User:Psyched 2024/Disruptive mood dysregulation disorder

DSM-V Diagnostic Criteria
According to the DSM-V, there are multiple criteria that must be met. Criteria A requires severe and recurrent outburts that manifest as verbal and/or behavioral rage that are grossly out of proportion (by intensity or duriation) to the situation. Citeria B requires that the temper outburst be inconsistent with the child's developmental level while Criteria C requires that the outburts occur 3 or more times per week, on average. Criteria D states that the mood between the outburst is also persistently irritable or angry most of the day and nearly every day. Criteria E states that Criteria A-D must have been present for 12 or more months without a period of 3 or more consecutive months where there were no symptoms. Similarly, Criteria F states that Criteria A and D should be present in at least 2 of 3 settings (home, school, peers) and at least 1 setting should have severe symptoms. Criteria G states that DMDD should not be diagnosed before 6 years of age or after 18 years of age for the first time while Criteria H states that Criteria A-E should be seen in the patient's history before 10 years of age. Criteria I states that there should never have been a period of more than 1 day where symptoms for mania or hypomania are met (except duration), but this excludes moments of mood elevation due to a very positive experience or upcoming event. Criteria J similarly states that these behaviors should not exclusively occur during major depressive disorder (MDD) episodes and are not better explained by another mental disorder. Of note, DMDD cannot co-exist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder but can co-exist with major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders. Lastly, Criteria K states that symptoms cannot be caused by the effects of substance use, another medical condition, or another neurological condition.

Comorbidities
The core features of DMDD—temper outbursts and chronic irritability—are sometimes seen in children and adolescents with other psychiatric conditions. Differentiating DMDD from these other conditions can be difficult. Three disorders that most closely resemble DMDD are attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and bipolar disorder in children.

ADHD
Attention deficit hyperactivity disorder (ADHD) is a neurodevelopmental disorder characterized by problems with inattention and/or hyperactivity-impulsivity. ADHD is characterized by inattention, hyperactivity, and impulsivity that are pervasive, impairing in multiple contexts, and age-inappropriate. ADHD also associated with impaired executive functioning, structural and functional abnormalities in brain parts, such as frontal-striatal, with specific gene mutation.

ODD
ODD is a disruptive behavior disorder characterized by oppositional, defiant, and sometimes hostile actions directed towards others. The DSM-5 considers DMDD a severe manifestation of symptoms associated with ODD. A diagnosis of both DMDD and ODD is not permitted or necessary; individuals who meet the diagnostic requirements for DMDD also meet the requirements for ODD.

Bipolar disorder
One of the main differences between DMDD and bipolar disorder is that the irritability and anger outbursts associated with DMDD are not episodic; symptoms of DMDD are chronic and displayed constantly on an almost daily basis. On the other hand, bipolar disorder is characterized by distinct manic or hypomanic episodes usually lasting a few days, or a few weeks at most, that parents should be able to differentiate from their child's typical mood and behavior in between episodes. The DSM precludes a dual diagnosis of DMDD and bipolar disorder. Bipolar disorder alone should be used for youths who show classic symptoms of episodic mania or hypomania.

Prior to adolescence, DMDD is much more common than bipolar disorder. Most children with DMDD see a decrease in symptoms as they enter adulthood, whereas individuals with bipolar disorder typically display symptoms for the first time as teenagers and young adults. Children with DMDD are more at risk for developing major depressive disorder or generalized anxiety disorder when they're older rather than bipolar disorder.

Conduct disorder
Conduct disorder is a behavior disorder characterized by repeated, persistent patterns of behavior that violate the rights of others and disregard major societal norms and rules. While both DMDD and conduct disorder are associated with argumentative and defiant behavior, DMDD is distinctly differentiated from conduct disorder by the DSM. Individuals with DMDD experience severe emotional dysregulation not seen in conduct disorder. Additionally, conduct disorder is described by a distinct lack of remorse and repeated physical harm and threats of harm to people and/or animals. Evidence of conduct disorder during childhood is one of the criteria for an adult diagnosis of antisocial personality disorder, however adults with a continued diagnosis of conduct disorder do not necessarily have antisocial personality disorder.

