Disruptive Mood Dysregulation Disorder Current Concepts and Controversies

Disruptive Mood Dysregulation Disorder: Current Concepts and Controversies
Disruptive Mood Dysregulation Disorder: Current Concepts and Controversies

Including disruptive mood dysregulation disorder (DMDD) in the latest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) was a controversial decision that continues to be the subject of much debate. But now that DMDD is a separate diagnosis, researchers hope to learn more about this devastating childhood disorder that is disruptive to both children and families.1

DMDD was added to the DSM-5 in 2013 to address the problem of overdiagnosing and overtreating bipolar disorder in children. It is hoped that new diagnostic criteria for children with extreme irritability and frequent temper tantrums will lead to targeted and more effective interventions.2,3


DSM-5 is bringing more attention to DMDD, which was once too often diagnosed as childhood bipolar disorder,” said Ellen Leibenluft, MD, chief of bipolar spectrum disorders at the National Institute of Mental Health in Bethesda, Maryland.

“Controversy existed because pediatric bipolar disorder was skyrocketing. It was believed that irritability in children with DMDD was a manifestation of mania or elation seen in older people with bipolar,” she added. “What our research shows is that children with extreme irritability do not grow up to have bipolar disorder. They are more likely to grow into anxiety disorder or unipolar depression.”

What Do We Know About DMDD?

DMDD may affect between 2% and 5% of children, but the exact incidence is not known. Children with DMDD have extreme temper tantrums and remain irritable almost all day, every day.4 Unlike pediatric bipolar disorder, which occurs more often in girls, DMDD is more prevalent among boys. A diagnosis is made when the behaviors happen in different settings and have been observed by parents, teachers, and peers.5

“Irritability is extremely common. It is one of the most common reasons children see a psychologist or psychiatrist. The bar for diagnosing extreme irritability of DMDD has been set very high,” said Leibenluft.

To be considered for diagnosis, symptoms must begin before age 10 years, but the disorder should not be diagnosed before age 6 years.

Symptoms of DMDD include:

  • Three or more severe temper tantrums per week. These are tantrums that are grossly out of proportion to the cause, and inappropriate for the child's age.
  • Persistently irritable or angry mood between tantrums without sustained periods of relief.
  • No evidence of mania or hypomania.
  • Symptoms must be present for at least one year and happen both at home and outside the home.

What Don't We Know About DMDD?

Controversy over DMDD continues, because there is still a lot that we do not know.

“Our group is the only group that has done a lot of research, and it was done with previously collected data. DMDD most closely resembles another disorder called oppositional defiant disorder,” said Leibenluft. “It is still possible that DMDD is really just the top 15% of oppositional defiant disorder.”

“The development of this disorder has been controversial, in part because there are no published data using the proposed diagnostic criteria for youths,” added Christopher Bellonci, MD, associate professor of psychiatry at Tufts University School of Medicine in Boston. “The scientific support for disruptive mood dysregulation disorder comes primarily from studies of related, but not identical, mood dysregulation.”

DMDD may overlap many other mood disorders in children including oppositional defiant disorder, ADHD, anxiety disorder, bipolar disorder, autism, and intermittent explosive disorder. That can make it difficult to tease out a diagnosis of DMDD.6

Another area open for debate is how to treat DMDD. “Because DMDD is a brand-new diagnosis, there are no evidence-based treatments for the disorder,” Bellonci said. “Further research is needed to confirm the validity of the disorder and then to develop psychosocial therapies to address the condition, especially given the high rates of impairment.”

“The best we can do at this point is individualize treatment,” Leibenluft said. “ADHD-type symptoms may be treated with stimulants, anxiety may be treated with a [selective serotonin reuptake inhibitor]. Cognitive behavioral therapy, psychosocial interventions, and diagnosing speech and language problems all may play an important role.”

When Does Irritability Become a Disorder?

“Severe temper tantrums occur in 81% of preschoolers. Over 20% may have severe tantrums more than three times per week,” Bellonci said. So how do you know when temper tantrums and other symptoms of irritability are red flags for DMDD or a related childhood disorder?

“It really comes down to the degree of impairment,” Leibenluft said. “Children with DMDD are often asked to leave school. They don't maintain friendships. Their parents are afraid to take them out to dinner or on vacation. DMDD is severely disturbing and disabling.”

It also isn't clear if children with DMDD will outgrow the disorder, Leibenluft added. However, giving DMDD its own designation in the DSM-5 will lead to more research into the disorder.

If you know a child who might benefit from being part of this research, contact NIMH at 301-496-8381.

Chris Iliades, MD, is a full-time freelance writer based in Cape Cod, Massachusetts.

This article was medically reviewed by Pat F. Bass III, MD, MS, MPH.

References

  1. Interview with Ellen Leibenluft, MD, Chief, Section on Bipolar Spectrum Disorders, Emotion and Development Branch, National Institute of Mental Health
  2. Ryan ND. “Severe Irritability in Youths: Disruptive Mood Dysregulation Disorder and Associated Brain Circuit Changes.” Am J Psychiatry. 2013; 170: 1093-96.
  3. New Diagnosis in DSM-5 Can Improve Treatment For Chronically Irritable Kids.” Psychiatry Advisor.  Posted Sept. 4, 2014.
  4. Grohol JM. “Symptoms of Disruptive Mood Dysregulation Disorder.” Psych Central. Accessed Oct. 15, 2014.  
  5. Disruptive Mood Dysregulation Disorder.” Child Mind Institute. New York, New York. Accessed Oct. 15, 2013.
  6. Interview with Christopher Bellonci, MD, Associate Professor, Psychiatry, Tufts University School of Medicine, Boston
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