Disruptive Mood Dysregulation Disorder: Where Did It Come from and Where Is It Going

Abstract

The possibility of a specific subtype of childhood mania had been discussed for many years (Carlson and Glovinsky 2009). Biederman et al. most clearly articulated this position when they stated “…the most common mood disturbance in manic children is severe irritability, with ‘affective storms’ or prolonged and aggressive temper outbursts. The type of irritability observed in manic children is very severe, persistent, and often violent. The outbursts often include threatening or attacking behavior toward family members, other children, adults, and teachers. In between outbursts, these children are described as persistently irritable or angry in mood” (Biederman et al. 2000). This conceptualization of bipolar disorder (BP), where criteria for mania are apparently met, generated a good deal of excitement and hope that a solution had been found for a complex set of childhood behaviors, namely irritability and explosiveness.

The counterpoint, nicely articulated by Klein et al. in a point/counterpoint with Biederman et al. (1998), stated “the clinical descriptions of mania have been remarkably consistent over the years, if not centuries, consisting of a distinct episode of elevated mood or irritability, with well established associate features…usually interspersed with episodes of major depression. No diagnostic criteria have ever been proposed for stable, continuous mania.”

After the NIMH conference on BP in 2000 (NIMH Roundtable 2001), which highlighted these divergent viewpoints, Leibenluft et al. (2003) decided to operationalize the two apparently contrasting descriptions of mania and validate them as similar or different. Note, however, that principal feature of “prepubertal mania” is a “prolonged and aggressive temper outburst,” is not a “business as usual” temper tantrum or a frequent snit or loss of temper. It is a volcanic severe outburst. Severe mood dysregulation (SMD) was a condition designed to capture this behavior in the context of severe irritability as the sustained mood in the context of which the explosions occur. Mania in children became controversial, in part, because investigators interpreted and operationalized the criteria differently (see Carlson and Klein 2014 for review). An important question for the future of disruptive mood dysregulation disorder (DMDD), the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) (American Psychiatric Association 2013) version of SMD, is how can we prevent this from happening again.

The series of 10 articles in this special issue highlights some of the methodological problems of understanding studies that examine DMDD entity using data that had not been gathered with DMDD in mind.

The first article is a chart review from three clinics in Turkey. Tufan et al. (this issue) have capitalized on the use of standardized rating scales to screen many charts. They then used chart narratives to further identify children with DMDD, as well as to determine rater agreement. We are provided with an actual case which is helpful. Unlike other conditions in child psychiatry where criteria were derived from an abundance of clinical cases and information, DMDD originated as a set of criteria and clinicians are now looking for the children. The authors found that although consensus was fairly high, there was most disagreement about whether irritable mood existed between episodes.

All but one of the articles submitted to this special issue “retrofitted” (to use Dr. Fristad's term) DMDD criteria to existing data sets and samples to help us understand the frequency, phenomenology, and possible treatment of DMDD. As can be seen from Table 1, almost all of the submissions defined irritability in terms of cranky, irritable, angry, and annoyed easily or “often loses temper”. In most cases, the items were taken from the oppositional defiant disorder (ODD) section of the Schedule for Affective Disorders and Schizophrenia, Childhood Version (KSADS) (Kaufman et al. 1997) or the depression section of the Preschool Age Psychiatric Assessment (PAPA) (Egger et al. 2006) or WASH U KSADS (Geller et al. 1996). In two studies that used rating scales, the word “irritability” was used in the scale. However, in none of the assessments was it possible to rate whether the irritable mood prevailed between outbursts.

Table 1.

