disruptive mood dysregulation disorder (dmdd) chelsea wiener

Disruptive Mood Dysregulation Disorder (DMDD)

Chelsea Wiener

Part 1

DMDD and the DSM V

DMDD Diagnostic Criteria: DSM V

A. Severe recurrent temper outbursts (verbal or behavioral aggression) “grossly out of proportion in intensity or duration”

B. Temper outbursts inconsistent with development levelC. Outbursts occur average of 3+ times/weekD. Mood in-between outbursts is irritably or angry most of

the day, nearly every dayE. A-D present 12+ months. No 3+ month period without all

of the symptomsF. A+D present in at least 2/3 settings (home, school, peers)

and severe in at least one setting

DMDD Diagnostic Criteria: DSM V

G. Diagnosis not made before age 6 or after age 18H. Age of onset for A-E before 10 years old

-No time period lasting more than a day when full symptom criteria met for manic or hypomanic

episodeJ. Symptoms not solely during major depressive disorder,

and not better explained by another mental disorder-diagnosis cannot coexist with ODD

K. Symptoms cannot be attributed to substance use or another medical or neurological condition

DMDD Diagnostic Features: DSM V

• Core feature: “chronic, severe persistent irritability”– Temper outbursts– Irritable angry mood in-between outbursts• vs. pediatric bipolar: distinct manic episodes

DMDD Prevalence: DSM V

• Unclear estimates for full DMDD criteria• Estimates for chronic and severe irritability:– 6 mo.- 1 year period= 2-5%• Higher in males and school age children

– (vs. bipolar: gender balance more equal)

DMDD Development & Course: DSM V

• Onset of symptoms before 10 years old (cannot be diagnosed before 6 years old)

• ~1/2 children presenting with severe chronic irritability meet criteria for DMDD 1 year later

• Later Risks:– Depression and anxiety in adulthood– Less evidence for development of bipolar disorder later in life

• DMVDD vs. Bipolar– Bipolar rates low prior to adolescence (less than 1 percent);

DMDD more common prior to adolescence and become less common over time

Risk and Prognostic Features: DSM V

• Temperamental– Irritability prior to diagnosis– May also have symptoms for ADHD, anxiety, depression

• Genetic + Physiological– Risks for both DMDD (chronic irritability) and bipolar:

• Similar familial rates of anxiety, depression, and substance use• Similar face-emotion labeling deficits• Compromised decision making and cognitive control

– Risks for DMDD (chronic irritability) alone:• Dysfunction in attention related to emotional stimuli

Consequences of DMDD- DSM V

• Chronic severe irritability associated with:– Problematic relationships• Family, classmates, friendships

– Trouble in school– Dangerous actions, suicide attempts, aggression,

psychiatric hospitalization• Common with pediatric bipolar as well

Differential Diagnosis for DMDD*Bipolar

-episodic-manic episodes include cognitive, behavioral and physical symptoms, and sometimes elevated mood and grandiosity-cannot be dually diagnosed; cannot be diagnosed with DMDD if ever manic for a day

*ODD-DMDD children often have ODD symptoms, but less so vice versa-15% children who meet ODD criteria meet DMDD criteria-only DMDD diagnosis is made-DMDD has recurrent severe outbursts-DMDD has “severe impairment” in at least one setting, and impairment in a

second setting

Differential Diagnosis for DMDDADHD (can be dually diagnosed)

Depression (can be dually diagnosed)-if irritability only during depressive episodes, then DMDD diagnosis not made

Anxiety disorders (can be dually diagnosed)-if irritability only when experiencing anxiety, then DMDD diagnosis not made

Intermittent explosive disorder-DMDD includes irritability in-between outbursts-IED needs 3 mos. active symptoms for diagnosis vs. 12 mos. For DMDD

Autism spectrum-if outbursts are only in relation to disturbed routines as part of autism spectrum,

no DMDD diagnosis made

Comorbidity

• Highly comorbid• Strongest overlap with ODD– Only DMDD diagnosis made

• Comorbid with mood, anxiety, autism spectrum syndromes and symptoms

DSM V Schematic

DMDD

Temperament

Chronic irritability

Symptoms for:ODD, ADHD, anxiety, MDD

Genetic/Physiological

Familial anxiety, depression, substance use

Face emotion labeling differences Attention/

cognition differences

Risk For:Depression, anxiety, suicidality, severe aggression, dangerous behavior, psychiatric hospitalization

