DYSRUPTIVE MOOD DYSREGULATION

DISORDER (DMDD)

Introduction DMDD- Disruptive mood

dysregulation disorder

A new diagnosis in field of

mental health

Children with DMDD have

severe and frequent temper

tantrums that interfere with

their ability to function at

home, in school or with their

friends.

AACAP 2013 Facts for families on DMDD

Irritability

• Irritability is an understudied

symptom in pediatric

psychopathology that crosses over

boundaries of various diagnostic

categories while it is often used to

diagnosis childhood or adolescent

bipolar disorder which may lead to

supposedly lifelong therapeutic

regimens while the actual diagnosis

may be DMDD

INDIAN JOURNAL OF APPLIED RESEARCH june2014;4(6);428-430

Disruptive mood dysregulation disorder (DMDD)

Occasional temper tantrums are also a normal part

of growing up.

However, when children are usually irritable or

angry or when temper tantrums are frequent,

intense and ongoing, it may be signs of a mood

disorder such as DMDD.

Unlike pediatric bipolar disorder, DMDD is

thought to occur more often in boys than

girls. AACAP 2013 Facts for families on DMDD

DMDD

DMDD is a new disorder created to more accurately

categorize some children who had previously been

diagnosed with pediatric bipolar disorder.

These children do not experience the episodic

mania or hypomania characteristic of bipolar

disorder, and they do not typically develop adult

bipolar disorder, although they are at elevated risk

for depression and anxiety as adults.

AACAP 2013 Facts for families on DMDD

Causes of DMDD

• Early psychological trauma and abuse.

• Family structure (recent death in the family,

divorce, relocation); 

• Poor diet (lack of nutrition or vitamin deficiencies,

underlying medical conditions);

• A neurological disability that causes poor

behavior, such as migraine headaches.

Symptoms of DMDD Severe temper outbursts at least three

times a week

Sad, irritable or angry mood almost

every day

Reaction is bigger than expected

Child must be at least 6 years old

Symptoms begin before age 10

Symptoms are present for at least a

year Child has trouble functioning in more than one place (e.g.,

home, school and/or with friends)

Why the new diagnosis?

First, no DSM-IV category captures the

symptomatology of children characterized primarily

and fundamentally by severely impairing non-

episodic irritability.

DSM-IV disorders do not accurately capture the

phenotype exhibited by severe irritability.

Oppositional defiant disorder does have

irritability but it is not required; can be diagnosed

only on the basis of oppositional behavior

Limitations of DSM-IV

DSM-IV provides no definition of irritability,

despite the inclusion of this symptom as a

criterion for at least six diagnoses in children

(manic episode, oppositional defiant

disorder, generalized anxiety disorder,

dysthymic disorder, posttraumatic stress

disorder, and major depressive episode)

Problems with Childhood Bipolar Disorder

From 1994 to 2003, diagnosis of Bipolar Disorder in children went up

4000%

Increased diagnosis thought to be caused by “loose” translation of

DSM-IV criteria for Bipolar Disorder when applied to children

Researchers considered changing criteria for children but concluded

that original Bipolar Disorder criteria should stand

DMDD was developed to identify children not meeting diagnosis of

Bipolar Disorder yet having significant impairment.

DSM V removes “Bipolar Disorder Not Otherwise Specified”

category which was commonly applied to children not meeting

full criteria.

DSM V Criteria A. Severe recurrent temper outbursts manifested verbally (e.g.,

verbal rages) and/or behaviorally (e.g., physical aggression

toward people or property) that are grossly out of proportion in

intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times

per week.

D. The mood between temper outbursts is persistently irritable or

angry most of the day, nearly every day, and is observable by

others (e.g., parents, teachers, peers).Shelly R. Hart DSM 5 and School Psychology DMDD‐

DSM V Criteria E. Criteria A-D have been present for 12 or more months.

Throughout that time, the individual has not had a period lasting 3

or more consecutive months without all of the symptoms in

Criteria A-D.

