Disruptive Mood Dysregulation Disorder (DMDD): A New Diagnosis, But Not a New Problem

The Power of Socialization article by Dr. Sam Goldstein

The addition of new diagnoses in psychiatry is not a rare event. Afterall the first edition of the Diagnostic and Statistical manual of the American Psychiatric Association, published in 1952 was 130 pages containing a 106 single listed-disorders. The Revised Fifth Edition of this manual is over 500 pages and although it claims only 70 disorders, many have many dozens of subtypes and permutations leading to many hundreds of diagnoses! The first edition did not contain any childhood diagnoses. These were introduced many years later in the DSM III. Since then very few new childhood conditions have been added. So, it was with great interest in 2013 when DSM 5 introduced the DMDD diagnosis. The ICD-10-CM (International Classification of Diseases) contains a diagnostic category, Persistent Mood (affective) Disorder, unspecified. It went in to effect on October 1, 2021. It includes the American ICD-10-CM version of DMDD. Other international versions of ICD-10 may differ. But is this diagnosis needed? Are the diagnostic criteria well validated? Do we know what happens to these children as they transition into adulthood? I will address these questions in this month’s article. Whether you are a parent, educator, mental health professional, coach or extended family member I encourage you to take a few minutes and read on.

Explosive anger outbursts and persistent irritability are among the most problematic symptoms in child and adolescent mental health. They can present as a feature of many different psychiatric disorders. There have been increasing concerns over the past thirty years that youth with chronic irritability and anger outbursts are being increasingly misdiagnosed as having bi-polar disorder. These concerns led to the creation of a new diagnosis for DSM-5, Disruptive Mood Dysregulation Disorder (DMDD) in 2013. The development of this disorder has been controversial, in part because there are no published data using the proposed and now utilized diagnostic criteria for youths. The scientific support for DMDD comes primarily from studies of the related but not identical construct of Severe Mood Dysregulation (SMD). SMD was a diagnostic condition proposed but never formalized. DMDD has two symptom criteria: severe temper outbursts and irritable or angry mood. The diagnosis has criteria for frequency (at least three outbursts per week), persistence (irritable/angry mood most of the day, nearly every day), duration (at least 12 months, with no more than 3 consecutive months without meeting symptom criteria), age (minimum age 6 years), age at onset (before age 10), and context (present in multiple settings). Lastly, the disorder has a relatively complex set of diagnostic exclusion criteria, which include a requirement to use the DMDD diagnosis when a child meets criteria for both disruptive mood dysregulation and oppositional defiant disorders. DMDD symptoms are relatively common in referred children, but the full disorder is much less common. For example, in the Great Smoky Mountains Study sample, the lifetime prevalence rates of DMDD was 4.4%.

As a new diagnosis we know little about co-morbidity, effective treatment nor outcome into adulthood for DMDD. Recent studies suggest that children with DMDD are at greater risk than others to experience a myriad of child and adult psychiatric disorders. They may in fact suffer from more adult psychiatric disorders than other childhood conditions growing up. Thus, treatment for DMDD is based on what has been helpful for other disorders that share similar symptoms. However, children diagnosed with DMDD often end up on a cocktail of psychiatric medications with inconsistent benefit. Counseling can be helpful in assisting these children to better understand their temperament and develop coping strategies. DMDD is a condition for which there is not an IDEIA (Special Education) classification within the U.S. schools, creating an additional conundrum for Educational Professionals when children with DMDD act out at school.

As of this date a comprehensive DMDD clinician’s textbook has not been published. With the contribution of colleagues from multiple countries, I am editing the first comprehensive, clinical textbook on DMDD to be published next year. I am also just starting to collect data worldwide for the first parent completed questionnaire to aide in the assessment and diagnosis of DMDD. Research often takes many years to filter into clinical practice. In the interim mental health professional, physicians and educators are increasingly asked to evaluate these children and prescribe medical, educational and mental health treatment not only to the child but to the family as well.

Many children now receiving the DMDD diagnosis were diagnosed and treated for severe ADHD, Impulse Control Disorder or Bi-polar Disorder of Childhood. If you suspect your child, student, patient, or extended family member may suffer from this condition I suggest you start by watching my Webinar on this subject ( Consider as well the following at risk criteria a child may present with:

  •   A.  Severe, recurrent temper outbursts (verbal and/or behavioral) that are grossly out of proportion in intensity or duration to the situation/provocation.
  •   B.  Outbursts are inconsistent with the developmental level.
  •   C.  Occur three or more times/week.
  •   D.  Mood between temper outbursts is persistently irritable or angry most of the day, nearly every day.
  •   E.  Duration is 12 or more months, without symptom-free interval of three or more consecutive months.
  •   F.  Symptoms are present in at least two of three settings (home, at school, with peers) and are severe in at least one setting.
  •   G.  Age at onset, either by history or observation, is before 10 years.
  •   H.  Diagnosis should not be made for the first time before age 6 years of age or after 18 years.
  •   I.  Full symptom criteria for manic/hypomanic episode have never been met for longer than 1 day.
  •   J.  Behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by other disorders like dysthymia, autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder. (Diagnosis cannot coexist with Bi-polar Disorder, Intermittent Explosive Disorder, and ODD).
  •   K.  Symptoms not due to effects of a substance, medical or neurological condition.

This list is a good place to start but not a good place to finish. Even if you check off many of these criteria, a professional evaluation is a necessity. Checklists do not diagnose. As of this date there a hundred or so peer reviewed studies specifically about DMDD. Many hundreds more are need to understand this complex, debilitating childhood pattern of behavior now called DMDD. ◆

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