Phasic Irritability in Adolescents with Externalizing Symptoms: A Qualitative Study

2.1 Ethics

The study protocol was approved by the cantonal ethical committee for research on human subjects (CER-VD; Project ID: #2019-02318). Each adolescent and their legal representative signed a written consent to participate. The participants received a monetary incentive (a gift voucher of 100 CHF) for their participation in the whole study (see Plessen et al., 2022; Turri et al., 2024). The results were reported following the Standards for Reporting Qualitative Research (O’Brien et al., 2014).

2.2. Participants

Fourteen male adolescents with externalizing symptoms aged between 12 and 17 years were included in the study to have sufficiently various subjective experiences for the qualitative analyses. Only male participants were included in the pilot study because externalizing behaviours are more prevalent in this gender (Kessler et al., 1994) and because we favoured a homogeneous group, in view of the limited number of participants.

The presence of externalizing symptoms was established by using a cut-off score (T-score >65) on the Youth Self Report/Child Behaviour Check List (Achenbach, 2013; Vermeersch & Fombonne, 1997; Vreugdenhil et al., 2006). This self-report questionnaire allows the assessment of skills (e.g., leisure, social relationships, academic performance) and emotional and behavioural problems in children and adolescents between the ages of 6 and 18 years old (Achenbach et al., 2001). Note that 35.7% (five participants) reported comorbid internalizing symptoms (T-score >65).

To estimate the verbal intelligent quotient of the participants the two subtests (i.e., similarities and vocabulary) of the WISC-V (Wechsler, 2014) were administered. The Mean standard score is of 10.54 (SD = 2.56, ranging from 5.0 to 14.5). Participants were excluded if their French proficiency was insufficient or if they had any current diagnosis of psychotic or autism spectrum disorders, or were treated with psychotropic medication (e.g., antipsychotic) known to affect emotional regulation. Table 1 describes the socio-demographic characteristics of each participant.

2.3. Procedures

Data collection was conducted from January to June 2021. The study procedure consists firstly of quantitative questionnaires to assess externalizing symptoms and secondly of individual interviews (either face-to-face or via videoconference). In particular, the interviews were recorded and then transcribed verbatim. The interviews lasted about 30 minutes. The interviewers were trained psychologists with specific knowledge in the domain of developmental questions and behaviour.

2.4. Measures

Prior to the interviews, we created a semi-structured grid to explore the same themes in all participants. In particular, we questioned the participants about their emotional experiences, their attempts at emotional regulation, and the time course of their thoughts around a specific episode of phasic irritability.

During the interview, adolescents were asked to describe in detail a specific event or situation (described as “the most significant one”) that led to an episode of phasic irritability (e.g., “Where they lost control of themselves and spoke or acted in a manner they regretted afterwards”). Then, we explored the precursors (e.g., “What state of mind were you in the days leading up to this event?”), the rationale for the episode of phasic irritability (e.g., “Why did you act the way you did?”), the subjective experience during the moment (e.g., “What sensations in your body did you feel? What did you think about during the event?”), the end of the episode (e.g., “What helped you regain control of yourself?”), the aftermath of the episode (e.g., “How did you feel after the act?”), and strategies used to avoid potential future episodes (e.g., “Do you know of any techniques that could help you stay in control of yourself?”).

2.5. Data analyses

We relied on content and thematic analyses to qualitatively analyse the data collected through the detailed interviews. The interviews’ transcripts were analysed using thematic analysis to identify and report the themes and topics within the data. About 15% of the transcripts were double-checked to ensure the quality of the transcription (no problem was identified). Four researchers developed the thematic analysis grid. The transcripts were first read through several times to get a general idea of the data collected, then classified according to the themes and sub-themes identified by the analysis. To refine the thematic analysis form, we used a three-step procedure: first, each researcher did it individually; second, we discussed in subgroups of two; and third, we all discussed together. Finally, after each researcher (n = 4) had coded two participants, the form was adapted and finalised. After the coding, reported in an Excel^© sheet, the research team relied on a triangulation procedure (investigator and data triangulation) (Carter et al., 2014), thus, reducing the risk of bias as much as possible. Again, four researchers screened the results of the thematic form and then discussed the main themes and topics that emerged and the best way to describe the data to achieve a consensus.

3.1. Expression of phasic irritability

Phasic irritability occurred in different ways. Indeed, we observed that episodes of phasic irritability were expressed by verbal aggression (e.g., insults/hurtful language/threatening, shouting: “Yeah, I shouted at him, I insulted him very violently […] it wasn’t very nice.” or “I said, ‘Yeah, I’m going to beat the shit out of you!’ I said stuff like that.”), by physical aggression (e.g., hitting an object, hitting another person, pushing another person, breaking an object: “And then I got up and hit him.” or “I broke his cup, and that’s it.”), or by a combination of verbal and physical aggression (“I started saying mean things […] I slammed the door” or “I remember […] that I grabbed him, that I insulted him.”).