Secondary Features:Problematic relations with others (peers, family), poor performance in school, low frustration tolerance, dangerous behaviors, suicidality

Primary Features: severe, chronic irritabilitytemper tantrums

Part 2: Development and Prevalence of DMDD

• Development of DMDD– Development of Severe Mood Dysregulation

Disorder (SMD)• DMDD Predictors, Prevalence, Comorbidity• SMD Prevalence, Comorbidity, Course

Development of DMDD: pediatric bipolar disorder and Severe Mood Dysregulation

Disorder• Large increases since 1990’s of new pediatric BP cases (Zepf &

Holtmann, 2012)– Children being diagnosed without characteristic episodes (at least 1

week mania, 4 days hypomania)– Can be lead to problems of lifelong medication (Marguiles et al.,

2012)

development of Severe Mood Dysregulation (SMD) proposed by Leibenluft et al. (2003)• Probability of SMD children developing manic or hypomanic episode 50x

lower than pediatric BP children (Stringaris et al., 2010)• SMD children found to have higher ADHD and ODD comorbidity rates

(82.1%, 78.6% respectively) than BP children (45.2%, 25.8%) (Stringaris et al., 2010)

Development of DMDD: Severe Mood Dysregulation Disorder

Leibenluft et al. (2003)

A. Age 7-17 yrs. old– Onset before 12 yrs.

B. Abnormal mood (anger or sadness) at least half the day on most days– noticeable to others

C. Hyperarousal– at least 3: insomnia, agitation, distractibility, racing thoughts, pressured speech,

intrusiveness

D. Increased reactivity to negative emotional stimuli– E.g. temper tantrums, verbal rages, aggression to people or property

• Average 3+x/week for past 4 weeks

E. B-D present for a least 12 months (including current) and no 2 month remissionF. Severe symptoms in at least one setting (school, home, peers), and at least mild

symptoms in another setting

SMD Diagnosis: Exclusions

A. Elevated mood, grandiosity/inflated self-esteem, decreased need for sleep (episodic)

B. Symptoms occur in distinct periods (>4 days)C. Schizophrenia, schizophreniform disorder,

schizoaffective illness, pervasive developmental disorder, PTSD, substance abuse in past 3 months

D. IQ<80E. Symptoms result of drug, abuse, medical or

neurological condition

Concerns regarding development of DMDD

• More juvenile diseases may lead to more pediatric medication

• Lack empirical support for DMDD in particular (support for SMD)

• Not 100% overlap between SMD and DMDD– Hyperarousal component of SMDD– Different age onsets– One study found 47.4% DMDD children met SMD

criteria; 58.1% SMD met DMDD (Dougherty et al., 2014)

DMDD Prevalence and Comorbidity

Copeland et al. (2013)– Looked at 3 previous large scale studies and calculated rates of

DMDD using symptoms endorsed via psychiatric interview– Ages 2-17*

• Prevalence– 3 month rate: .8-3.3%

• .8-2.9% if use exclusion criteria with other disorders• More common in pre-schoolers*

– Temper tantrums (especially in pre-schoolers) and negative mood were most common symptoms endorsed

– Age onset X<10: no difference on prevalence rate when older

DMDD Prevalence and Comorbidity

• Comorbidity– Most comorbidity with depressive disorders and ODD

• Depressive disorders– Odds ratio: 9.9-23.5

» Among those with depression, 11.8-23% had DMDD• w/o depression: .8-2.9% had DMDD

» Among those with DMDD, 12.4-35.8% had depression• w/o DMDD: 1.4-3.2% had depression

• ODD– Odds ratio: 52.9-103.0

» Among those with ODD, 23-37.7% had DMDD• w/o ODD: .4-1% had DMDD

» Among those with DMDD, 57.4%-70.6% had ODD• w/o DMDD: 2.2-3.8% had ODD

– DMDD diagnosed alone 8%(preschoolers)-38% of the time

DMDD Correlates and Predictors

Dougherty et al. (2014)– Interviewed children at 3 yrs. old then 6 yrs. old

• Prevalence: 8.2% (full criteria)– Didn’t take into account exclusions for other disorders

(e.g. mania, IED)• 13.2% comorbid depressive disorder• 13.2% comorbid anxiety disorder• 10.5% ADHD• 55.3% ODD• 39.5% DMDD only

DMDD Correlates and Predictors• DMDD predictors:

