Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic negative mood, irritability, and severe, recurrent temperamental outbursts. Age of onset is prior to 10 years old and a typical feature is perpetual feelings of anger and irritability, even between outbursts. Disproportionate verbal or physical outbursts may be present. Treatment involves cognitive-behavioral interventions and medications to target the symptoms of presentation.

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Overview

Definition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children with an age of onset < 10 years old and characterized by:

  •  Persistent irritability or angry mood
  •  Frequent temper outbursts disproportionate to the situation

Epidemiology

  • DMDD is a new inclusion in the latest DSM. 
  • Lifetime prevalence: approximately 3% among children 9–19 years of age
  • Higher prevalence in boys than girls (3:1)

Etiology

  • Poorly understood 
  • May include biological as well as psychosocial factors
  • Structural brain changes:
    • Lower activity of the amygdala → plays a role in the interpretation and expression of emotions
    • Increased activity of the medial frontal gyrus and anterior cingulate cortex → plays a role in evaluating and processing negative emotions

Diagnosis

DSM-V diagnostic criteria:

  • Severe, recurrent anger outbursts (verbal or behavioral)
  • Outbursts are not appropriate for the age of the patient.
  • Outbursts occur at least 3x per week in 2 different settings.
  • The child is always angry or irritable between outbursts.
  • Onset: 6–10 years of age
  • Duration: 12 months (asymptomatic periods do not last > 3 months)
  • Exclude other mental disorders or substance use.

Management

Psychosocial therapy

Psychosocial therapy should be the main pillar of treatment for DMDD.

  • Cognitive behavioral therapy (CBT) is a commonly used form of psychotherapy to teach coping and anger management skills to patients.
  • Parent training:
    • A method to help parents interact with the child and reduce trigger-causing outbursts 
    • More appropriate for younger patients

Medication

  • Because the diagnosis is relatively new, a 1st-line drug is not yet available.
  • Medications are recommended if the disorder is associated with other diseases or symptoms.
Table: Pharmacotherapy for different target symptoms in DMDD
Target symptomsPharmacological agents
Depressive mood, irritability, anxietySelective serotonin reuptake inhibitors (e.g., fluoxetine)
Severe aggression2nd-generation antipsychotics (e.g., risperidone)
Impulsivity, hyperactivity, inattentionStimulants (e.g., methylphenidate) or nonstimulants (e.g., guanfacine)

Differential Diagnosis

  • Bipolar disorder: a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (e.g., distractibility, impulsivity, increased activity, decreased sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. Some clinicians theorize the chronic and persistent nature of disturbed mood and irritability in DMDD may be an early presentation of bipolar disorder. Disruptive mood dysregulation disorder can be distinguished from bipolar disorder: unlike bipolar disorder, the irritability in DMDD is persistent and does not occur in episodes.
  • Oppositional defiant disorder (ODD): a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness for at least 6 months. Oppositional defiant disorder includes symptoms of defiance and annoyance not present in DMDD. The diagnosis of DMDD is based on irritable outbursts manifesting in multiple settings, which is not a requirement for the diagnosis of ODD. 
  • Intermittent explosive disorder (IED): an impulse-control disorder characterized by abrupt episodes of recurrent, severe, and angry outbursts with a normal mood maintained between episodes. Intermittent explosive disorder lasts > 3 months. As opposed to persistent irritability in DMDD, the presence of a period with a normal mood in IED differentiates the conditions.
  • Conduct disorder: a mental disorder in the pediatric population. Conduct disorder includes recurrent behavior of exhibiting noncompliance for the basic rights of others or societal norms > 1 year. Examples of behaviors include violation, destruction, theft, lying, and severe defiance of rules. Compared to conduct disorder, the presentation of DMDD is less severe in nature and does not involve aggressive behavior toward people/animals, destruction of property, theft, etc.
Table: DMDD compared to differential diagnoses
DisorderMain differentiating criteriaAge of onsetDuration
DMDDPatient is angry all the time with frequent outbursts.Typically 6–10 years of age> 12 months
Intermittent explosive disorderRecurrent, severe, anger outbursts with a normal mood between outburstsAdolescence to adulthood
  • > 3 months without symptoms
  • > 12 months with symptoms
Oppositional defiant disorder
  • Angry or irritable mood, argumentative behavior, and vindictiveness directed at adults or other authoritative figures
  • Does not involve aggressive behavior toward people/animals, destruction of property, or theft
Childhood or adolescence> 6 months
ADHDLimited attention and/or hyperactivity symptoms in 2 different settings< 12 years of age> 6 months
Conduct disorderInvolves aggressive behavior toward people/animals, destruction of property, or theftChildhood or adolescence> 1 year
DMDD: disruptive mood dysregulation disorder
ADHD: attention deficit hyperactivity disorder

References

  1. Roy, A.K., Lopes, V., Klein, R.G. (2014). Disruptive mood dysregulation disorder: A new diagnostic approach to chronic irritability in youth. The American Journal of Psychiatry, 171(9), 918–924. https://doi.org/10.1176/appi.ajp.2014.13101301
  2. Sadock, B.J., Sadock, V.A., Ruiz, P. (2014). Kaplan and Sadock’s synopsis of psychiatry: Behavioral sciences/clinical psychiatry (11th ed.). Chapter 31, Child Psychiatry, 1242–1244. Philadelphia, PA: Lippincott Williams and Wilkins.
  3. Meyers, E., DeSerisy, M., Roy, A.K. (2017). Disruptive mood dysregulation disorder (DMDD): An RDoC perspective. Journal of Affective Disorders, 216, 117–122. https://doi.org/10.1016/j.jad.2016.08.007

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