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Journal Articles Course: J003 Rages, Pediatric Bipolar & Severe Mood Dysregulation (SMD)

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This is a course based on reading freely available, peer-reviewed journal articles

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Read two journal articles and receive one CE credit for just $7. The full text of the journal articles can be obtained for free online via The articles have been field tested and it should take approximately one hour total to read both articles. They are titled "Rages-What Are They and Who Has Them?" and "Different Psychophysiological and Behavioral Responses Elicited by Frustration in Pediatric Bipolar Disorder and Severe Mood Dysregulation."

Todd Finnerty, Psy.D. is the instructor for the course. Contact Dr. Finnerty with any questions via or (330)495-8809.

Course objective #1: You will be able to list characteristics of children who have been hospitalized for episodes of rage.

Course Objective #2: You will be able to describe differences between children with Bipolar I and those with Severe Mood Dysregulation (SMD)

The articles can be obtained for free here:

Rages--what are they and who has them?

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Authors: Carlson GA, Potegal M, Margulies D, Gutkovich Z, Basile J.
Abstract: "OBJECTIVE: The purpose of this study was to examine rages and define their associated clinical and diagnostic conditions systematically. Children's severe anger outbursts, sometimes called "rages," have been associated with many disorders, including mania, "severe mood dysregulation," and oppositional defiant/conduct disorder. Although reactive aggression has been studied extensively, there are almost no data on this important and disabling clinical phenomenon. METHOD: A total of 130 different 5-12 year olds were hospitalized over 151 consecutive admissions were evaluated diagnostically with information from parents, children, doctors, nursing staff, and teachers. Rages were operationally defined as agitated/angry behaviors requiring seclusion or medication because the child could not be verbally redirected to "time out." Rage behaviors were categorized as they occurred with the specially designed Children's Agitation Inventory. Hypotheses were that rages would be associated with prior treatment failure, and that children with rages would have the most co-morbidities, including learning/language disorders. We did not expect narrow-phenotype bipolar disorder to be specifically associated with rages. RESULTS: Of 130 children, 71 (54.6%) were admitted for rages. Preadmission rages and admission taking an atypical antipsychotic significantly predicted the subsequent number of in-hospital rages. Attention-deficit/hyperactivity disorder with learning/language disorder significantly predicted the occurrence and number of rages. Bipolar disorder was the referring diagnosis in 17/49 (34.7%) admissions with rages and 15/102 (14.7%) of admissions without rages (odds ratio [OR] 3.05, confidence interval [CI] 1.36, 6.80). However, a consensus diagnosis of bipolar disorder occurred in 5 (9.1%) of the sample with rages and 5 (5.8%) in the rest of admissions. CONCLUSIONS: Psychiatrically hospitalized children with multiple rages have complex, chronic neuropsychiatric disorders and have failed prior conventional treatment. One third of children with rages had been given a bipolar diagnosis prior to admission. However, only 9% of children with rages were given that diagnosis after careful observation."
Journal of Child and Adolescent Psychopharmacology,2009 Jun;19(3):281-8.

Different Psychophysiological and Behavioral Responses Elicited by Frustration in Pediatric Bipolar Disorder and Severe Mood Dysregulation

Full text on the web
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Authors: Rich BA, Schmajuk M, Perez-Edgar KE, Fox NA, Pine DS, Leibenluft E.
Abstract: "OBJECTIVE: Researchers disagree as to whether irritability is a diagnostic indicator for pediatric mania in bipolar disorder. The authors compared the behavioral and psychophysiological correlates of irritability among children with severe mood dysregulation (i.e., nonepisodic irritability and hyperarousal without episodes of euphoric mood) and narrow-phenotype bipolar disorder (i.e., a history of at least one manic or hypomanic episode with euphoric mood) as well as those with no diagnosis (i.e., healthy comparison children). METHOD: Subjects with severe mood dysregulation (N=21) or narrow-phenotype bipolar disorder (N=35) and comparison subjects (N=26) completed the affective Posner task, an attentional task that manipulated emotional demands and induced frustration. Mood response, behavior (reaction time and accuracy), and brain activity (event-related potentials) were measured. RESULTS: The severe mood dysregulation and narrow-phenotype bipolar disorder groups both reported significantly more arousal than comparison subjects during frustration, but behavioral and psychophysiological performance differed between the patient groups. In the frustration condition, children with narrow-phenotype bipolar disorder had lower P3 amplitude than children with severe mood dysregulation or comparison subjects, reflecting impairments in executive attention. Regardless of emotional context, children with severe mood dysregulation had lower N1 event-related potential amplitude than comparison subjects or children with narrow-phenotype bipolar disorder, reflecting impairments in the initial stages of attention. Post hoc analyses demonstrated that the N1 deficit in children with severe mood dysregulation is associated with oppositional defiant disorder symptom severity. CONCLUSIONS: Results indicate that while irritability is an important feature of severe mood dysregulation and narrow-phenotype bipolar disorder, the pathophysiology of irritability may differ among the groups and is influenced by oppositional defiant disorder severity."
The American Journal of Psychiatry, 2007 Feb;164(2):309-17.

CE Quiz Questions

The quiz questions that you will be asked are:

Question #1(True/False) The person taking this quiz is the one registered for the course and has reviewed the materials (you must answer "True").
Question #2(True/False) In the "Rages" article, many of the children came to the hospital having already received a diagnosis of bipolar disorder. However, after being observed most did not receive a diagnosis of Bipolar I (narrow phenotype).
Question #3(True/False) The hospital staff generally did not observe any manic behaviors during most of the rages.
Question #4(True/False) ADHD complicated by ODD/Conduct Disorder and language disorders/LD were the major diagnoses in children with rages.
Question #5(True/False) All children who experienced rages were found to have bipolar disorder in this study.
Question #6The authors concluded that rages may be initiated and perpetuated by
a. impulsivity and low frustration tolerance from severe ADHD
b. inability to process and express frustration because of learning or language problems
c. elevated, grandiose, pleasure-seeking behaviors
d. both a and b
Question #7(True/False) According to the Rich, et. al. article, individuals with severe emotional dysregulation may have deficient initial attention regardless of emotional context.
Question #8(True/False) This study found that there were no differences in the psychophysiological mechanisms of frustration between children with bipolar disorder and those with severe mood dysregulation.
Question #9(True/False) The authors' "narrow phenotype" bipolar disorder criteria differed from DSM-IV by their exclusion of children diagnosed with bipolar disorder due to irritability only.
Question #10(True/False) Per the authors, all children with ADHD or ODD will meet criteria for Severe Mood Dysregulation.
Question #11(True/False) According to the authors, ODD has prominent mood components including irritability.

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