Substance Use Disorders
Substance use disorders (SUD) encompass a broad range of specific diagnoses, but they all generally have the characteristics of cognitive, behavioral, and physiological symptoms that cause someone to continue to use a substance despite significant impairment. One salient feature of SUDs is that they change the brain circuitry in such a way that the changes can persist beyond detoxification. In general, though, examining the comorbidity of SUDs in DMDD is important as it may be linked to self-medication for underlying mood disorders or trauma; however, while there are reports in community and clinical samples of comorbidity for SUDs with DMDD, there has been no formal examination of this link.

Evaluation
Evaluation of DMDD requires that professionals conduct comprehensive psychosocial assessments to differentiate a DMDD diagnosis from other depressive and anxiety disorders, with particular focus on the nature of the irritability that is present. Usually, a professional will use a semistructured interviews to elicit the “irritability” as caused by feelings of anger or crankiness or the child being easily annoyed. In any respect, however, there is difficulty in measuring this "irritability" as no consensus or well-validated scales have been established. In fact, more scales for parents and teachers measure the frequency of outbursts rather than the severity while other scales that capture aggressive behavior rely heavily on forms of physical aggression, which is not required for a DMDD diagnosis. Further, there tends to be a discrepancy in how clinicians interpret the irritability from a diagnostic criterion as well as there being a discrepancy in the reports of "temper outbursts" between parents and professionals.

Differential Diagnosis
Differentiating DMDD from these other conditions can be difficult. A few disorders that closely resemble DMDD, including attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), anxiety disorders, and childhood bipolar disorder, intermittent explosive disorder, major depressive disorder (MDD), and conduct disorder. ADHD, anxiety disorders, MDD, and conduct disorder were discussed above as they can also be comorbidities of DMDD; however, ODD, intermittent explosive disorder, and bipolar disorder cannot be diagnosed simultaneously in patients with DMDD per Criteria J of the DSM-V.

Oppositional Defiant Disorder
Oppositional defiant disorder (ODD) is a disruptive behavior disorder characterized by oppositional, defiant, and sometimes hostile actions directed towards others, especially those with authority. Though both ODD and DMDD have symptoms of outburst and irritability, they differ in terms of severity, duration, and pervasiveness, with DMDD being more severe, longer and more often in duration, and causing impairment across multiple settings. A diagnosis of both DMDD and ODD is not permitted or necessary; individuals who meet the diagnostic requirements for DMDD also meet the requirements for ODD.

Intermittent Explosive Disorder
IED is a disruptive behavior disorder that is generally characterized by impulsive and aggressive outbursts that are usually rapidly occurring with little to no warning that last for less than 30 minutes due to a minor provocation. People with IED tend to have less severe episodes of verbal and non-destructive physical outbursts between the severe destructive or assaltive outbursts. These outbursts must begin no earlier than the age of 6 years and should occur at least 3 times in a 12-month period. The primary differentiation between IED and DMDD is that, in DMDD, irritability continues persistently between outbursts while in IED, irritability tends to be centered on the outbursts themselves.

Bipolar disorder in children
Since both disorders can cause considerable functional impairment, one of the main differences between DMDD and bipolar disorder is the periodicity of the behavioral symptoms. Both conditions can commonly cause dangerous behavior, suicidal ideation or attempts, severe aggression, and psychiatric hospitalization. The irritability and outbursts in DMDD are chronic and displayed constantly on an almost daily basis. On the other hand, bipolar disorder in children is characterized by distinct manic or hypomanic episodes usually lasting a few days, or a few weeks at most, that usually can be differentiated from baseline behavior. The DSM-V precludes a dual diagnosis of DMDD and bipolar disorder as bipolar disorder in children alone should be used for youths who show classic symptoms of episodic mania or hypomania.

