Juvenile-HD

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10 The Most Commonly Asked Questions
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JHD Handbook-Chapter 1
JHD Info-Stanford Univ.
Physician's Guide To HD
Caring for People with HD
Physical & Occupational Therapy In HD
Understanding Behaviour in HD-Dr. Jane Paulsen
Understanding Behavioral-Dr. Edmond Chiu
Advanced Stages Caregivers Handbook
First Shift-Certified Nursing Assistants
Activities of Daily Living-HD
Unified HD Rating Scale (UHDRS) Motor Section
Westphal Variant
SECTION 1 - AT RISK
Age & Probability Chart
At Risk For HD-What Next?
At-Risk Checklist
Best Interest of Child?
Crystal Ball?
Food For Thought
Parent Hasn't Tested?
Q&A On Risk of Inheriting JHD
Testing Children
SECTION 2 - GENETIC TESTING
Genetic Disorders & Birth Defects
Genetic Testing for HD
Genetic Counseling-In General
Psychological Impact
Intro: Genetics/Genetic Testing
Prenatal & Preimplanation
Prenatal Testing-In General
o Genetic Testing Resources
o Personal Stories
SECTION 3 - JHD
Coping With The Early Years
Age of HD Appearance
Age of Onset-Historical
Family-HD Underestimated
Children of Parents With HD
Child~Parent Ill
Clinical Description JHD
HD - What Kids Are Saying
HD & Me
JHD-Duration of Illness
JHD-Clinical and Research
JHD Symptoms
Parenting With HD
Patients/Families Coping
Talking With Children About HD
5 Stages of HD
JHD Resources
SECTION 4 - SYMPTOM RECOGNITION
Parent Resources
8 Fears of A Chronic Illness
Anxiety/Apathy/Irritability~HD
Anxiety, Fears & Phobias
Apathy-Physician's Guide
Ataxia
Attention-Perceptual/Unawareness Physician's Guide
Bed/Pressure Sores
Bed/Pressure Ulcer Guideline
Behavior Management
Bi-Polar Disorders
Botulinum toxin therapy
Bradykinesia
Caring Tips
Child Abuse-Reconizing Signs
Chorea-Physician's Guide
Chorea
Cognitive/Decision Making/Impulsivity
Cognitive-Short Tips
Contractures~Joints Locking
Dehydration-Physician's Guide
Dehydration
Delirium
Denial of HD
Depression~Physician's Guide
Depression-Understanding It
Depression-How To Help
Depression - Treatment Resistant Patient
Depression-Other Resources
-Read If Your Child Is On Antidepressant
Disgust - Impaired Recognition in HD
Dissociative disorders
Driving - Physician's Guide
Dyslexia
Dyslexia Resources
Dystonia
Dystonia/Rigidity & Spasticity Physician's Guide
Dystonia-Predominant Adult-Onset HD
Epileptic Seizures and Epilepsy
Epilepsy-Seizures~PG
-Seizures ~Special Populations
Falling~Safety
Falling - Subdural Hematoma Risk
Fevers - Unexplained
Fevers, sweating & menstural cycles in HD
GERD (Stomach)
HD Principle Treatments
Hallucinations/Psychosis~PGHD
Hand muscle reflexes in HD
Hypothalamus - A Personal Theory
Insomia ~Physician's Guide
Irritability~Temper Outburst Physician's Guide
Learning Disability
Mania/OCD~Physician's Guide
Mood Disorder Rate In HD
Myoclonus (Movements)
Nails-What To Look For
Night Terrors
Obsessive Compulsive OCD
Panic Disorder
Personality disorders
Pneumonia
Pneumonia-Advanced Stages
Pneumonia - Aspirated (Inhaled)
Prosody - Social Impairment
Sexuality~Physician's Guide
Skins Sensitivity
Sleep Disorders
Smoking-Physician's Guide
Spasticity
Stress
Tremors
Why Certain Symptoms Occur
Symptom & Treatment Resources
SECTION 5 - COMMUNICATION
Communication Resources
Communication Problems
Communication Strategies For HD~Jeff Searle
SECTION 6 - EATING/SWALLOWING/NUITRITION
Hints For Weight Loss in HD
HD & Diet~HSA Fact Sheet 7
Nutrients: Some Possible Deficiency Symptoms
Nutrition and HD~Anna Gaba (Recipes)
Nutrition Information In HD~Naomi Lundeen
Speech & Swallowing~Lynn Rhodes
Swallowing & Nutrition Physician's Guide To HD
