DMDD

Essential Features of Disruptive Mood Dysregulation Disorder (DMDD)

File photo. Credit | CBCOpens in new window For a generation or more, clinicians have been aware that chronic and severe irritability in children predicts emotional and interpersonal difficulties later in life. In recent years, however, some clinicians have sought to equate these behaviors with a form of bipolar disorder; as a result, such children have been treated with antipsychotic and mood-stabilizing medication. But many other clinicians see something else in the child who habitually flies off the handle at the slightest (or no) provocation: the antagonism of oppositional defiant disorder (ODD) or the impulsivity of ADHD. Or perhaps something new altogether? That “something new” is now called disruptive mood dysregulation disorder (DMDD), a depressive disorder specific to children.

Disruptive mood dysregulation disorder (DMDD) is a newer diagnosis for children who have frequent, severe temper outbursts and are chronically irritable. Every few days, these children succumb to a burst of temper, during which they may threaten, yell, and even attack other people verbally, sometimes physically.

These outbursts occur in a manner—and at times and places—that are not consistent with the child’s developmental stage. And between eruptions, the child’s mood is habitually angry or irritable. Although behavioral symptoms are directed outward, they reflect an irritable, angry, or sad mood state.

For a diagnosis of DMD to be made, it is essential that for at least a year, several times a week, and on slight provocation, a child has severe tantrums—screaming or actually attacking someone (or something)—that are inappropriate for the child’s age and stage of development. Between outbursts, the child seems mostly grumpy or sad. The attacks and intervening moods occur across multiple settings (home, school, with friends) and occur at leasts 3 times per week for most months over the course of a year.

This combination of problematic behaviors places children at risk for serious consequences at school, in their families, and with peers. Even patients with milder symptoms may find themselves excluded from traditional childhood experiences, such as party invitations and play dates. More severely affected children may be suspended from school and may even require constant supervision to prevent harm befalling them and others.

Although the behaviors associated with DMDD often begin in early childhood, this diagnosis is not made until a child is 6 years of age; additionally, the symptoms must be evident before age 10. This age requirement ensures that diagnosis is not based on the erratic moods associated with early childhood or puberty.

DMDD was added to the DSM due to a concern in the field that some children and adolescents are inappropriately diagnosed with bipolar disorderOpens in new window because the frequency of children and adolescents being given this diagnosis has significantly increased over the past 25 years (Copeland et al., 2013).

The major concern in misdiagnosing youth as having bipolar disorder is due to increases in the prescribing of atypical antipsychotics to youth, which can result in serious physical health problems (Kealy et al., 2014).

DMDD is differentiated by another diagnosis, intermittent explosive disorder (IED)Opens in new window, based on the frequency of outburst requirement (two per week for IED and three per week for DMDD). Furthermore, although youth with IED can experience persistent irritability, there is not a requirement for persistent irritability in IED.

DMDD and oppositional defiant disorder (ODD)Opens in new window both include the criteria for irritability and temper outbursts; however, the requirement for DMDD is more severe than ODD (three outbursts per week compared to two per week).

DMDD also has a longer duration requirement (12 compared to 6 months) and must result in profound impairment across two settings. ODD does not have this requirement. Due to the relative newness of the DMDD diagnosis, there are gaps in knowledge of the disorder. The prevalence of DMDD is not yet known, but it is estimated to be somewhere from 2 percent to 5 percent (APA, 2013).

Treatment

As DMDD is a newly recognized condition, there haven’t been many research studies on its treatment. Current treatments are mainly based on research focused on other childhood conditions associated with irritability, such as anxiety and ADHD. The good news is that many of these treatments also work for DMDD.

The two main treatment options for DMDD are psychotherapy (talk therapy) and medications. In many cases, healthcare providers recommend psychotherapy first before trying medications.