3.2. Emotions leading to a phasic irritability episode

Anger or even rage was often used to explain phasic irritability (“He had left me out at work, so I got mad and punched a wall” or “Both times, there was anger.”). However, it appeared that anger was sometimes experienced conjointly with another emotion or feeling. For example, adolescents expressed having felt both anger and injustice prior to phasic irritability (“I felt unfairly accused because my mother didn’t understand my case […] she didn’t want me to go out, and that made me a bit angry […].”). Another example was given by other adolescents reporting frustration and anger simultaneously before the episode of phasic irritability (“[Interviewer […] you tend to accumulate, rather, your emotions and your anger […]] Yeah, that’s it; […] but then a lot of frustration […].”).

3.3. Context

Phasic irritability occurred mainly in a familial context (e.g., at home) or a school/work context. Regarding the presence of others during the event, peers (e.g., friends or girlfriend), family members (e.g., parents or siblings), and professionals (e.g., teachers or social workers) were the most frequently mentioned in the adolescents’ narratives (“I was with … we were at the dinner table, I was with my mother, there were my sisters, there was my mother’s boyfriend […]” or “It was in class with a teacher.”).

More specifically, adolescents with externalizing symptoms expressed phasic irritability either through insults, hurtful language, or threats (“[…] I insulted my mother a little bit, like that, and then, like, I really yelled at her, and then I went right back down, and, like, uh, well, I said directly hurtful things […]” or “I said ‘I’m gonna beat you up.’, stuff like that.”). Moreover, phasic irritability may also manifest as physical aggression such as pushing others (“[…] it was with a teacher […] he pushed me out of my chair, so I pushed him too”) or by slamming a door or hitting an object (“[…] I slapped my hand on the plate, the plate fell on the floor […]. And so I went to my room, I kicked my wardrobe […].”).

3.4. Precursors

Regarding the adolescents’ mindset prior to phasic irritability, the results highlighted that the adolescents reported being stressed/overwhelmed (“That’s it, you can say stress, events, tests at school, during this week.”) and that the stress/overwhelm felt was generally accompanied by nervousness and frustration. However, six adolescents reported feeling happy/calm in the days leading up to the event (“[…] I was kind of happy that the weekend was coming […].”).

In terms of personal resources, the main diminished resources reported by the adolescents were related to tiredness/insomnia (“[…] it’s the accumulation of certain things, also tiredness” or “Well, it was a period when I didn’t sleep much, but it was a period that lasted quite a while.”) and/or tensions/conflicts in the days preceding phasic irritability (“In addition, the day before, we had already gotten upset.”).

3.5. Emotional arousal and regulation

Most adolescents mentioned a feeling of anger (or even hatred) before, during, and sometimes even after phasic irritability. Indeed, phasic irritability occurred with a rise in symmetry (or negative loop) between both partners (“It was rather an escalation. […] At the beginning, at first, I was trying to be a little more lenient, but then, little by little, it (anger) increased […].”) or an explosion of anger (“[Interviewer: “[…] it just kind of exploded.”] Yeah.” or “[…] I would say suddenly it exploded […].”), sometimes preceded by a negative loop rising (“[…] and then it (anger) went up the second time a little bit, and then suddenly it exploded.” or “[Interviewer] […] it was anger in fact [Youth: Yeah] as an emotion that was rising [Youth: Yeah] more and more, and then it exploded […].”).

Some of the statements reported (e.g., feeling like an actor in the scene/present, expressing a disproportionate reaction with hindsight) demonstrated that most participants presented inadequate emotional regulation strategy. For example, most of them described phasic irritability as a disproportionate reaction (“[…] I would still say it was something disproportionate yeah, a little out of the norm.” or “I think it was disproportionate, especially at the time I did it.”). As well, most felt completely present, mindful or conscious at the time of phasic irritability (“I was in the body, and I was doing the act/action” or “[Interviewer : You were seeing the scene from…] Yes, from my point of view.”).

In addition, most adolescents used strategies, whether on a behavioural, cognitive, or sensory level, to regulate negative emotions like anger before phasic irritability. At the behavioural level, although some adolescents mentioned doing nothing/waiting, isolation/leaving the place seems to be the adolescents’ main strategy (“When there’s something that pisses me off, sometimes I leave.” or “Listening to music and being alone, most of all.”). At the cognitive level, relaxation or meditation-related themes emerged from the adolescents’ discourse (“Try to calm down, sit quietly in a place, meditate a bit […].”). As well, rationalising/relativising things (“[…] just saying to myself, ‘well, I put things in perspective and that’s how it is, that’s how it is’ […].”) was one of the most mentioned cognitive strategies to regulate emotions. Unfortunately, although adolescents were able to mention adequate strategies during the interviews, most had failed to implement them to cope with or regulate emotions leading to phasic irritability episodes.