– ODD– ADHD– Maternal CBCL-DP classification

• Focus on attention problems, anxious/depressed feelings, aggressive behavior

– Lower peer functioning • Rated by teacher

– Higher surgency (rated by mom) • “high-intensity pleasure, impulsivity, activity, low shyness”• Child behavior questionnaire

– Lower effortful control (rated by mom and dad) • “inhibitory control, attention focusing, low-intensity pleasure”

– Higher child negative emotional intensity (rated by teacher)– Parental lifetime substance use disorder– Greater parental hostility

• Observed in lab

DMDD Stability and Comorbidities

• Axelson et al. (2012)– 706 children (6-12 yrs.) from Longitudinal Assessment of Manic

Symptoms Study– Retrospective DMDD diagnosis

• Didn’t exclude ODD+bipolar

– Intake:• DMDD present in 26% of participants, more common in those with

elevated manic symptoms• DMDD+ vs. DMDD-

– Higher DBD rates, dysthymia, elimination disorders, ADHD (not bipolar) for DMDD+

– Multivariate model: ODD Odds Ratio: 68.7; CD Odds Ratio: 77.8– didn’t differ on biological parent depression, bipolar, anxiety, psychosis,

substance use disorder, or CD


– 1 Year Follow Up DMD Stability:• 53% of those who met DMDD at intake did so a year

later• 64% of those who met DMDD at 1 yr. follow up had

DMDD at intake

– 2 Year Follow Up DMDD Stability:• Of those who met DMDD criteria at least 1 time, 19%

met all 3 times– vs. of those with ADHD at least 1 time, 61% had all 3 times

*questions of stability

DMDD Stability and Comorbidities• DMDD at intake not associated with increased risk for later bipolar, anxiety, psychosis, CD,

depressive disorders

• 71% with ODD/CD had DMDD (3% without ODD/CD had DMDD)– Intake:

• 58% of ODD children had DMDD• 61% of CD children had DMDD• 96% DMDD children had ODD or CD• 96% DMDD met ODD or CD vs. 40% BP had comorbid ODD or CD• 77% DMDD+ met ADHD and ODD/CD

• 44% of those with ADHD had DMD, 23% without ADHD had DMDD

• No differences for MDD, Bipolar, Anxiety

*questions of comorbidity with ODD and CD*population considerations

Prevalence, Co-occurence and Course of SMD

Brotman et al. (2006)• Used participants from Great Smoky

Mountains Study (community sample)• Looked at modified SMD– Chronically irritable, angry, depressed– Excessive reactivity 3+/week– Hyperarousal• Insomnia, pressured speech, distractibility, physical

restlessness, racing thoughts, intrusiveness


• Lifetime prevalence 3.3% for 9-19 yrs. old• Co-occurrence at time first met SMD criteria:– 67.7% had co-occurrence of another disorder• 26.9% ADHD• 25.9% CD• 24.5% ODD• 14.7% anxiety• 13.4% depression


• SMD at Wave 1 (mean age~10.6) predicted depressive disorders at last wave (mean age~18.3)– Odds Ratio: 7.2– Depressive disorders at Wave 1 didn’t predict

depressive disorders at last wave– Not predictive of ADHD, CD, ODD, substance

abuse, anxiety

Development and Prevalence of DMDD: Review

• DMDD Development:– Increased in diagnosis of pediatric BP without distinct manic

episodes SMD (includes hyperarousal component) DMDD• DMDD Prevalence ~ 1-8%

– Common comorbid conditions: ADHD, depression, ODD • ADHD comorbidity estimates may vary widely based on sample used

– Diagnostic stability unclear• DMDD Predictors

– ODD, ADHD, temperament, parent factors• SMD prevalence ~3%• SMD predictive of later depressive episodes

Part 3: DMDD Research

• Emotional Labeling/Emotional Differences• Neural Differences• Treatment

Face Emotion Labeling Deficits- SMD vs .BD

Rich et al. (2008)• Participants: NP BD (have had manic or hypomanic

episode), SMD, NC• Emotional expression multimorph task (morph task)– Gradations of facial emotions

• 100% neutral to 100% expressive– Happiness, surprise, fear, sadness, anger, disgust

– Participants can “stop” at any point and provide answer (correct identification), then continue and change answer

Face Emotion Labeling Deficits- SMD vs. BD

• Morph task results:– BD and SMD children needed more morphs before

first responding (regardless of correct response), and responding correctly

• Social functioning and morph task results:• SMD: worse family function (measured by LIFE scale)

related to worse recognition r = -.71• BD: poorer social reciprocity (measured by SRS) with

poor recognition r = -.48

Face Emotion Labeling Deficits- SMD vs. BD

Guyer et al. (2007)• Compared the following groups (7-18 yrs. old) on a

facial emotion labeling task:– BD, SMD, ANX/MDD, ADHD/CD, control

• ANX/MDD: Generalized anxiety, social phobia, separation anxiety, or major depression

• High and low intensity expressions of happiness, sadness, anger, fear.