While individuals with bipolar disorder typically display symptoms for the first time as teenagers and young adults, DMDD is usually diagnosed between the ages of 6 and 10. While DMDD is more common than pediatric bipolar disorder prior to adolescents, most children with DMDD see a decrease in symptoms as they enter adulthood. Children with DMDD are more at risk for developing major depressive disorder or generalized anxiety disorder when they are older rather than bipolar disorder.

Treatments
The creation of DMDD as a specific diagnosis in the DSM-V was intended, in large part, to prevent the misdiagnosis of bipolar disorder in children, with hopes of avoiding medication mismanagement in younger mental health patients. Interestingly, recent studies indicate that children diagnosed with DMDD are 12.5% more likely to be prescribed any psychoactive medication, and 7.9% more likely to be prescribed an antipsychotic medication than children diagnosed with bipolar disorder.

At this time, DMDD does not have a standardized treatment course as few treatment studies have been conducted, so, instead, treatment guidelines from other disorders with similar characteristics as DMDD are used. Thus, treatments for DMDD are based on treatments associated with irritability in disorders like SMDD, ODD, bipolar disorder, anxiety, ADHD, MDD, conduct disorder, or general aggressive behavior and include both psychopharmacological and psychotherapy, which appear to work. At this time, the NIMH is funding studies to improve current treatments and find new ones specifically for DMDD.

Psychopharmacology
Generally, it is recommended that children start with psychotherapy first, though in some instances psychotherapy with psychopharmacology is prescribed as first line treatment. Recent trends have shifted toward prescription of antidepressants, specifically selective serotonin reuptake inhibitors (SSRIs), and psychostimulants (such as methylphenidate) for patients with DMDD. Of note, these medications are theoretically better suited for patients with DMDD than those diagnosed with bipolar disorder, as antidepressants and stimulants may risk triggering more labile moods or manic episodes in patients with bipolar disorder. Stimulant and antidepressant medications are prescribed both for their treatment of DMDD symptoms and in cases of comorbid ADHD and depressive disorders. Atypical antipsychotics that are especially efficatious with irritability, specifically risperidone and aripiprazole, are another primary intervention for children with DMDD, prescribed in as much as 58.9% of DMDD patients age 10–17. Risperidone, specifically, has been shown to have a strong effect on aggressive behavior. On the other hand, lithium, an anti-manic medication, and anticonvulsant medications, often implicated in the treatment of bipolar disorder, show moderate reduction of aggression in hospitalized children with conduct disorder, and are often prescribed to children with DMDD based on this history. A medication that is both anti-manic and anticonvulsant, divalproic acid, has shown limited support for treating the mood dysregulation seen in DMDD. On the other hand, some research has found that lithium has not been shown to outperform a placebo in alleviating the signs and symptoms of DMDD.

Without specific FDA approval for any drug to treat DMDD, there is variability in the treatments of DMDD due to the limited data on DMDD and the selection of treatments based on other mental or emotional disorders. Overall, the high comorbidity of DMDD makes treatments complicated, and usually a combination of psychopharmacology and psychosocial therapeutic interventions are required.

History and Epi
DMDD is a newly classified disorder, first appearing in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) in 2013. The DSM is used for the assessment and diagnosis of mental disorders; it does not include specific guidelines for the treatment of any disorder.

Researchers at the National Institute of Mental Health (NIMH) developed the DMDD diagnosis to diagnose more accurately youth who may have been previously diagnosed with pediatric bipolar disorder (despite not experiencing the symptoms needed for a diagnosis of bipolar disorder).

By 2018, the rate of clinical diagnosis for DMDD became more prevalent than the rate of diagnosis for bipolar disorder in children ages 10–17 years old. From 2013 to 2018, the rate of bipolar diagnosis in this age range decreased significantly, indicating that many children who would have been diagnosed with bipolar disorder prior to 2013 are now being diagnosed with DMDD.

The DSM-5 includes several additional diagnostic criteria which describe the duration, setting, and onset of the disorder: the outbursts must be present for at least 12 months and occur in at least two settings (e.g. home and school), and it must be severe in at least one setting. Symptoms appear before the age of 10, and diagnosis must be made between ages 6 and 18.