Finally, we could distinguish between adolescents who reported having managed to regulate their mood by themselves (e.g., leaving the room, walking away) (“[…] I walked away. I went back to my room. I wanted to be as far away as possible at that time. […] I wanted to be left alone.”) and those who reported having regulated their phasic irritability thanks to the help of others (e.g., talking) (“I was talking with him [a friend from the foster care institution]; after that it was better […].”)

3.6. Summary and integration of the results

Figure 1 consists of a graphical integration of the qualitative results.

Figure 1

Various psychosocial contexts, precursors and consequences of phasic irritability were identified in the adolescents’ narratives. Phasic irritability occurs mostly in a family or school context. Family members, peers, or professionals (e.g., educators) are often present. In terms of the subjective emotional experience, it appears that most of the adolescents interviewed present with a combination of high arousal and low self-regulation capacity. High anger reactivity associated with poor emotional regulation sustained by inappropriate strategies (e.g., hurtful thoughts towards others, rumination) was found to favour the triggering of phasic irritability episodes. Furthermore, a period marked by a higher mental load (leading to mental fatigue) and/or a negative mindset (e.g., stressed, overwhelmed) was often reported before phasic irritability episodes. Lastly, phasic irritability manifests first through verbal aggression and then could escalate into physical aggression.

4.1. Context and expression

In terms of context, we observed that phasic irritability occurs primarily in a social environment, particularly a familiar environment (e.g., home) in the presence of family members or peers, which could be related to conflictual relationships with close relatives. The presence of family or friends, thus, plays a pivotal role in triggering an episode of phasic irritability (Sheehan & Watson, 2008). The episodes were mainly expressed by verbal aggression (e.g., insults, hurtful language, threats, shouting), which can be viewed as more acceptable within the family than physical aggression towards others (e.g., shoving and hitting others).

The social learning theory (Akers & Jennings, 2015) emphasises the importance of the interactions between adolescents and their peers or adult referees (e.g., neighbours, teachers). Indeed, it has been observed that adolescents tend to internalise the norms of the group they belong to (Rubin, 1998). This defines their attitudes, values, or behaviour, among other things. Adolescents living in a violent environment (familial context or elsewhere) may imitate those aggressive behaviours when they are experiencing frustration or feeling like victims of injustice. Thus, adolescents exhibiting aggressive behaviours are more likely to be surrounded by peers who also exhibit those characteristics (Fortuin et al., 2015), and their interactions with peers and family members have an impact on their emotional regulation and the expression of episodes of phasic irritability.

4.2. Emotional trigger and anger-distress model

Anger was described almost systematically in the adolescents’ narratives as the emotion associated with phasic irritability. Although negative feelings of anger tend to be more intense during the adolescent period (Gore & Colten, 1991) and especially in youths with externalizing disorders (Eisenberg et al., 2001), adolescents who excessively feel and express anger are more likely to exhibit externalizing symptoms (Kerr & Schneider, 2008). Rothbart and Bates (1998) proposed that precursors, such as frustration or anger, coupled with a susceptible emotional reactivity to external stimuli, would promote an episode of phasic irritability. Low frustration tolerance could be a determinant of anger leading to loss of control (Deborde & Vanwalleghem, 2011; Gatzke-Kopp et al., 2015) and, thus, to phasic irritability. In the same way, poor emotional regulation and a lack of anger regulation seem to promote various dynamic processes during phasic irritability.

Moreover, anger is sometimes enhanced by the appraisal of injustice which induces feelings of distress. This motivates efforts to reduce the perceived injustice (e.g., through physical aggression) (Markovsky, 1988). Thus, the imbalance between high negative emotion reactivity and low emotional regulation capacity may lead to an episode of phasic irritability (Rothbart & Bates, 1998). Emotional regulation strategies are therefore crucial to protect adolescents from experiencing overly intense emotional arousal and distress (Giesbrecht et al., 2010).

More specifically, to understand phasic irritability, anger dynamics is of crucial importance. Taking a broad picture of the phenomenon may contribute to delineate the time course of anger within phasic irritability (as depicted in Figure 1). In particular, in contexts susceptible to either enhance or decrease anger, the appraisal of injustice might have a central role. Then, if anger arousal exceeds the self-control threshold which may be reduced or depleted for different reasons (e.g., stressful life situations, lack of sleep), verbal aggression generally takes place, and in some cases escalates into physical aggression, which is a phenomenon also observed in adults (Potegal et al., 2023).

