DMDD : What We Know Now

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DMDD History


Disruptive Mood Dysregulation Disorder ( DMDD)  is  a disorder in the depressive disorder domain of the DSM 5. DMDD was originally conceived of as Severed Mood Dysregulation (SMD) and then criteria of hyper arousal was removed at the last minute. This diagnosis was introduced due to over diagnosis of Bipolar Disorder in youth but in many cases has created more confusion. The diagnosis  is controversial because it lacks valid empirical studies and has an absence of guidelines for medical treatment.Some have gone so far as to express alarm that children may be falsely diagnosed with a mental health condition when they don’t have one. This is concerning especially if these children are prescribed medication.  In response to mounting evidence, the  ICD 11 will have DMDD as a diagnostic specifier of Oppostional Defiant Disorder. It will no longer be a separate diagnosis or a disorder under the depressive disorder domain.

 


DMDD and Co Morbid Disorders

DMDD  co occurs with ADHD, autism spectrum disorder, and anxiety. Your child cannot carry a diagnosis of intermittent explosive disorder, oppositional defiant disorder, or bipolar disorder if they have DMDD. If your child has major depressive disorder, the symptoms they are displaying of DMDD must be present before the major depressive disorder, and after the major depressive disorder.


DMDD Criteria

  • Severe, recurrent temper outbursts out of proportion to the  situation.
  • Outbursts are inconsistent with the developmental level
  • Three or more times a week
  • Mood is irritable or angry most of the day nearly every day and observed by others
  • 12 or more months without a symptom free interval of more than three months
  • Symptoms are present across at least two settings and severe in at least one setting
  • Age is before 10 years old
  • Diagnosis is not made before 6 or after 18
  • Full symptom criteria for mania or hypomania is not has never been met for longer than a day
  • Behaviors do not occur exclusively during the episode of major depressive disorder and are not better explained by another disorder
  • Symptoms are not due to a medical neurological or substance

What about DMDD and Bipolar Disorder?


It’s important to note that your child who has DMDD may not be diagnosed correctly. If they are not, these facts are not relevant.

Much has been speculate about the relationship between DMDD and Bipolar disorder. Its important to note that the chronic irritability that is required for the diagnosis of DMDD has not been found to be a predictor of bipolar disorder. The chronic irritability seen in  DMDD is related to behavioral problems in early adolescence  and later generalized anxiety As a child becomes an adult it seems to be related to  unipolar depression.

Episodic irritability has been linked to later bipolar disorder.

What else  we know about the difference between Bipolar disorder and DMDD?

We know that the neural circuits responsible for attention deficits seem different between  (DMDD) and Bipolar disorder.

In DMDD the circuits seem show a deficiency in bottom up attention processing. In bipolar disorder the deficiency is primarily one that is in executive functioning and is top down. Also, studies show different neural pathways to negative affect  in DMDD versus bipolar disorder.

Inability to read emotional cues

In children who have DMDD they demonstrate hyperarousal when they find stimuli frustrating. Both children who have bipolar disorder and DMDD show a dysfunction in emotional processing that is related to reading aggression in neutral responses. It appears that fear is triggered because facial expressions can’t help them identify emotions in others. This difficulty has been identified to be worse in those with DMDD. They show abnormal amygdala activation when performing facial recognition tasks. Bipolar disordered patients seem to primarily have difficulty only  when shown fearful facial patterns.

 

Other DMDD Facts

What are some of the characteristics that youth with DMDD have in common?

These youth are more likely to:

  •  have self-injurious behaviors and suicidal ideation
  •  have higher rates of STDs
  •  have regular smoking habits
  •  engage in illegal or risky behaviors
  •  come in contact with the police
  • illegally break into buildings and to become involved in physical fights physical fighting

 

Social risk factors for DMDD

These youth are more likely to:

  • Come from disadvantaged families
  • Have divorced parents
  • Be dismissed from work
  • Have difficulties keeping a job

Risk factors for DMDD

  • Children born with mothers impacted by peripartum depression had higher rates of DMDD
  • Paternal depression and substance use are risk factors for worse symptoms of irritability
  • One or both parents not living with the child
  • One or both parents did not graduate
  • Early trauma, grief, divorce, malnutrition, vitamin deficiencies
  • Offspring of the depressed are more likely to have DMDD
  • Hypothesized that offspring of bipolar disorder  more likely to be diagnosed by not confirmed

 

Medications for DMDD

In the past, the fear was that antidepressants and stimulants would cause mania, but the belief is now that psychostimulants, antidepressants, SSRIs and SNRIs are good for treating chronic irritability.

Other drugs with a good outcome on irritability and depression are atypical antipsychotics and if ADHD is present methylphenidate. In some cases, clonidine, guanfacine, lithium, and anticonvulsants are used.

Treatments for DMDD

Behavioral Therapy, Parent Training, and DBT- C are currently recommended treatments.

Behavioral therapies teach children different methods of responding to situations more positively and this would involve parents. Parent training would teach parents ways to examine and explore their behaviors to facilitate more positive responses.

Therapy that is effective with emotional regulation and oppositional defiant disorder would likely also be effective with children categorized as ODD.

What is DBT C? It is a special form of DBT for children It consists of:

  •  individual therapy
  •  telephone coaching calls
  •  therapist team consultation
  •  parent training

One randomized control trial found DBT C for the treatment of DMDD is a successful treatment. This makes sense because emotional dysregulation is a feature of DMDD and DBT targets this deficit. 43 children 7-12 were randomly assigned to DBT-C or Treatment as usual (TAU. All were stable on meds for 6 weeks and could be treated, outpatient. They were assessed by blinded raters and after 8, 16, 2 and 3 months follow up. The Clinical Global Impression Improvement scale was used focusing on improvement in behavior outbursts and angry irritable mood.

The results of this study showed treatment satisfaction was significantly higher in the DBT-C group with 90.4 participants satisfied compared to 36 in the other group.


References

Bruno, A., Celebre, L., Torre, G., Pandolfo, G., Mento, C., Cedro, C., Zoccali, R., & Muscatello, M. (2019). Focus on Disruptive Mood Dysregulation Disorder: A review of the literature. Psychiatry Research, 279, 323-330.

Eshel, N., & Leibenluft, E. (2020). New Frontiers in Irritability Research—From Cradle to Grave and Bench to Bedside. JAMA Psychiatry, 77(3),

Knopf, A. (2017). DBT found effective for children with DMDD. The Brown University Child and Adolescent Behavior Letter, 33(11), 3-4.


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