dmdd disruptive mood dysregulation disorder
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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
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