From a transdiagnostic perspective and taking the Research Domain Criteria (Insel et al., 2010; Insel, 2014) as a framework, these results are in line with the conceptualization of irritability as a consequence of frustrative non-reward, as well as an observed enhanced attention towards threat (Giller et al., 2021; Kryza-Lacombe et al., 2022; Naim et al., 2022; Salum et al., 2017; Tseng et al., 2021; Zhang et al., 2021).

4.4. Emotion regulation strategies

Adolescents described their reaction as disproportionate and reported knowing strategies to regulate their emotions, even if they felt unable to stop the expression of phasic irritability. For instance, the adolescents mentioned isolation/leaving the place or practising meditation. However, when faced with negative emotional experiences, adolescents would primarily use maladaptive emotional regulation strategies which promote loss of control over behaviour (Zahn-Waxler et al., 1994). Moreover, we observed that some adolescents used self-regulatory processes (regulating by themselves), whereas others used co-regulatory processes (regulating themselves with the help of others), which are two different emotional regulation strategies.

4.5. Precipitating factors – lower self-regulatory threshold

The likelihood of manifesting an episode of phasic irritability can be amplified by certain parameters, such as the state of mind (e.g., stress, nervousness) and the availability of the regulatory resources. In the current study, young people reported generally feeling nervous, stressed, and/or overloaded in the days leading up to phasic irritability. Some adolescents also reported feeling tired and/or having tension/conflict during this time lapse. Fatigue is known to decrease self-control resources (Guessous et al., 2006) and increase the likelihood of losing control (and, thus, exhibiting an episode of phasic irritability) when the threshold is crossed (Hoyle & Miller, 2012).

4.6. Self-awareness

Previous studies have observed associations between low self-awareness, emotion dysregulation, and conduct problems such as anger proneness (Morosan et al., 2020). Anger has indeed been shown to impair the mentalizing and self-regulation brain networks, a pattern that has also been observed in externalizing disorders (Alia-Klein et al., 2020). For example, individuals with a higher sensitivity to threat – such as irritable people, as previously mentioned – showed reduced activity of the mentalizing brain network when provoked (Beyer et al., 2014). Mentalizing is thought to be a prerequisite to emotion regulation as it allows for a reappraisal of highly emotional situations (Schwarzer et al., 2021). Interestingly, most participants included in our study have rather reported being entirely self-aware during their phasic irritability episode, which suggests a sustained activation of the mentalizing network.

4.7. Implications for further research

Further studies should focus on the frequency and duration of phasic irritability episodes. As observed in younger children more frequent phasic irritability episodes have been related to externalizing behaviours, whereas longer phasic irritability episodes were associated with internalizing symptoms (Van den Akker et al., 2022). However, less is known about these episodes in adolescents. Moreover, further studies could also target the feelings occurring after episodes of phasic irritability (e.g., regrets or counterfactual thinking) and not restrict their focus on reactive aggression (e.g., considering proactive aggression). Moreover, cultural diversity should also be considered in future studies, to avoid promoting globalizing and cultural-blind explanations. In addition, other variables should be taken into account in future studies. For example, it was shown that children in foster care who spent less time in institutions and more time in foster families showed lower levels of irritability compared to their institutionalized counterparts (Niu et al., 2024). Likewise, a previous study on expressed emotion has shown that the quality of familial relationships can impact irritability levels in adolescents with ADHD (Uçar et al., 2022).

4.8. Limitations

Despite the richness of our data and results, there are some limitations that need to be acknowledged. First of all, we sampled only male adolescents to assure a more homogenous sample, and because externalizing behaviours are more prevalent in male adolescents. In order to be more representative of the general population, further studies should not be restricted to adolescents identifying as males, and the expression of phasic irritability studied in all genders, including gender diverse persons. Additional methodological issues may have impacted our results. For instance, participants were asked to recall the “most extreme” event and not the most recent one. In most cases, the episode recalled by the participants had happened within the three months preceding the interview. We cannot rule out that this methodological choice has induced memory recall bias in some participants. Moreover, asking for “out of control behaviour” may have induced certain representation in the participants’ mind compared to other episodes where they think that their behaviours were justified and within their control. In the interpretation of certain responses, we assume that the adolescents sometimes had difficulty focusing on the specific moment of an episode of phasic irritability and answered in reference to their behaviours in general. Indeed, the capacity for insight is not fully developed in adolescents with antisocial behaviours (Steinberg, 2008), which is related to low mentalisation skills, with difficulty accessing and understanding one’s mental states and emotions (Deborde et al., 2015). We cannot exclude that social desirability may have encouraged the minimisation of certain behaviours, such as verbal or physical aggression. Moreover, other psychological processes such as self-esteem (Li et al., 2017) may play an important role in phasic irritability episode. These processes were not taken into account in the current study and, thus, should be assessed in future research to have a broader picture and deeper insights of phasic irritability.