Irritability and Outburst Definitions used by Authors in this Volume

	Author	Irritability definition	Outburst definition	Sample	Findings
1	Tufan	Conners parent rating scale: “is cranky or sullen”; “quick to fight and anger”	Descriptions in clinic records Case example given	403 charts reviewed from three clinics in Turkey; n = 36 had “DMDD”	Consensus not reached in 1/4 of cases; no agreement on irritability between outbursts; 69.4% had ADHD, 47.2% had ODD; 30.6% had ADHD+ODD
2	Mayes	Pediatric behavior scale-parent checklist items—irritable; gets angry or annoyed easily	Pediatric behavior scale-parent checklist items—loss of temper/has temper tantrums	Community sample N = 665 children ages 6–12	9.2% had “DMDD” of whom 92% had ODD; 3% with conditions other than ODD exhibited DMDD symptoms (vs. 66% of children with ODD). Only one child had “DMDD” symptoms in isolation
3a	Carlson	Depression section of the PAPA A (Eggers et al.); “annoyed, irritated, cranky, lose temper”	Follow up of “temper loss” question-did it result in a tantrum; what kind; how often	Community sample of 6 year olds N = 462	92 children (19.2%) lost their tempers at least 3×/week; only 40 (8.7% of sample) had actual tantrums with irritability T scores: attention problems 56.0, anxiety/depression 55.2, aggression 60.3. Dysregulation profile 10.3%
3b	Carlson	CASI IV-irritable “often/very often” from depression section	Outburst description/severity frequency from irritability inventory	University outpatient clinic sample N = 229 6 year olds; 15% nonwhite	N = 114 very often lost temper; n = 25 had severe tantrums and irritability (10.9% of sample); T scores from CBCL: attention problems 74.4; anxiety/depression 64.5; aggression 72.5; dysregulation profile 45.8%
4	Kessel	Depression section of the PAPA A (Eggers et al.); “annoyed, irritated, cranky, lose temper”	Follow up of “temper loss” question-did it result in a tantrum; what kind; how often	Community sample of 9 year olds N = 373	“DMDD” symptoms at age 3 predicted reward sensitivity at age 9 using event related potential and a monetary task
5	Althoff	Parent questionnaire-“often loses temper; fights with others”	CIDI—intermittent explosive disorder items with frequency	Community sample N = 6483 teens	5.26% met “broad criteria” for “DMDD”; all had met criteria and/or been treated for something else; only 0.12% had full “DMDD” criteria
6	Freeman	KSADS-ODD module-easily annoyed; angry and resentful	KSADS-ODD module “severe temper outbursts” 2–5×/week	Medicaid clinic sample n = 597 ages 6–18	31% had “DMDD” CBCL T scores: attention problems 72; anxiety/depression 63; aggression 80
7	Fristad	KSADS-ODD module-easily annoyed; angry and resentful	KSADS-ODD module “severe temper outbursts” 2–5×/week	Longitudinal assessment of manic symptoms sample N = 140 with “DMDD” and n = 77 with BPNOS ages 6–12.9	Groups very similar symptomatically and on most P-GBI endorsements, including irritability. On YMRS interview, the bipolar children were more severe on classic manic symptoms and had more “probable” bipolar family members
8	Mitchell Goldstein	KSADS-ODD module-easily annoyed; angry and resentful	KSADS-ODD module “severe temper outbursts” 2–5×/week	Adolescent tertiary care clinic n = 113 with BP I, II, NOS	27 bipolar teens (25%) had a history of “DMDD”; all had ODD unlike the rest of the bipolar teens where less than 20% had ODD. Functional impairment and family conflict were higher in this group; rates of ADHD were higher
9	Baweja Waxmonsky	Irritability from WASH U KSADS, disruptive behavior disorders structured parent interview and mood severity index	Disruptive behavior disorders structured parent interview-triggers, frequency, duration of outbursts	N = 41 children aged 6–12 with SMD and ADHD combined type who had CNS stimulant optimized in open medication trial	Over 6 weeks, 2 of 3 mood indicators improved but effect size was small (0.26–0.29). Significant but small to medium effects for ADHD and ODD symptoms; no association with CNS stimulants and worsening in mood or behavior
10	Blader	Ratings indicating at least “most of the time” on negative mood items from the emotion regulation checklist and CDRS	Retrospective modified overt aggression scale	N = 156 children aged 6–12 with ADHD and aggression in a treatment trial; open stimulant medication lead-in averaging 70 days	Aggressive behavior and periodic rageful outbursts remitted among 51% of whole cohort. Persistent mood symptoms at baseline did not affect the odds that aggressive behavior would remit during treatment. Reductions in symptoms of sustained mood disturbance accompanied reductions in periodic outbursts

ADHD, attention-deficit/hyperactivity disorder; BP, bipolar disorder; CBCL, Child Behavior Checklist; CIDI, Composite International Diagnostic Interview; DMDD, disruptive mood dysregulation disorder; KSADS, Schedule for Affective Disorders and Schizophrenia, Childhood Version; ODD, oppositional defiant disorder; SMD, severe mood dysregulation; PAPA, Preschool Age Psychiatric Assessment; P-GBI, parent General Behavior Inventory; NOS, not otherwise specified; YMRS, Young Mania Rating Scale.

