Disruptive mood dysregulation disorder

DMDD is a newly classified disorder, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The DSM is used for the assessment and diagnosis of mental disorders; it does not include specific guidelines for the treatment of any disorder.

Researchers at the National Institute of Mental Health (NIMH) developed the DMDD diagnosis to diagnose more accurately youth who may have been previously diagnosed with pediatric bipolar disorder (despite not experiencing the symptoms needed for a diagnosis of bipolar disorder).[5]

The DSM-5 includes several additional diagnostic criteria which describe the duration, setting, and onset of the disorder:[3] the outbursts must be present for at least 12 months and occur in at least two settings (e.g. home and school), and it must be severe in at least one setting. Symptoms appear before the age of 10, and diagnosis must be made between ages 6 and 18.[6][7]

The core features of DMDD—temper outbursts and chronic irritability—are sometimes seen in children and adolescents with other psychiatric conditions. Differentiating DMDD from these other conditions can be difficult. Three disorders that most closely resemble DMDD are attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and bipolar disorder in children.[4]

ADHD is a neurodevelopmental disorder characterized by problems with inattention and/or hyperactivity-impulsivity.[3]

ODD is a disruptive behavior disorder characterized by oppositional, defiant, and sometimes hostile actions directed towards others.[3] The DSM-5 considers DMDD a severe manifestation of symptoms associated with ODD. A diagnosis of both DMDD and ODD is not permitted or necessary; individuals who meet the diagnostic requirements for DMDD also meet the requirements for ODD.[8]

One of the main differences between DMDD and bipolar disorder is that the irritability and anger outbursts associated with DMDD are not episodic; symptoms of DMDD are chronic and displayed constantly on an almost daily basis. On the other hand, bipolar disorder is characterized by distinct manic or hypomanic episodes usually lasting a few days, or a few weeks at most, that parents should be able to differentiate from their child's typical mood and behavior in between episodes. The DSM precludes a dual diagnosis of DMDD and bipolar disorder.[3] Bipolar disorder alone should be used for youths who show classic symptoms of episodic mania or hypomania.[3]

Prior to adolescence, DMDD is much more common than bipolar disorder. Most children with DMDD see a decrease in symptoms as they enter adulthood, whereas individuals with bipolar disorder typically display symptoms for the first time as teenagers and young adults.[3] Children with DMDD are more at risk for developing major depressive disorder or generalized anxiety disorder when they're older rather than bipolar disorder.[7][9]

Conduct disorder is a behavior disorder characterized by repeated, persistent patterns of behavior that violate the rights of others and disregard major societal norms and rules. While both DMDD and conduct disorder are associated with argumentative and defiant behavior, DMDD is distinctly differentiated from conduct disorder by the DSM. Individuals with DMDD experience severe emotional dysregulation not seen in conduct disorder. Additionally, conduct disorder is described by a distinct lack of remorse and repeated physical harm and threats of harm to people and/or animals. Evidence of conduct disorder during childhood is one of the criteria for an adult diagnosis of antisocial personality disorder,[10] however adults with a continued diagnosis of conduct disorder do not necessarily have antisocial personality disorder.

Evidence for treatment is weak, and treatment is determined based on the physician's response to the symptoms that people with DMDD present. Because the mood stabilizing medication, lithium, is effective in treating adults with bipolar disorder, some physicians have used it to treat DMDD although it has not been shown to be better than placebo in alleviating the signs and symptoms of DMDD.[9] DMDD is treated with a combination of medications that target the child's symptom presentation. For youths with DMDD alone, antidepressant medication is sometimes used to treat underlying problems with irritability or sadness. For youths with unusually strong temper outbursts, an atypical antipsychotic medication, such as risperidone, may be warranted. Both medications, however, are associated with significant side effects in children. Finally, for children with both DMDD and ADHD, stimulant medication is sometimes used to reduce symptoms of impulsivity.[4]

Several cognitive-behavioral interventions have been developed to help youths with chronic irritability and temper outbursts. Because many youths with DMDD show problems with ADHD and oppositional-defiant behavior, experts initially tried to treat these children using contingency management. This type of intervention involves teaching parents to reinforce children's appropriate behavior and extinguish (usually through systematic ignoring or time out) inappropriate behavior. Although contingency management can be helpful for ADHD and ODD symptoms, it does not seem to reduce the most salient features of DMDD, namely, irritability and anger.[4]

All children can become irritable sometimes. It’s a normal reaction to frustration. Children experiencing severe irritability (as observed in DMDD) have difficulty tolerating frustration and have outbursts that are out of proportion for the situation at hand. These outbursts occur more often and are more severe than what you would typically expect for children of this age.

For example, a parent tells the child to stop playing a game and do their homework. Any child might be frustrated or annoyed. But a child with DMDD may become extremely upset and emotional and have an intense temper outburst with yelling or hitting. A child with DMDD experiences these intense temper outbursts a few times a week.[5]