Swallowing & Nuitrition Resources
Swallowing Warning Signs
5 Swallowing Problems
Taste changes in HD
Weight Gain
Resources-Drinks/Shakes
-Feeding Tubes~Advanced Stages of HD
-Feeding Tube~Jean Miller
-Feeding Tubes: One More Word ~Jean Miller
-Feeding Tubes & Baby Foods
-Feeding Tube~Dental Care
-Feeding Tube Instructions~Jean Miller
-Feeding Tube Resources
SECTION 7 - THERAPIES
Finding a Therapist - Behavoir
What Is A Physiotherapist?
Physical Therapy In HD
Speech-Language Therapy
Therapy Descriptions
Therapy Resources- Easter Seal
Therapy Resources
SECTION 8 - MEDICATIONS
HD Treatments
Medications-Movement Disorders
Medication/Emergency Info Forms
Cutting Prescriptions
Drugs-Look 'Em Up
-Adolescents Under 25
-Antidepressant Adverse Effects
-Anti-psychotic
-Anxiety-Antidepressant
A-Z Mental Health Drugs
-Creatine
-EPA~Fish Oil
-Haldol/Haloperidol - Clinical Sheet
-Haldol~Clinician Description
-Haldol & HD
-Haldol/HD Patient Experiences
-Haldol~ Patient Handout
-Mood Stabilizers: ASK 3 Questions
-Neuroleptic Malignant Synd WARNING
-Olanzipine-Risperidone/blood tests
-Celexa/Luvox/Paxil/Prozac/Zoloft
-Psychiatric Drugs & Children
Sertraline ~Zoloft
-Spasticity Meds/Treatments
-SSRI Medications
-Tardive Dyskinesia WARNING
-Weight Gain Medications
-Sites/Help the Medicine Go Down
-Vitamin & Mineral Deficiencies
SECTION 9 - SURGERIES
Surgery-Movement Disorders
o Surgery Resources
SECTION 10 - PROCEDURES
Clinic Visits-How To Prepare
CT Scans, MRI's etc.
Swallowing Tests
Tests Commonly Used
o Procedures Resources
SECTION 11- ALCOHOL/DRUGS
Alcohol-Parent's Guide
Alcohol-Talking To Your Child
Drugs-What To Do?
Drugs-Talking To Your Child
Disciplining-Ages 0-13 & Up
SECTION 12- SUICIDE
Straight Talk On Suicide
Teen Suicide-You Need To Know
o Suicide Resources
SECTION 13 - DIVORCE
Divorce & Child Stress
Tips For Divorcing Parents
SECTION 14 - DISABILITY ISSUES
Guides To Disability Issues
Caring-Child & Medical Technology
Caring for a Seriously Ill Child
Child Long Term Illness
Disability-Special Education Plan
IFSP Early Intervention Process
Disability Resources
Financial Planning
Wishes Can Come True-Children's Wish Foundations
Special Needs Resources
Special Needs Camp - About
Special Needs Camp - Finding One
SECTION 15 - ASSISTIVE TECHNOLOGY
Child Assistive Technology
Adaptive Equipment Resources
Products
SECTION 16 - EMOTIONAL ISSUES
Signs of Unhealthy Self-Esteem
Emotional Behavior Links
o Emotional Support Resources
SECTION 17 - GRIEF
Helping Child Deal With Death
o Grief Addtional Resources
SECTION 18 - ADD/ADHD
ADD & Teens
Conduct Disorders
FAQS & Related Info
Understanding AD/HD
What Is AD/HD?
Research Articles
Resources
SECTION 19 - HD SUPPORT GROUPS
HD Support Groups
National Youth Association
SECTION 20 - HD LINKS
HD Links
Related Resources
Tips For Friends
SECTION 21 - BENEFITS/INSURNACE
HD Disability
Benefits Check UP - See What You Can Get
Medical Insurance Bureau's Facts On You!
Medicare-Medicaid
Medicare Rights-Home Health & Hospice
Medicare Rights Center Resources
No Insurance? Try This!
Prescription Drug Cards Part I
Prescription Drug Cards Part II
Social Security-Children With Disabilities
SECTION 22 - ARTICLES/JHD
JHD and ADD
SECTION 23 - CAREGIVING
Articles-Resources
Caregiver Self-Assessment
Caregiver's Handbook
"First Shift With A Person With HD"
Getting Respite Care/Help At Home
Helpful Forms-Info
Home Emergency Preparations
Symptom Management
Ten Tips
Useful Tools
SECTION 24 - BIO
Our Personal Experience
Coping At The End
Kelly E. Miller
Song & Verse
Letter From My Heart
GUESTBOOK
Irritability~Temper Outburst Physician's Guide