Severe recurrent verbal or physical temper outbursts, grossly out of proportion in intensity or duration to situation or provocation and inconsistent with developmental level, were defined more variably. In three instances, “severe temper outbursts” two to five times per week from the KSADS ODD module were used. The KSADS does not rate duration, severity, or what is done during the outburst. The four studies that use the PAPA (Egger et al. 2006), Composite International Diagnostic Interview (CIDI) (Kessler and Ustün 2004), Irritability Inventory (Carlson et al. this issue), and Retrospective Modified Overt Aggression Scale (RMOAS) (Blader et al. 2009) rating scale get more specific information about the quality and severity of the outburst not just the frequency although there is no indication of the duration of the outburst. The frequency, intensity, and duration of the outbursts are important considerations. Verbal outbursts (e.g., cursing and shouting) for a few minutes three times a week, while unpleasant, have fewer consequences than punching holes in walls, turning over desks, and needing the police called once a week. Although the mania section of the KSADS has a query for explosive anger, the item is not used in these reports and our current semistructured interviews by and large do not allow for that distinction within a single section of an interview. Frequency appears to be the only marker of severity and the only thing measured.

Three different community studies of children aged 6, 6–12, and adolescents examined the frequency of “broad criteria” (i.e., without diagnosis exclusions). In two of three studies, either severe outbursts, that is, actual verbal or physical tantrums were rated (Carlson et al. this issue) or intermittently explosive outbursts (Althoff et al. this issue) were counted. The third study (Mayes et al., this issue) used “loss of temper/has temper tantrums often or very often” and it is not possible to tell which. Among 6 year olds, 8.7% was irritable and not only lost their temper but also had tantrums. This was similar to the rate in 6–12 year olds of 9.2%. Among teens from the National Comorbidity Study of Adolescents (Merikangas et al. 2010), the rate was lower (Althoff et al. this issue), that is, 5.6%.

A 5%–10% community rate of temper loss with outbursts in more than one setting is not trivial, regardless of whether the onset is by age 10 (one of the DMDD criteria). The question is how well do community samples represent what child and adolescent psychiatrists treat in clinical settings. Carlson and colleagues (this issue) address that question by comparing a community and clinical sample of 6 year olds from the same catchment area. Community sample parents said they had irritable children with frequent verbal and physical tantrums. However, their Child Behavior Checklist (CBCL) (Achenbach and Rescorla 2001) scores for anxiety/depression (T 55.2), attention problems (T 56), and aggression (T 60.3) scales were rarely into the generally accepted clinical range although there was impairment. The mean Children's Global Assessment Scale (CGAS) (Shaffer et al. 1983) score was 61.9. Contrast this with the clinical sample where the comparable CBCL scores for anxiety/depression (T64.5), attention problems (T 74.4), and aggression (T 72.5) were a standard deviation higher, and the CGAS score (39.5) was 20 points lower. With a few exceptions, these are not the same children and it is unclear the degree to which findings are interchangeable. Kessel et al. (this issue) report that the symptoms of irritability and temper outbursts in 3 year olds predict abnormalities in reward sensitivity at age 9. While this may explain the depression trajectory seen in children with DMDD in community samples, can the findings be mapped onto a clinical sample with mostly externalizing disorder findings? That is an important question for future research.

Freeman et al. (this issue) report DMDD symptoms in a largely minority, Medicaid clinical sample. The rate of DMDD symptoms was three times higher in these 6–18 year olds (average age 10.4) than in the 6 year olds, judging from the CBCL T scores at least as aggressive if not more so. Normatively, then DMDD symptoms decrease with age. Clinically, rates may increase with age.