• Results: SMD and BD made more errors than other groups (but did not differ from each other)

Attentional Differences to Emotional Stimuli- SMD vs. BD

Rich et al. (2010)• Assessed SMD, BD, and NC (~10-15 yrs. old) on

“impact of emotional stimuli on attention”• Emotional Interrupt Task:– Fixation point emotional picture (negative,

positive, neutral) target (circle or square) picture blank screen• Press left button if circle, right if square

– reaction time

Attentional Differences to Emotional Stimuli- SMD vs. BD

Attentional Differences to Emotional Stimuli- SMD and BD

• Results:– Between-groups response time differences• BD slower to respond than NC after seeing all pictures • SMD slower to respond than NC after neutral pictures

– Within-groups response time differences• NC and BD significantly slower to respond after

negative and positive pictures vs. neutral pictures• ***SMD did not vary based on emotion

– BD and SMD lower accuracy than NC

Attentional Differences to Emotional Stimuli- SMD and BD

• Attention interference scores: subtract neutral RT from neg./pos. RT– SMD lower RT interference (regardless of

comorbidities) than BD and control for both positive and negative pictures

• SMD RT interference for negative pictures related to impaired peer relationships (r=-0.35), and impaired social reciprocity (r=-0.47)

Emotional Labeling/Emotional Differences: A Review

• SMD children more time to correctly facial expressions

• Make more errors in identifying correct facial expressions

• Emotional stimuli have less effect on attention

Amygdala Activation and Emotional Processing

Brotman et al. (2010)• Compared children with SMD, BP, ADHD, and

NC on amygdala activation during emotional processing of neutral faces using fMRI

• 8-17 yrs. old• Emotional face paradigm:– Happy, angry, fearful, and neutral faces– Passive viewing of face, rate how hostile (perceived

threat), subjective fear (how afraid), and nose width

Amygdala Activation and Emotional Processing

• Results:– BP and SMD more rated more fear for neutral faces than NC– Activation differences in left amygdala during fear+nose-width rating

contrast:• ADHD hyperactivation vs. NC, BP, and SMD• SMD hypoactivation vs. NC, BP, ADHD

– No differences in left amygdala activation during hostility and nose-width rating contrast

– Activation differences in left amygdala during nose width vs. fixation trials• SMD hyperactive vs. BP, ADHD, NC• NC hypoactivation vs. BP And ADHD

*even though SMD rated faces are more fearful, showed under activation of amygdala

Neural Responsiveness to changes in facial expression

Thomas et al. (2012)• 8-18 yrs. old BD, SMD, NC• Pictures went from neutral to 100% angry, and

neutral to 100% happy– 25% increments– Nose width and hostility ratings


• Amygdala activation analysis– NeutralAngry• Left amygdala differences

– NC had an increase in amygdala activation as anger increased, BD and SMD did not

– NeutralHappy• No differences

*again, amygdala underactivation for SMD


• Whole brain analysis– Neutral Angry• Left posterior cingulate (LPC): NC more activation with

increased anger – Authors suggest more effortful processing– LPC activated by emotional stimuli and connected to

amygdala and other regions


• Whole brain analysis– Neutral Happy

• Main effect of group on right inferior parietal lobule (brodmann area), left middle occipital gyrus and fusiform gyrus, right middle occipital gyrus and cuneus, and left middle/superior frontal gyrus.– BD had more negative slope than SMD and NC (except left middle occipital

gyrus)» BD children: increase expressions of happiness associated with

decrease in activation– SMD had a more positive slope than NC for all

» SMD children: increase in expressions of happiness associated with increase in activation

*these brain these brain regions associated with emotional processing, face processing, and attention

