Jared’s school and Mom have left me 10 messages combined — all before lunchtime. He has been suspended from school — where he is in a self-contained classroom — for the sixth time this year. He was asked to do a math assignment — which he refused. Encouraged by the teacher to try it, he shouted back at her, “Why are you always doing this to me?!” His aide stepped in closer to him, and she and teacher told Jared that he had to calm down. Instantaneously, Jared exploded, throwing a book and a pencil across the room. He pushed the aide to get to a chair and then he tipped the chair over. The teachers removed the other children, called the crisis group, and then called Jared’s mom. (Details have been changed to protect patient privacy.)
I am treating Jared for Disruptive Mood Dysregulation Disorder (DMDD) — a diagnosis that was unavailable prior to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM 5) being published in 2013.
DMDD Symptoms
According to the DSM 5, DMDD is characterized by a pattern of “severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocations.” The diagnosis requires that the outbursts occur, on average, three or more times per week. The mood in between episodes must be persistently irritable or angry most of the day, nearly every day, and be observable by others. Symptoms must persist steadily for at least 12 months and in at least two of the following three settings — home, school, peers.
DMDD was added to the DSM 5 to try to capture the many children whose primary emotional/behavioral difficulties are related to frequent and severe “meltdowns” in response to minor triggers. They struggle to regulate their emotional and behavioral responses demands or stimuli. While all children are developing these skills over time, these children’s emotional and behavioral modulating systems are not developing the same way as their peers. They can’t self-soothe or de-escalate effectively when their emotional “circuits” light up.
Frequent and severe tantrums, along with irritable mood are some of the most common reasons children are referred to child psychiatrists. The symptoms disrupt their lives and interfere with their development. And yet tantrums and irritability are not specific to any particular psychiatric diagnosis. These patterns can be seen in depression, anxiety, bipolar disorder, borderline personality disorder, attention deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder (OCD), trauma, and autism spectrum disorder — just to name a few.
I think of these symptoms as a “final common pathway” for many different psychiatric and neurodevelopmental conditions. Just as a cough is a “final common pathway” for many conditions such as asthma, pneumonia, influenza, bronchitis, emphysema, and many more. The symptoms tell us broadly that something is wrong and we need to start looking — but they aren’t themselves a diagnosis.
Differentiating Moody from Manic
When kids have emotional reactivity and dysregulation, they are often referred to as “moody” — or as “having mood swings.” This characterization of these children led to a decade’s long debate among child psychiatrists as to whether or not irritability and dysregulation were childhood expressions of mania — which would mean that these children would be diagnosed with bipolar disorder. This has been an energetic discussion in my field, because trying to help these children and their families is so much of what we do. Calling these kids “bipolar” seemed to capture something about them, and gave some diagnostic clarity — at least initially.
Unfortunately, this thinking led to a massive increase in the number of children diagnosed with bipolar disorder. It became clearer over time that while many adults with bipolar disorder had emotional dysregulation and irritability as children (and continue to have them in adulthood), most children with emotional dysregulation and irritability did not eventually develop bipolar disorder. Those children often develop depression and anxiety, and a variety of other psychiatric illnesses, but only a small percentage develop bipolar disorder.
In the DSM 5, the bipolar type 1 diagnosis requires at least one manic episode. The symptoms include elevated or irritable mood, high energy with a decreased need for sleep, big and grandiose ideas about themselves and about what they are thinking and doing, increased levels of activity, decreased judgment and increased impulsivity, rapid speech and racing thoughts, and sometimes psychosis. Most importantly these symptoms must occur in an episode that looks significantly different than the person’s baseline — everyone can see it — and it lasts a minimum of seven days (shorter only if it results in an inpatient hospitalization). Bipolar type 2 requires an episode of hypomania — which includes some similar symptoms to mania but much less severe. Hypomania must last four days and must also be a change from baseline.
DMDD, on the other hand, presents with chronic irritability and regular, frequent, and severe outbursts. There is not a sustained change in mood, energy, thinking, or activity — except during the outburst itself. These occurrences are part of the child’s baseline; they happen all the time. This is moodiness on a scale of minutes to hours rather than days. The diagnosis of DMDD is not made if other conditions can be identified as the primary cause of the outbursts — such as depression, PTSD, autism spectrum disorder, separation anxiety disorder, or obsessive compulsive disorder — and many others. However, if there are major dysregulation patterns not explained by the other disorders, these diagnoses can go together. For example if a child has separation anxiety disorder, but their outbursts don’t occur only in the context of separation from a caregiver, they could receive both diagnoses.
DMDD overlaps significantly with the diagnosis of oppositional defiant disorder (ODD). If symptoms of both are present, then only the DMDD diagnosis is used. (I almost never use the diagnosis of oppositional defiant disorder — and that is another blog post for another day.) If a child or adolescent develops full blown symptoms for mania or hypomania, then the bipolar diagnosis steps in and DMDD is not used.
It is notable that many — if not all — children with a DMDD diagnosis also have ADHD. While many children with ADHD have short fuses, DMDD is at another level in terms of mood responses. And while kids with ADHD may be impulsive all the time, impulsivity during an emotional/behavioral outburst is not quite the same. When someone is in the midst of a rage or meltdown, they say and do things that they wouldn’t do if they were thinking clearly. Emotions have hijacked their impulse control. This is the same with children during their dysregulation episodes.
A Developing Story
The DMDD diagnosis was developed and put into DSM 5 in an effort to capture children with significant emotional dysregulation — chronic mood outbursts and irritability – who don’t meet criteria for a manic episode. The concept of irritability as an important symptom on its own — different from sadness or fear or mania — is becoming more well-developed by child psychiatry researchers. It is not a diagnosis — recall the cough discussed earlier in this post. But it is a symptom that we need to observe and find out more about when we see it.
There is a growing body of research using brain imaging — functional MRIs — to understand what happens in the brains of children with high levels of irritability compared to control children with more typical levels of irritability. For example, an interesting finding is that the brains of children with high irritability levels seem to respond differently to perceived threats in the environment. Some researchers are looking at differences in brain responses between DMDD and bipolar disorder. This area of research is just beginning, so we don’t know what we will ultimately find. But understanding these phenomena at the level of the brain and central nervous system can help us begin to develop targeted psychotherapies and other approaches to treating and helping these children and their families.
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