An important diagnostic issue is the relationship of DMDD to other disorders. For instance, in virtually all of the samples, the point is made that “DMDD” almost never occurs alone, and ODD is extremely prevalent to the point that some authors conclude that DMDD has little to add to our nosology over and above ODD.

Another concern is the degree to which DMDD provides a better diagnostic home for irritable children with outbursts than BP. Two articles examine these disorders together. Mitchell et al. (this issue) found 27 of 116 adolescents from a tertiary care sample who met criteria for bipolar spectrum disorder, that is, BP I, II, and not otherwise specified (NOS) and had co-occurring DMDD. While this seems like a contradiction since mania is an exclusionary diagnosis, the authors reason that DMDD should be treated like any other comorbidity. It is possible to have DMDD, in other words, and develop an episode of mania, hypomania, or BPNOS. When that occurred, impairment was even worse than what was seen in bipolar spectrum disorder alone. The combination was associated with more family conflict, and not surprisingly, the diagnosis was interchangeable with ODD (i.e., 100% of bipolar/DMDD youth versus only 20% of the bipolar youth without DMDD). The authors' point is that having a diagnosis of DMDD does not preclude the fact that you could develop a manic episode.

The report from Fristad et al. (this issue) compared children with BPNOS to those with DMDD. Their sample comprised 6–12 year olds whose parents endorsed some manic symptoms on the parent General Behavior Inventory (P-GBI-10) (Youngstrom et al. 2008). The samples had similar rates of impairment and irritability and differed along expected lines. A bipolar family history was more likely in those with BPNOS. On the Young Mania Rating Scale (YMRS; Young et al. 1978) ratings (from parent and child interview), children with BPNOS had higher scores than children with DMDD although on parent ratings alone (using the P-GBI only), there were very few differences. Almost all (98%) of the DMDD youth had a disruptive behavior disorder (vs. 53% of the BPNOS sample). Like the Canadian sample, a cohort of children was found to have both DMDD and bipolar spectrum disorder although they were excluded from this study and, like the Canadian study, the authors conclude that distinguishing DMDD from BP is difficult.

Finally, two studies provide some data on treating children with DMDD-related difficulties. Baweja et al. (this issue) recruited children aged 6–12 with either SMD or DMDD to take part in a study, the first step of which is stimulant optimization. They found that stimulants were well tolerated and produced a statistically significant improvement in both attention-deficit/hyperactivity disorder (ADHD) and disruptive mood/ODD symptoms although children continued to be quite symptomatic. They conclude that children with ADHD selected for chronically irritable mood and temper outbursts have more problems, but are not more treatment resistant than youth with ADHD lacking these features. These data are in keeping with prior studies showing that inpatient children with ADHD “manic symptoms” improved significantly, but because they were more symptomatic at the start, improvement did not seem as robust as with “non-manic” ADHD children (Carlson and Kelly 1998). Data from the MTA study examining ADHD children with the CBCL dysregulation profile support this finding as well (Galanter et al. 2003, 2005).

Blader et al. (this issue) also used open stimulant optimization in a treatment trial but reach a different conclusion. Their respondents with ADHD were recruited to have a significant level of aggression derived from the RMOAS (Blader et al. 2009). The authors report that with the remission of aggression, negative mood symptoms also improve. We suspect that in the Blader sample, negative mood accompanied the ADHD symptoms as part of the emotion dysregulation seen in that condition. A similar finding was reported by Fernández de la Cruz et al. (2015) when examining stimulant response to irritability as defined by only ODD symptoms as opposed to the CBCL dysregulation profile (Galanter et al. 2003, 2005).

Taken together, the studies in the journal confirm something that we've recognized for years: children with non-episodic, manic-like symptoms are more impaired and difficult to treat than children with similar conditions without those features. While DMDD may be an old wine in a different bottle, if we pay close attention to consistent definition of its components, define irritability the same way, separate temper loss from temper outbursts, frequency from severity, perhaps the new label will allow us to understand and treat the components more successfully.

Footnotes

Disclosures

No competing financial interests exist.

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