Neural Responses to Frustration

Deveney et al. (2013)• 8-17 yrs. old.• SMD (met criteria for DMDD) vs. NC on Posner

spatial cue task– Includes monetary rewards, and frustration• Two squares cue in one square target

– Respond to target location, cue predicted 75% of time

• Frustration portion:– For one section of task, computer gave feedback that

response was “too slow” 60% of time regardless of speed

Neural Responses to Frustration• Results:

– SMD children reported more frustration at end of frustration task vs. NC– During frustration task SMD responded more slowly than NC on invalid

trials– Amygdala analysis:

• SMD less activation in left amygdala on negative feedback trials• SMD within group differences: less activation in left amygdala on negative vs.

positive feedback trials (no difference for NC)

– Striatum analysis:• SMD less activation in left and right striatum during negative feedback trials• SMD less activation during negative vs. positive feedback trials (not seen in NC)

– Whole brain analysis: • SMD less activation during negative feedback in parietal, parahippocampal, and

thalamic/cingulate/striatal regions• SMD less activation in these regions during neg. vs. pos. feedback (not seen in NC)


• Implications– slower RT time during frustration task may be related

to difficulty shifting spatial attention from cue (involvement of parietal hypoactivation)

*Attention allocation skills important for emotional regulation

– possibility of decreased striatal response during negative feedback being related to reward processing• Outcome worse than expected experience as more

frustrating because unexpected and averse links to exaggerated responses to frustrating events

Neural Responses: SMD vs. BP

Rich et al. (2011)• Neural response differences: SMD vs. BD vs.

NC on Affective Posner task• Results: – SMD reported feeling more aroused (agitated)

than BD and control during negative feedback– SMD and BP reported more unhappiness

throughout task


http://www.ncbi.nlm.nih.gov/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Click%20on%20image%20to%20zoom&p=PMC3&id=3158808_nihms292599f1.jpg

Neural Responses: SMD vs. BP– Left anterior cingulate cortex (ACC):

• Negative feedback: SMD > control• Positive feedback: Control > SMD

– Medial frontal gyrus (MFG): • Negative feedback: SMD > control• Positive feedback: Control > SMD

– Superior frontal gyrus (SFG):• Negative feedback: BD > SMD and control• Positive feedback: no differences

– Insula:• Negative feedback: SMD and control > BD• Positive: BD > SMD

– Supplementary motor area (SMA):• Negative feedback: control > SMD• Positive feedback: BD> SMD and control


• Implications:– ACC, PFC, Insula: related to frustration– ACC and MFG: related to evaluating, resolving, and

monitoring emotional conflict– SFG: related to executive attention– BA 6 (in SMA): cognitive activity– Insula: processing negative and positive affect*greater arousal in negative situations

Neuropsychological test performance: SMD vs. ADHD

Uran & Kılıç (2014)• Participants:

– 7-18 yrs. old. referred to University clinic– Compared SMD vs. ADHD vs. NC on neuropsychological test– Neuropsychological tests:

• Wisconsin card sorting task (WCST)– Evaluates planning, searching, shifting cognitive sets, cognitive flexibility

• Stroop task– Selective attention and response inhibition

• Trail making task– Visual attention and task switching

• Controlled oral word association test– Verbal fluency and reasoning

• Controlled oral word association test– Verbal fluency and reasoning

• Category naming test (CNT)– Producing words, attention, set shifting

Neuropsychological test performance: SMD vs. ADHD

– Performance on neuropsychological tests was comparable between ADHD and SMD participants• ADHD < control on measures of WCST, TMT, Stroop,

COWAT• SMD < control on COWAT

– Further comparisons of SMD vs. ADHD• Parents and teachers rated SMD higher in hyperactivity,

social problems, impulsivity, emotional reliability

Neural Differences: A Review• SMD hypoactivation of amygdala with fear-inducing faces and angry

faces• Different brain activation patterns when viewing expressions of

happiness in areas of brain related to emotional processing and attention

• Different brain activation patterns during negative feedback in areas of the brain related to emotional conflict, executive attention, cognition, processing affect

• Greater reports of frustration, negative feelings, and arousal during frustration/attention tasks

• Greater difficulty in attention deployment• SMD children perform comparably to NC children on multiple

neuropsychological tests

Treatment for SMD: Lithium?

