses for treating irritability are not known but one should start at a low dose and increase gradually as
in the treatment of depression (see table 13). These agents may be particularly useful when the irritability seems tied to
obsessions and perseveration on a particular topic.
As in the treatment of (see table 13). These agents may be particularly useful when the irritability seems tied to obsessions
and perseveration on a particular topic.
As in the treatment of depression, improvement may not occur for several weeks. Mood stabilizers such as divalproex sodium
and carbamazepine have also been helpful and could be administered as outlined for bipolar disorder (see table 15).
Low dose neuroleptics may be helpful, particularly the newer, "atypical" ones which have fewer side effects.
Long-acting benzodiazepines, such as clonazepam (Klonopin), starting at low doses, e.g. 0.5mg/day, have also been helpful.
The clinician must carefully monitor patients treated with these agents, as overdosing can lead to falls or aspiration.