F. Criteria A and D are present in at least two of three settings

(i.e., at home, at school, with peers) and are severe in at least

one of these.

G. The diagnosis should not be made for the first time before

age 6 years or after age 18 years.

H. By history or observation, the age at onset of Criteria A-E is

before 10 years.Shelly R. Hart DSM 5 and School Psychology DMDD‐

DSM V Criteria I. There has never been a distinct period lasting more than 1 day

during which the full symptom criteria, except duration, for a

manic or hypomanic episode have been met.

J. The behaviors do not occur exclusively during an episode of

major depressive disorder and are not better explained by

another mental disorder (e.g., autism spectrum disorder,

posttraumatic stress disorder, separation anxiety

disorder, persistent depressive disorder [dysthymia]).

K. The symptoms are not attributable to the physiological effects

of a substance or to an other medical or neurological conditionShelly R. Hart DSM 5 and School Psychology DMDD‐

Advantage of evolution

• The addition of DMDD as a diagram in DSM 5

has now made it incumbent on the psychiatrist

to diagnose this condition and differentiate it

from ADHD or ODD.

• One important role of DMDD will be in reducing

the large number of children who will otherwise

be misdiagnosed as bipolar disorder using DSM

criteriaINDIAN JOURNAL OF APPLIED RESEARCH june2014;4(6);428-430

ICD-11 vs. DSM V

• The ICD 11 classification plans to include

disruptive mood dysregulation with dysphoria

disorder as a counterpart to DMDD in DSM 5.

• The criteria for the two are similar except that

ICD has a uniform one month duration criteria for

all mental disorders unlike the one year

guidelines of DMDD in DSM 5

INDIAN JOURNAL OF APPLIED RESEARCH june2014;4(6);428-430

Comparison Bipolar disorder DMDD

Discrete mood episodes of mania and depression

Severe, non-episodic irritability

Lifelong episodic illness Does not develop into Bipolar Disorder

Decreased focus on irritability in DSMV

Associated with severe outbursts/tantrums

Can be diagnosed at any age but rare in

childhood; peak onset in 20s-30s

Cannot be first diagnosed before 6 or

after 18

Psychosis may be present

Not associated with psychosis

Comparison

Comparison

Neurobiology of DMDD

Very little is known about the neurobiology of DMDD

and its relationship with ADHD and Learning

disabilities and its impact on their neurobiology.

Genetic studies though few are available for DMDD.

The studies show a clear link to depression and not

bipolar disorder.

Thus the impact of this genetic link on treatment

and prognosis is enormousINDIAN JOURNAL OF APPLIED RESEARCH june2014;4(6);428-430

Risk factor

Children with a history of chronic irritability are

more likely to be diagnosed with disruptive mood

dysregulation disorder.

Research has also demonstrated that children

with DMDD usually do not go on to have bipolar

disorder in adulthood. They are more likely to

develop problems with depression or anxiety

AACAP 2013 Facts for families on DMDD

Treatment There is no set way to treat DMDD; however, studies have found

certain treatments to be effective at lessening the outbursts and

decreasing the effects. These include:

Medication

Antipsychotics

Antidepressants (SSRI,SNRI)

Anticonvulsants (AEDs)

Sleep aids

Psychotherapy

Combination of the two

Pharmacotherapy

Liu et al, JAACAP 2011

SSRI-first choice for DMDD

• Antidepressants have been recommended as the

first choice for the management of DMDD as the

underlying disorder is one of mood.

• A concern in children and adolescents is the use

of SSRIs and their links to suicidality which

though resolved via

Impact and concerns

Media has been quite hostile to a diagnosis of DMDD and

believe that the earlier were difficult will now be labelled

as DMDD and medicated as well.

The other fear is the misuse of the DMDD diagnosis in

juvenile crimes and courts to seek pardon for violent acts

triggered by some events which should ideally not be

pardoned easily.

The acceptance of DMDD by medical insurance companies

in settling claims is another issue worth discussing

INDIAN JOURNAL OF APPLIED RESEARCH june2014;4(6);428-430