Disruptive Mood Dysregulation Disorder (DMDD)

Children may develop some of the same conditions more commonly associated with adulthood, such as anxiety and depression. However, there is a subset of psychiatric disorders that are particularly associated with childhood – some exclusively diagnosable in those 17 years of age or younger. They are: 

• Avoidant-Restrictive Food Intake Disorder (ARFID): ARFID, previously referred to as Selective Eating Disorder, is characterized by a persistent refusal to consume certain foods or food groups with an arbitrary negative connotation, such as those of a particular color, texture, or smell. Children with this disorder are extremely picky eaters and/or have little interest in eating food. Since their condition limits the variety of food they consume, children with ARFID may experience excessive weight loss, disrupted growth patterns, and malnutrition. 
• Pica: Pica is a compulsive eating disorder in which a person regularly craves and consumes nonfood items for at least one month after 2 years old – when it is then considered developmentally abnormal. Common items children with pica consume include dirt, paper, cigarette butts, chalk, wood, and crayons. The disorder is most commonly seen in children, but is also seen in individuals with developmental disabilities.
• Pediatric Bipolar Disorder: As the name suggests, this condition simply refers to the presence of bipolar disorder in children and adolescents. It is characterized by extreme shifts in mood and behavior between highs and lows, formally known as manic/hypomanic and depressive episodes. Pediatric bipolar disorder is more often seen in adolescents, but may be recognized and diagnosed in children as young as 6 years old. Studies indicate that the disorder affects 1-3% of those ages 6-18. 
• Attention Deficit Hyperactivity Disorder (ADHD): Along with anxiety and depression, ADHD is one of the more widely known psychiatric disorders amongst the general public. It is characterized by three overarching themes: inattentiveness, hyperactivity, and impulsivity. Most cases of the disorder develop and are diagnosed in children between ages 3 and 7. Children with the disorder typically display heightened distractibility, talkativeness, and loss of social function. 
• Oppositional Defiant Disorder (ODD): ODD is a type of behavioral disorder. It is characterized by recurrent patterns of anger, irritability, defiance, and/or vindictiveness toward people outside of their siblings – most commonly authority figures, such as parents or teachers. Children with ODD may be uncooperative, short-tempered, resentful, or hostile. The disorder is typically diagnosed in those 8 years of age or younger. 
• Separation Anxiety Disorder (SAD): Separation anxiety disorder is characterized by a state of excessive emotional distress during impending separation from caretakers or individuals a child is most attached to. Although separation anxiety is a normal part of development commonly seen in babies 8-12 months old, identifying significant separation anxiety after age 2 is considered developmentally abnormal. Children with separation anxiety disorder may experience repeated nightmares involving separation as well as physical panic symptoms when separated from their major attachment figures. This can lead to impairment in social, academic, and occupational settings. 
• Disruptive Mood Dysregulation Disorder (DMDD): DMDD is characterized by a chronic irritable/angry mood state and temper outbursts that seem disproportionate to the situation that prompted them. This disorder is the main focus of today’s blog and is discussed in greater detail below. 

What is Disruptive Mood Dysregulation Disorder (DMDD)?

Of the psychiatric disorders heavily associated with childhood, DMDD is unique for a few reasons. While the others described above are heavily associated with childhood because of their age of onset and their higher prevalence in children, DMDD is the only condition listed that is exclusively diagnosed in children and adolescents ages 6-18, and the diagnostically-recognized age of onset is before 10 years old. Additionally, DMDD is a newly recognized disorder – the latest published DSM, the DSM-5 (2013), is the first diagnostic manual it appeared in. A significant reason for its push to become a distinct diagnosis was to more accurately diagnose children and adolescents who may have previously been diagnosed with pediatric bipolar disorder – despite failing to meet all of the disorder’s diagnostic criteria. 

