What is Disruptive Mood Dysregulation Disorder?
Disruptive mood dysregulation disorder (DMDD) is a childhood disorder of extreme temper outbursts that are frequent (three or more times per week), severe, out of proportion to the situation, and age-inappropriate. For example, a child who is chronically irritable at school may throw a chair at a peer during one of these temper outbursts. Something as inconsequential as being served milk instead of juice can provoke a screaming episode lasting half-hour or more. In between these episodes, mood is irritable or angry most of the day nearly every day. These symptoms occur in at least two settings (at school, home, or with peers). The occurrence of a manic or hypomanic episode rules out the diagnosis of disruptive mood dysregulation disorder.
Disruptive mood dysregulation disorder is a fairly new diagnostic entity, appearing for the first time in the Diagnostic and Statistical Manual of Mental Disorders published in 2013 (DSM-V). This became necessary because some children and adolescents were being overdiagnosed and treated for bipolar disorder even when they didn’t meet the full criteria, so one had to differentiate children who experience explosive outbursts who have a different outcome.
The prevalence rate of disruptive mood dysregulation disorder is around 3%. It is more commonly diagnosed in boys than in girls. About 90% of children with DMDD meet the criteria for ADHD; about 20% of those with ADHD qualify for a diagnosis of DMDD. Children with disruptive mood dysregulation disorder are at greater risk to develop depression and anxiety disorders in adulthood.
Symptoms of Disruptive Mood Dysregulation Disorder
The key characteristic that distinguishes DMDD from bipolar disorder is persistent irritability because in bipolar disorder alternating episodes of irritability and heightened mood are present. The symptoms are a combination of persistently irritable or annoyed mood that hangs on for an unusually long time, usually more than half of the child’s waking hours, and excessive or frequent temper outbursts.
Thus, DMDD has two major symptom criteria: severe temper outbursts and irritable or angry mood. The temper outbursts are manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) and are intense, don’t fit the child’s developmental age, completely out of proportion to the situation. 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).
The diagnosis thus has criteria (as per DSM-5):
- Frequency (three or more outbursts per week)
- Persistence (irritable/angry mood most of the day, nearly every day)
- Duration (symptoms for at least 12 months, with no more than 3 consecutive symptom-free months)
- Current age (minimum 6 years)
- Age at onset (before age 10 years)
- Context (symptoms present in at least two of three settings – at school, at home, with peers – and are severe in at least one of these)
The disorder also has the following set of diagnostic exclusion criteria (as per DSM-5):
- There has never been more than 1 day during which the criteria 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 [dysthymia]).
- The symptoms are not attributable to substance abuse or to another medical or neurological condition.
- The diagnosis should not be made for the first time before age 6 years or after age 18 years.
Once all the diagnostic inclusion and exclusion criteria are met, these children and adolescents with persistent, explosive irritability and anger are typically highly impaired, often requiring inpatient admission and medication.
DMDD shares symptoms of chronic negative mood and temper outbursts with oppositional defiant disorder (ODD). However, symptoms are much more severe, frequent, and chronic in individuals with DMDD than in those with ODD. In individuals who meet diagnostic criteria for both ODD and DMDD, only the more severe disorder DMDD is diagnosed.
Causes of Disruptive Mood Dysregulation Disorder
The exact cause of DMDD is not known. Impairment of perception of others’ facial emotions does appear to be related to DMDD and may play a role. Social or environmental factors contributing to the cause of DMDD have not been reported.
Treatment of Disruptive Mood Dysregulation Disorder
Treatment consists of behavioral therapy, medications such as antidepressants and stimulant drugs, or a combination of the two. It can take many trials to arrive at the right combination of treatments.
The goal in DMDD treatment is to help children learn to regulate their emotions and avoid extreme or prolonged outbursts. Dialectical behavior therapy for children (DBT-C) and parent training are very effective treatments.
In DBT-C, the child is taught skills to cope when her feelings become too intense or unmanageable, such as mindfulness, emotional regulation, distress tolerance, and interpersonal effectiveness skills. Parents, too, learn these skills, both to help their child and to manage their own emotional response to this, by avoiding reinforcing outbursts and instead rewarding desired behaviors.
Medication is prescribed only when behavioral therapy is not available, or not effective alone. There are no FDA-approved medications to treat disruptive mood dysregulation disorder. Pharmacological treatment ranges from stimulants to treat aggression, mood stabilizers such as atypical antipsychotics (e.g., risperidone [Risperdal] and aripiprazole [Abilify]) and valproate to treat mood dysregulation, or selective serotonin uptake inhibitors (SSRIs) to treat depressive symptoms.