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Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is a childhood mental disorder involving chronic, non-episodic 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor.

Last updated: Mar 1, 2022

Editorial responsibility: Stanley Oiseth, Lindsay Jones, Evelin Maza

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 Angry mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder
  •  Frequent temper outbursts disproportionate to the situation

Epidemiology

  • Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: approximately 3% among children 9–19 years of age
  • Higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in boys than girls (3:1)

Etiology

  • Poorly understood 
  • May include biological as well as psychosocial factors
  • Structural brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification changes:
    • Lower activity of the amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy → plays a role in the interpretation and expression of emotions
    • Increased activity of the medial frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy gyrus and anterior cingulate cortex → plays a role in evaluating and processing negative emotions

Diagnosis

Clinical 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 Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy (CBT) is a commonly used form of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy to teach coping and anger management Anger management System of psychological and/or therapeutic techniques used to control and or reduce the triggers, degrees, and effects of anger. Oppositional Defiant Disorder skills to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
  • Parent training:
    • A method to help parents interact with the child and reduce trigger-causing outbursts 
    • More appropriate for younger patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship

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 symptoms Pharmacological agents
Depressive mood, irritability, anxiety Anxiety Feelings or emotions of dread, apprehension, and impending disaster but not disabling as with anxiety disorders. Generalized Anxiety Disorder Selective serotonin reuptake inhibitors Selective Serotonin Reuptake Inhibitors Serotonin Reuptake Inhibitors and Similar Antidepressants (e.g., fluoxetine Fluoxetine The first highly specific serotonin uptake inhibitor. It is used as an antidepressant and often has a more acceptable side-effects profile than traditional antidepressants. Serotonin Reuptake Inhibitors and Similar Antidepressants)
Severe aggression Aggression Behavior which may be manifested by destructive and attacking action which is verbal or physical, by covert attitudes of hostility or by obstructionism. Oppositional Defiant Disorder 2nd-generation antipsychotics (e.g., risperidone Risperidone A selective blocker of dopamine D2 receptors and serotonin 5-HT2 receptors that acts as an atypical antipsychotic agent. It has been shown to improve both positive and negative symptoms in the treatment of schizophrenia. Second-Generation Antipsychotics)
Impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder, inattention Inattention Attention Deficit Hyperactivity Disorder Stimulants Stimulants Stimulants are used by the general public to increase alertness and energy, decrease fatigue, and promote mental focus. Stimulants have medical uses for individuals with ADHD and sleep disorders, and are also used in combination with analgesics in pain management. Stimulants (e.g., methylphenidate Methylphenidate A central nervous system stimulant used most commonly in the treatment of attention deficit disorder in children and for narcolepsy. Its mechanisms appear to be similar to those of dextroamphetamine. Stimulants) or nonstimulants (e.g., guanfacine)

Differential Diagnosis

  • Bipolar Bipolar Nervous System: Histology disorder: a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (e.g., distractibility, impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, increased activity, decreased sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of 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 Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of bipolar Bipolar Nervous System: Histology disorder. Disruptive mood dysregulation disorder can be distinguished from bipolar Bipolar Nervous System: Histology disorder: unlike bipolar Bipolar Nervous System: Histology disorder, the irritability in DMDD is persistent and does not occur in episodes.
  • Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder (ODD): a continuous pattern of angry/ irritable mood Irritable mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder, argumentative/ defiant behavior Defiant behavior Oppositional Defiant Disorder, or vindictiveness Vindictiveness Oppositional Defiant Disorder for at least 6 months. Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. 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 Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder ( IED IED Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder): an impulse-control disorder characterized by abrupt episodes of recurrent, severe, and angry outbursts with a normal mood maintained between episodes. Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder lasts > 3 months. As opposed to persistent irritability in DMDD, the presence of a period with a normal mood in IED IED Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder differentiates the conditions.
  • Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder: a mental disorder in the pediatric population. Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder includes recurrent behavior of exhibiting noncompliance Noncompliance Clinician–Patient Relationship 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 Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder, the presentation Presentation The position or orientation of the fetus at near term or during obstetric labor, determined by its relation to the spine of the mother and the birth canal. The normal position is a vertical, cephalic presentation with the fetal vertex flexed on the neck. Normal and Abnormal Labor of DMDD is less severe in nature and does not involve aggressive behavior toward people/ animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, destruction of property, theft, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).
Table: DMDD compared to differential diagnoses
Disorder Main differentiating criteria Age of onset Duration
DMDD Patient is angry all the time with frequent outbursts. Typically 6–10 years of age > 12 months
Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder Recurrent, severe, anger outbursts with a normal mood between outbursts Adolescence to adulthood
  • > 3 months without symptoms
  • > 12 months with symptoms
Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder Childhood or adolescence > 6 months
ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder Limited attention Attention Focusing on certain aspects of current experience to the exclusion of others. It is the act of heeding or taking notice or concentrating. Psychiatric Assessment and/or hyperactivity Hyperactivity Attention Deficit Hyperactivity Disorder symptoms in 2 different settings < 12 years of age > 6 months
Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder Involves aggressive behavior toward people/ animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, destruction of property, or theft Childhood or adolescence > 1 year
DMDD: disruptive mood dysregulation disorder
ADHD ADHD Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. Attention Deficit Hyperactivity Disorder: attention deficit hyperactivity disorder Attention Deficit Hyperactivity Disorder Attention deficit hyperactivity disorder is a neurodevelopmental disorder characterized by a pattern of inattention and/or hyperactivity-impulsivity that occurs in at least 2 different settings for more than 6 months. Although the patient has normal intelligence, the disease causes functional decline. 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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