Dickstein et al. (2009)• Why Lithium?– Irritability and aggression

• Participants: 7-17 yrs.• Weaned off medication for 4 half lives , 2

weeks of placebo/hospitalization evaluated for SMD, if criteria still met randomized to lithium or placebo for 6 weeks


• Results:– After placebo period: 25 randomized, 20 no longer met

criteria for SMD– Clinical Global Impressions Scale

• No between groups differences regarding CGI < 4 (improved, much improved, or symptom free)– 3/14 lithium and 1/11 placebo

– Positive and Negative Syndrome Scale Factor 4– Measures excitement, hostility, uncooperativeness, poor impulse

control

• No between group differences

– Little evidence for metabolite differences

Treatment for SMD: Risperidone?

Krieger et al. (2011)• 21 participants– 19 completed full 8 week study– Baseline, 2 week, 4 week, 6 week, 8 week

evaluations– Mean: 10 yrs. old– Comorbidities:• 71.4% ADHD, 66.7% anxiety disorders, 81% ODD


• Results:– ABC Irritability (Irritability Scale of the Aberrant

Behavior Checklist)• Baseline average: 25.89 (18+ is considered “severe

impairing irritability”)• Significantly reduced over time

– Week 2 mean: 12.03 (ES 1.39)– Week 4 mean: 15.48 (ES 1.51)– Week 6 mean: 12.29 (ES 1.77)– Week 8 mean: 11.28 (ES 1.83)


– Clinical Global Assessment Scale• Significant reductions from baseline (mean = 4.53)

– Week 2 mean: 2.85– Week 4 mean: 2.96– Week 6 mean: 2.69– Week 8 mean: 2.64

– Children’s Depression Rating Scale• Significant reductions from baseline (mean=34.28)

– Week 2 mean: 24.11– Week 4 mean: 26.40– Week 6 mean: 25.93– Week 8 mean: 22.50

Treatment for SMD+ADHD patients: Methylphenidate and Behavior

ModificationWaxmonsky et al. (2008)• 101 Participants from a Summer Treatment Program for ADHD

– Ages 5-12– 2 hours academics a day, 7 hours recreation– Some campers with SMD

• Behavior modification (BMOD) and medication (methylphenidate/MPH) component– High, low, and no BMOD

• Every 3 weeks, switch BMOD condition

– Placebo, .15 mg, .3 mg, .6 mg MPH condition• Changed each day

• SMD group had Young Mania Rating Scale (YMRS) score of more than 12 (to test concerns about stimulant use)

• Parents had skills training course at home

Treatment for SMD+ADHD patients: Methylphenidate and Behavior Modification

– BMOD Levels• High: social skills training, reward/cost point system,

time-outs, report cards detailing behavior, individualized behavior plans etc.• Low: weekly contingency rewards (vs. daily in HBM),

behavior plans not individualized• None: no contingent rewards


Treatment Conditions:

Treatment for SMD+ADHD patients: Methylphenidate and Behavior

Modification• Results:

– SMD group elevated ODD and CD ratings throughout camp– Significant reduction in ADHD, ODD, and CD symptoms over time

for all groups (but no group X time interaction)– ADHD ratings:

• 85% of SMD showed at least a 50% improvement in time following activity rules (FAR), seatwork completed (SC), and non compliance to staff requests (NC)– For over half of SMD participants, it was low or medium medication with an active

BMOD condition

• FAR– All MPH and BMD doses affected SMD and non SMD children comparably with

regards to FAR, percentage of seatwork completed, and non compliance to staff requests» Exception: .3 mg low intensity BMOD


– Percent of Rules followed by dosage:» Placebo

• Non SMD vs. SMD: 34.59/32.48%» .15 mg

• Non SMD vs. SMD: 48.05/43.99%» .3 mg

• Non SMD vs. SMD: 56.6/53.62%» .6 mg

• Non SMD vs. SMD: 67.16/63.14– Percent of Rules followed by behavior modification therapy condition:

» none:• Non SMD vs. SMD: 34.59/32.48%

» low:• Non SMD vs. SMD: 49/45.23%

» high:• Non SMD vs. SMD: 54.4./51.79%


• Medication side effects:– No exacerbation of manic symptoms– Side effects more frequent at .6 mg dose (11 ppl had to reduce- 2

SMD and 9 non SMD)– SMD subjects: increase in trouble sleeping and being withdrawn,

but irritability ratings decreased• YMRS Scores

• 8.3 (34%) point total improvement in SMD subjects– ODD cluster (47% of difference)– ADHD cluster (23% of difference)– Mania cluster (25% of difference) – Decline of 11 points (31%) in children depression rating scale revised

