Disruptive Mood Dysregulation Disorder (DMDD)

Disruptive Mood Dysregulation Disorder (DMDD) is a new controversial DSM-5 diagnosis for children with chronic and severe persistent irritability and severe anger outbursts. DMDD was created for patients previously diagnosed with the also controversial diagnosis of childhood (pediatric) bipolar disorder and concerns about over-diagnosis and over-treatment with antipsychotics. Although DMDD is officially classified as a mood disorder under the DSM-5, it often co-presents during childhood with other non-mood diagnoses such as conduct disorder and oppositional defiant disorder.

• The epidemiology of DMDD is not well understood as it is a new diagnosis; it is estimated to have a prevalence between 2 to 5%.^[1]
• Individuals presenting to clinical attention are most commonly male.

• Approximately 50% of children with severe, chronic irritability will have a presentation that continues to meet criteria for DMDD 1 year later.
  • Symptoms of DMDD generally become less severe as children transition into adulthood.
• DMDD is not a “pre-bipolar” diagnosis, and the rates of conversion from severe, nonepisodic irritability to true bipolar disorder are very low.^[2]
• In both DMDD and pediatric bipolar disorder, severe aggression, reckless behavior, suicidal ideation or suicide attempts, and psychiatric hospitalization can be common.^[3]

• DMDD has extremely high comorbidity with other psychiatric disorders and it would be rare for an individual to only have a diagnosis of DMDD.
• The strongest overlap is with oppositional defiant disorder (ODD)
• Individuals can present with a wide variety of concerns including disruptive behavior, mood, anxiety, and sometimes autism spectrum symptoms.^[4]

• A prior history of chronic irritability is a risk factor.^[5]

Severe recurrent temper outbursts manifested verbally (e.g. - verbal rages) and/or behaviourally (e.g. - physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

The temper outbursts are inconsistent with developmental level.

The temper outbursts occur, on average, 3 or more times per week.

The mood between temper outbursts in persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. - parents, teachers, peers).

Criteria A, B, C, and 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 to D.

Criteria A and D are present in at least 2 of the 3 settings (i.e. - at home, at school, with peers) and are severe in at least 1 of these.

The diagnosis should not be made for the first time before age 6 years or after age 18 years

By history or observation, the age of onset of Criteria A to E is before 10 years.

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.

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.

The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

• It is important to note that according to the DMDD diagnostic criteria, the age of onset of the primary symptoms must have occurred before age 10.^[6]
• In addition, the diagnostic label can only be applied to individuals between age 6 to 18.^[7]
  • This means it cannot be applied to those younger than 6 or older than 18.

• There are no validated scales for DMDD.
• National Institute for Mental Health (NIMH) research groups have used versions of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children to diagnose DMDD.^[8]

• Bipolar I and Bipolar II disorder
  • The central feature differentiating disruptive mood dysregulation disorder and bipolar disorders in children involves the longitudinal course of the core symptoms. In children, as in adults, bipolar disorders are an episodic illness with discrete episodes of mood changes that can be differentiated from the child's typical presentation. For example, the mood change that occurs during a manic episode is distinctly different from the child's usual baseline mood.
  • Additionally, during a manic episode onset (just like adults), there are additional associated cognitive, behavioural, and physical symptoms (e.g. - grandiosity, distractibility, increased goal-directed activity)
  • Thus, in the case of a manic episode, parents and/or children should be able to identify a distinct time period during which the mood and behavior were markedly different from usual.
  • Compare this with DMDD, where irritability is persistent and is present over many months to years. This is why the diagnosis of DMDD cannot be assigned to a child who has ever experienced a full-duration hypomanic or manic episode (irritable or euphoric) or who has ever had a manic or hypomanic episode lasting more than 1 day.
• Oppositional defiant disorder (ODD)
  • While symptoms of ODD also occur in children with DMDD, the mood symptoms seen in DMDD are relatively rarer in ODD. The diagnosis of DMDD requires severe impairment in at least 1 setting (i.e. - home, school, or among peers) and mild to moderate impairment in a 2nd setting. Thus, a child that meets diagnosis for DMDD will very likely meet criteria for ODD, but not vice versa (only 15% of individuals with ODD would meet criteria for DMDD).
• Attention-deficit/hyperactivity disorder, major depressive disorder, anxiety disorders, and autism spectrum disorder.
  • Unlike children with bipolar disorder or ODD, a child whose symptoms meet criteria for DMDD also can receive a comorbid diagnosis of ADHD, major depressive disorder, and/or anxiety disorder. However, children whose irritability is present only in the context of a major depressive episode or persistent depressive disorder (dysthymia) should receive one of those diagnoses and not a diagnosis of DMDD.
  • Children with autism spectrum disorder can also have temper outbursts and the child should not receive a DMDD diagnosis.
• Intermittent explosive disorder (IED)
  • Children with IED present with episodes of severe temper outbursts, much like children with DMDD. However, unlike DMDD, IED does not require persistent irritability and/or disruption in mood between outbursts.
  • In addition, IED requires only 3 months of active symptoms, compared to the 12-month requirement for DMDD. Thus, these two diagnoses should never be made in the same child. For children with severe outbursts plus persistent irritability, the diagnosis of DMDD should be made over IED.^[9]

• As clinically indicated.

• Management of DMDD should focus on helping children and adolescents improving emotional dysregulation through parental, school, and professional support. Social skills training may also be helpful.
• There are no FDA-approved medications for use in DMDD.