As briefly described, DMDD is a condition characterized by persistent irritability and anger as well as frequent, severe temper outburst that are out of proportion to the situation and developmental context. The key diagnostic criteria of DMDD outlined by the DSM-5 include: 

1. Severe, recurrent temper outbursts manifested verbally and/or behaviorally that are grossly out of proportion in intensity or duration to the situation of provocation.
2. The temper outbursts are inconsistent with developmental level.
3. The temper outbursts occur, on average, three or more times per week.
4. The mood between temper outburst is persistently irritable or angry most of the day, nearly every day, and is observable by others. 
5. Criteria A-D have been present for 12+ months, with no more than 3 consecutive months of symptom-free period.
6. The symptoms/behaviors must be present in at least two of three settings (i.e. home, school, with peers) and are severe in at least one of these. 
7. The diagnosis should not be made before age 6 or after 18 years.
8. By history of observation, the age at onset is before 10 years.

Moodiness and temper outbursts, or tantrums, are not exclusively seen in children with DMDD, but there are distinctions between typical child irritability/outbursts and clinically significant irritability/outbursts. Whereas typical irritability may be soothed by an understanding parent or time left alone, DMDD-related irritability may not respond to such external efforts. The irritability and/or outburst tend to persist for a duration, and at an intensity, that is unpredictable and follows no reason. Overall, children with DMDD experience great difficulty regulating their emotions in an age-appropriate manner.  

Differential Diagnosis

Despite DMDD’s formal introduction as a depressive disorder in the DSM-5, there is still controversy in regard to its validity as a distinct disorder from others, especially Pediatric Bipolar Disorder and Oppositional Defiant Disorder (ODD). Here, we’ll explore some of the key factors that led to its establishment as a distinct diagnosis.

DMDD vs. Pediatric Bipolar Disorder

Since irritability and emotional lability are the two of the most identifiable symptoms of pediatric bipolar disorder, it makes sense that children now diagnosed with DMDD were once grouped into pediatric bipolar disorder diagnosis. A significant difference between the two involves the duration of irritability. While pediatric bipolar disorder is characterized by symptoms that tend to be episodic, children with DMDD persistently display a mood state of irritability and/or anger – even between full temper outbursts. Additionally, the DSM-5 diagnostic criteria notes that if a child has ever experienced a manic or hypomanic episode, such as those often seen in pediatric bipolar disorder, the diagnosis of DMDD cannot be assigned. 

DMDD vs. ODD

Although they are both diagnostically recognized by an angry/irritable mood, temper outbursts are exclusively a diagnostic feature of DMDD. More specifically, DMDD diagnosis requires evidence of an average of three temper outbursts per week for at least 12 months. Another distinction between the disorders involves the duration of a child’s irritable mood. While ODD only requires presence of angry/irritable mood, argumentative/defiant behavior, or vindictiveness once a week for at least 6 months (in those over 5 years old), DMDD diagnosis requires presence of that mood state most of the day, nearly every day for at least 12 months.  

Treatment for DMDD

Children with DMDD display higher rates of health care service use, hospitalization, and school suspension. They are also more likely to develop other mood disorders, such as anxiety and depression, as they enter adolescence and adulthood. For these reasons, it is imperative that children receive professional psychiatric assistance as early as possible. 

Because DMDD is a newly classified disorder, accepted treatment methods are primarily based on research focused on other childhood disorders associated with irritability and outbursts, such as anxiety, ADHD, ODD, and major depression. The two primary forms of treatment for DMDD include psychotherapy (talk therapy) and medication. In most cases, psychotherapy is utilized first and medication is introduced later if needed. Cognitive behavioral therapy (CBT) and dialectical behavior therapy (DBT) are some of the most widely used forms of psychotherapy. They both involve teaching children and adolescents how to cope with the thoughts and feelings that contribute to their depressed, anxious, irritable/angry, or distressed mood state. Additionally, these forms of psychotherapy aid children and adolescents in developing and practicing skills to regulate their emotions and avoid extreme or prolonged outbursts. Finally, there are no medications approved by the FDA for the treatment of DMDD, but certain medications have demonstrated success in reducing the symptoms of disorders with similar symptomology. Medications, such as stimulants, antidepressants, and atypical antipsychotics, have been used to treat irritability, mood problems, outburst, and aggression in children with other disorders like ADHD and autism. Still, clinicians generally practice increased precaution when treating psychiatric disorders in children with medication because of the side effects and overwhelming focus of medication research on adult populations. Therefore, the use of medication to treat DMDD is typically only seen when other approaches have not been successful because of the particularly vulnerable population DMDD affects. More research on the effects of these medications on specifically children diagnosed with DMDD is needed.