How to Diagnose and Treat Disruptive Mood Dysregulation Disorder

DSM-5 includes the addition of a new diagnosis, disruptive mood dysregulation disorder (DMDD). Now that DMDD is viewed as a distinct mental health condition, Ellen Leibenluft, M.D., chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health and a member of the DSM-5 Work Group on Childhood Disorders, believes that it is important for psychiatrists to know the history behind the disorder and how to properly diagnose and treat the condition.

According to Leibenluft, DMDD was added to DSM to provide a more accurate diagnosis for children who present with severe and chronic irritability.

“Many children with DMDD were receiving a diagnosis of pediatric bipolar disorder due to the irritability that they were presenting,” Leibenluft explained during an interview with Psychiatric News. She said that it was once commonly accepted by psychiatrists that episodes of extreme irritability in children with DMDD was a manifestation of mania or elation that is seen in adults with the bipolar disorder. “But when my research group and other researchers observed that these children did not display manic episodes into adulthood, it became difficult to think of them as having bipolar disorder,” Leibenluft said. “Instead, these children were at risk of having unipolar depression and anxiety disorder.”

With substantial evidence showing phenotypical differences between children with bipolar disorder and children with DMDD, in addition to evidence that distinguished familial history of mental illness between both groups, the DSM-5 Work Group on Childhood Disorders thought it was necessary to lay a foundation for DMDD as a standalone diagnosis in DSM-5, according to Leibenluft.

To be considered for a DMDD diagnosis in accordance with DSM-5 criteria, children must present symptoms before the age of 10, but should not be diagnosed before the age of 6 or after age 18. Symptoms—which must be present for at least one year prior to diagnosis—include the following:

• Three or more severe temper tantrums a week that are inappropriate for the situation and the child’s age.

• Persistent irritability or angry moods between tantrums without sustained periods of relief.

• No evidence of mania or hypomania.

According to Leibenluft, some symptoms of DMDD overlap with other mental disorders, in particular oppositional defiant disorder (ODD).

“Usually you want some kind of distinction between diagnoses,” said Leibenluft, who noted that children with DMDD experience psychiatric symptoms that are just as severe as those with bipolar disorder in terms of impairment, number of medications, and psychiatric hospitalizations. “These are a really sick group of kids. The feeling was that even though DMDD is not that distinct from ODD, symptoms for DMDD were severe enough for the disorder to have its own standalone diagnosis.”

Other psychiatric disorders that are commonly linked to DMDD diagnosis include attention-deficit/hyperactivity disorder (ADHD) and anxiety disorder. Leibenluft said that when symptoms of these comorbid psychiatric diagnoses are present in patients with DMDD, treatment options for DMDD must be carefully selected by physicians.

Although antipsychotic treatment has been used in some children with DMDD, the question remains if antipsychotics should be used as a first-line treatment, she noted.

“If you view the children as having comorbid bipolar disorder, then the answer would be ‘yes,’” Leibenluft answered. “If you view the child as having comorbid ADHD, then you may want to put them on a treatment with a stimulant,” she added. According to Leibenluft, a fair amount of literature shows that stimulant use in children with ADHD with severe irritability does help decrease irritability.

“At this point, we do not have sufficient data from clinical trials on treatments for DMDD yet. But drawing on the literature, comorbidities, and clinical presentations in these children, doctors can receive some form of guidance for treating patients with DMDD,” Leibenluft concluded. ■