INDEX Page

HD~Irritability/Temper Outbursts
 
Chapter 4-Physicians, Guide to the Management of  HD

Irritability and Temper Outbursts

One of the most typical complaints we hear from HD families is concern about irritability and temper outbursts. These signs can be present for a couple of reasons.

First, it is important to assess for depression when increased irritability is reported. Oftentimes, irritability and temper outbursts diminish when a mood disorder is treated. Many times, however, irritability or outbursts remain even in the absence of a mood disorder.

Examination of the underlying causes of irritability and temper outbursts is helpful in diminishing the frequency and severity of these behaviors. Persons with HD are continually challenged by previously routine tasks or activities that are experienced as overwhelming. HD results in a progressive loss of abilities that often "sneak up" on persons with HD. Several patients have confided that "I didn't realize I could no longer do it."

Close attention should be paid to the signals, verbal or nonverbal, that patients are upset or wanting something, so that they do not get to the stage of exploding before they receive attention.

Knowledge of the person and sensitivity to his needs means that some situations can be anticipated and potential frustration defused. It may be possible to identify situations which trigger frustration and either avoid them or provide diversional activities. An awareness of the person's capabilities is very important, so that he is encouraged to be as independent as possible and allowed to take risks without risking constant exposure to failure.

Although this encouragement to maintain independence is not always possible at work, it is critical to encourage in the home. The person with HD should be encouraged to do things for himself and to participate in primary decision-making as long as possible, except perhaps in situations where safety is an issue (i.e. driving or cooking). Family members should be responsible for providing a safe environment so that no person is ever in danger. Remove dangerous implements, such as guns, from the house and have emergency numbers near the telephone.

Listed below are some general strategies for families to employ to minimize irritability and some coping skills for temper outbursts.

TABLE 8: COPING STRATEGIES FOR IRRITABILITY AND TEMPER OUTBURSTS

  • Assess your own expectations regarding the HD affected individual. A family member may be unwilling or unable to accept the patient's new limitations.
  • Try to keep the environment as calm and controlled as possible.
  • Speak in a low, soft voice. Avoid confrontations and ultimatums. Sit down and keep hand gestures quiet.
  • Try to identify circumstances which trigger> irritability and temper outbursts and avoid them.
  • Redirect the HD person away from the source of anger.
  • Learn to respond diplomatically, acknowledging the patient's irritability as a symptom of frustration.

Chapter 5-Physicians, Guide to the Management of  HD

Psychiatric Symptoms not Belonging to a Specific Diagnostic Category

Patients with Huntington's disease may suffer from a variety of emotional symptoms which do not fit any specific psychiatric diagnosis, but may nevertheless be a source of distress and a focus of treatment including irritability, anxiety and apathy.

Some of these symptoms are related to the disease itself, and others can be seen as a response to changing circumstances, such as a patient who becomes anxious about going to the market because her involuntary movements attract attention.

Patients with HD may undergo personality changes, becoming irritable, disinhibited, or obsessional. In some cases these changes represent an accentuation, or coarsening of personality characteristics the person already had. Other times they will be a radical departure from the patient's usual state, which can be very distressing to families.

Families should be reassured, as patients can usually be helped by better communication, environmental interventions, and judicious use of medications.

Irritability

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.

TABLE 16: COPING STRATEGIES FOR IRRITABILITY

  • Restructure the person's expectations and responsibilities to manage frustration. The environment should be as calm and structured as possible.
  • Respond diplomatically, acknowledging the irritability as a symptom. Confrontations and ultimatums should be avoided unless the issue is crucial.
  • Try to identify circumstances which trigger temper outbursts, and redirect the person away from the source of anger.
  • Family and caretaker support groups can provide valuable emotional support and are good places to learn and share effective strategies.

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.