Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder

New in DSM-5, disruptive mood dysregulation disorder (DMDD) showcases extremes of childhood. Most kids fight among themselves, but DMDD broadens the scope and intensity of battle. Minor provocations (insufficient cheese in a sandwich, a favorite shirt in the wash) can provoke these children to fly completely off the handle. In a burst of temper, they may threaten or bully siblings (and parents). Some may refuse to comply with chores, homework, or even basic hygiene. These outbursts occur every couple of days on average, and between them, the child’s mood is persistently negative—depressed, angry, or irritable.

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Their behavior places these children at enormous social, educational, and emotional disadvantage. Low assessments of functioning reflect the trouble they have interacting with peers, teachers, and relatives. They require constant attention from parents, and if they go to school at all, sometimes they need minders to ensure their own safety and that of others. Some suffer such intense rage that those about them actually fear for their lives. Even relatively mild symptoms may cause children to forgo many normal childhood experiences, such as play dates and party invitations. In one sample, a third had been hospitalized.

Perhaps as many as 80% of children with DMDD will also meet criteria for oppositional defiant disorder, in which case you would only diagnose DMDD. The diagnosis is more common in boys than in girls, placing it at odds with most other mood disorders, though right in line with most other childhood disorders. Although the official DSM-5 criteria remind us not to make the diagnosis prior to age 6, limited studies find that it is most common in preschool children. And it needs to be discriminated from teenage rebellion—the teens are a transitional period where mood symptoms are common.

The question has been asked: Why was DMDD not included in the same chapter with the disruptive, impulse-control, and conduct disorders? Of course, the original impetus was to give clinicians a mood-related alternative to bipolar I disorder. However, the prominent feature of persistently depressed (or irritable) behavior throughout the course of illness seems reason enough for placement with other mood disorders.

Partly because this diagnosis is intended for children, but mainly because I’m really worried about the validity of a newly concocted, poorly studied formulation (see the sidebar below), I’ll not provide a vignette or further discussion at this time. At the same time, I’m really, reallyworried about all those kids who are being lumbered with a diagnosis of bipolar disorder, with attendant drug treatment.

How many disorders can you name that originated in an uncomfortable bulge in the number of patients being diagnosed with something else? I can think of exactly one, and here is how it came about.

Beginning in the mid-1990s, a few prominent American psychiatrists sufficiently relaxed the criteria for bipolar disorder to allow that diagnosis in children whose irritability was chronic, not episodic. Subsequently, the number of childhood bipolar diagnoses ballooned. Many other experts howled at what they perceived to be a subversion of the bipolar criteria; thus were drawn the battle lines for diagnostic war.

In aggregate, a number of features seem to set these youngsters well apart from traditional patients with bipolar disorder: (1) Limited follow-up studies find some increase in depression, not mania, in these children as they mature. (2) Family history studies find no excess of bipolar disorder in relatives of these patients. (3) The sex ratio is about 2:1 in favor of boys, which is disparate with the 1:1 ratio for bipolar disorder in older patients. (4) Studies of pathophysiology suggest that brain mechanisms may differentiate the two conditions. (5) The diagnosis of childhood bipolar disorder has been made far more often in the United States than elsewhere in the world. (6) Follow-up studies find far more manic or hypomanic episodes in children with bipolar disorder diagnosed according to traditional criteria than in those whose principal issue was with severe mood dysregulation.

The epic internecine battle among American mental health professionals has been chronicled in a 2008 Frontline program (“The Bipolar Child”) on PBS and in a New York Times Magazine article by Jennifer Egan (“The Bipolar Puzzle,” September 12, 2008). The dispute continues; meanwhile, the DMDD category was crafted to capture more accurately the pathology of severely irritable children. The DSM-5 committee struggled to differentiate the two conditions, and I suspect that the struggles have only just begun.

Essential Features of Disruptive Mood Dysregulation Disorder

For at least a year, several times a week, on slight provocation a child has severe tantrums—screaming or actually attacking someone (or something)—that are inappropriate for the patient’s age and stage of development. Between outbursts, the child seems mostly angry, grumpy, or sad. The attacks and intervening moods occur across multiple settings (home, school, with friends). These patients have no manic episodes.

The Fine Print

Delve into the D’s: • Duration and demographics (1+ years, and never absent longer than 3 months, starting before age 10; the diagnosis can only be made from age 6 through 17) • Distress or disability (symptoms are severe in at least one setting—home, school, with other kids—and present in other settings) • Differential diagnosis (substance use and physical disorders, major depressive disorder, bipolar disorders, oppositional defiant disorder, attention-deficit/hyperactivity disorder, behavioral outbursts consistent with developmental age)