• Children Depression Rating Scale Revised: 34% improvement

Treatment for SMD and ADHD: Group Therapy

Waxmonsky et al. (2013)• Participants:– 7-12 years old boys– ADHD and SMD (all taking medication)

• 9 week pilot trial, 7 families• Therapy program: treatment of ADHD and impaired

mood (AIM)– 9 week parent and child intervention (separate interventions)

( 6 week follow up)– At academic research center– Used materials from 4 other interventions


– Parent sessions• Behavior modification principles• Improve relations, consistency, communication, praise

positive actions, appropriate time outs and contingencies, recognize triggers etc.

– Child sessions• Contingency management, problem solving skills,

emotion identification, cognitive “toolbox”


– Results:• Children’s Depression Rating Scale- Revised

– Pre, post, and follow up means: 30.43, 23.57, 24.69» Pre-Post treatment d = 1.17» Pre-Follow up d = 1.26

– “clinically meaningful change”: decrease of 40% from baseline score» 4 had shown baseline “clinically significant impairment”

• 2/4 showed clinically meaningful change at post, but not retained at follow up

• Young Mania Rating Scale– Pre, post, and follow up means: 14.71, 10.43, 9.71

» Pre-Post treatment d = 0.81» Pre-Follow up d = 1.43

– “clinically meaningful change”: decrease of at least 25% from baseline score» 6 had shown baseline “clinically significant impairment”

• 4/6 showed clinically meaningful change


– Behavior ratings• Small effects of parent ratings of ADHD, ODD, and CD, not

maintained at follow up

– Impairment ratings• Improvement of CGAS scores baseline to post (d = 2.17)

– Baseline mean: 47.86= “serious level of symptoms”– Post mean: 66.43 = “mild to moderate symptom severity”– Follow up mean: 53.57

– Parent behavior• Greatest gains seen for reductions in corporal punishment pre-

follow up (d = 0.93)– Baseline mean: 4.71– Follow up mean: 3.50

Treatment: A Review

• Lithium not shown to be effective in treating SMD• Risperidone shown to be effective– Reduces irritability ratings

• Combination of Methylphenidate and Behavior Modification effective in increasing rule-following and decreasing externalizing problems for comorbid SMD/ADHD children

• Parent and child interventions shown to reduce depression and mania symptoms in ADHD/SMD children

DMDD Research Schematic

DMDD/SMD


Differences in:*amygdala activationACC, MFG, SFG, Insula, Striatal

Emotion Processing Differences

Labeling deficits,different neural responses

TemperamentAgitation, irritability, low frustration tolerance

Parent FactorsHostility, lifetime substance use

Primary characteristic: chronic irritability

Secondary Characteristics:ODD behaviorsADHD behaviorshyperarousal

Risk for: mood disorders

Treatment

medication

Behavior modification

Vs. DSM V Schematic

DMDD

Temperament

Chronic irritability

Symptoms for:ODD, ADHD, anxiety, MDD


Familial anxiety, depression, substance use

Face emotion labeling differences Attention/

cognition differences

Risk For:Depression, anxiety, suicidality, severe aggression, dangerous behavior, psychiatric hospitalization

Secondary Features:Problematic relations with others (peers, family), poor performance in school, low frustration tolerance, dangerous behaviors, suicidality

Primary Features: severe, chronic irritabilitytemper tantrums

References

• Axelson, D., Findling, R.L., Fristad, M.A., Kowatch, R.A., Youngstrom, E.A…. Birmaher, B. (2012). Examining the proposed

disruptive mood dysregulation disorder diagnosis in children in the longitudinal assessment of manic symptoms

study. Journal of Clinical Psychiatry, 73(10), 1342-1350.

• Brotman, M.A., Rich, B.A., Guyer, A.E., Lunsford, J.R., Horsey, S.E. Reising, M.M.,… Leibenluft, E. (2010). Amygdala

activation during emotion processing of neutral faces in children with severe mood dysregulation versus adhd or

bipolar disorder. American Journal of Psychiatry, 167(1), 61-69.

• Brotman, M.A., Schmajuk, M., Rich, B.A., Dickstein, D.P., Guyer, A.E., Costello, E.J…. Leibenluft, E. (2006). Prevalence,

clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological Psychiatry, 60, 991-

997.

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