Fake views: Irritable mood or moody irritability or simply being irritable and moody?

Abstract

Irritable mood is a seemingly common symptom that features prominently in several the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5) psychiatric diagnoses (Toohey and DiGiuseppe, 2017). It is sometimes used interchangeably with irritability, but such imprecision, apart from lacking accuracy, is simply unhelpful. In DSM-5, irritable mood is qualified as ‘often the predominant mood is irritable’, and this elaboration provides a clue to its conceptualisation (Malhi et al., 2019a). The insinuation is that irritable mood is principally a ‘mood’, but that it has an ‘irritable expression’ (see Figure 1(a)). And so, DSM essentially considers irritable mood to be a ‘manifestation’ of mood. In other words – it is a kind of mood, notwithstanding the fact that clinically and experientially irritable mood is often quite different to mood without irritability. However, if irritable mood is conceptualised as a facet of mood, then it remains a type of mood regardless of how it appears. It is important to note that assigning primacy to mood does not exclude the role of other factors such as anxiety and personality that can contribute to irritability – it simply emphasises the core nature of irritable mood as having emanated from mood itself. Understanding the substance of irritable mood and having a clear and consistent concept of its construction is important, not only for classification and clinical usage but also for researching the phenomenon and obtaining a deeper understanding of how it (and by extension irritability) arises in the first place (Malhi et al., 2019b). However, in addition to the DSM-5 ‘definition’ of irritable mood (a mood with an irritable ‘face’), there are other ways in which it can be conceptualised. The first is a simple reversal of the two constructs, that is to say irritable mood may be a form of irritability that manifests with symptoms of mood (see Figure 1(a)). This possibility is important because it positions irritability as a totally separate entity that can be confused with mood when it has an affective expression. In other words, because one of the ‘faces’ of irritability is mood, it can appear to be an aberration primarily of mood even though its quintessence is that of a separate phenomenon (irritability) and mood is only a facet. To reflect this and differentiate it from irritable mood, it can be called ‘moody irritability’. It is important to note that these considerations are not purely theoretical as they have significant treatment implications. For instance, depending on which of these two conceptualizations (irritable mood versus moody irritability) is correct, it follows that treatments targeting mood alone are likely to be less effective if irritable mood is in fact moody irritability, that is, a form of irritability that is simply ‘disguised’ as mood. A third possibility is that mood and irritability are quite separate entities that occasionally overlap and in doing so create an admixture that is irritable mood. The margins of this overlap are likely to be fuzzy and difficult to delineate clinically, and hence, at an individual level it may be difficult to distinguish ‘overlapping irritable mood’ from its separate underlying components (i.e. pure irritability and pure mood; see Figure 1(b)). With respect to treatment in this model, the clinical scenario is then quite different and the treatment of either mood or irritability will alleviate irritable mood to some extent and should have some discernible impact, but effective treatment and the complete amelioration of irritable mood will require therapy that successfully addresses both irritability and mood. Thus far, we have considered irritable mood as a single entity (an outcrop of either irritability or mood) or the result of two entities that intersect/ overlap. But there is a further possibility, namely that irritable mood is a separate entity altogether. That is to say, it has a unique identity of its own that it is distinct from both irritability and mood. Explicating further, although irritable mood has elements that appear the same as irritability and mood, at its core it is neither. This Fake views: Irritable mood or moody irritability or simply being irritable and moody?