Disruptive mood dysregulation disorder (DMDD) is a new disorder in the DSM-5. Though it exhibits symptoms that are a common feature of other mood and behavioural disorders, there are unique features that are characteristic of DMDD.
DMDD, unlike common symptoms of bad mood, causes affected individuals to exhibit frequent, intense temper outbursts 3 or more times a week. Intervals between outbursts are often occupied with chronic irritability or anger. These behaviours are observed across multiple settings, at home, amongst peers, and with teachers. For a DMDD diagnosis to be made, symptoms should be observed over 12 months.
The symptoms which DMDD shares with some other mood disorders can make its diagnosis appear to be difficult. However, it also means that despite being a newly classified disorder, there are already existing treatment and management therapies that can be employed, allowing children with DMDD to flourish in their development.
Disruptive mood dysregulation disorder (DMDD) is a newly classified disorder affecting young children and adolescents, typically diagnosed between the ages of 6-10 and where symptoms start before age 10. DMDD differs from common symptoms of ‘bad mood’ as affected individuals exhibit developmentally inappropriate temper outbursts, severe irritability, and anger steadily over 12 months. The symptoms of DMDD make it difficult for children who have been diagnosed to maintain healthy relationships to actively participate in social settings or activities. As children mature, the symptoms of DMDD can often manifest into mood disorders such as depression or anxiety. This is why adolescents with DMDD tend to have higher rates of healthcare service use and hospitalisation. As DMDD is a newly classified disorder, there is still a lack of DMDD-specific treatment studies. However, DMDD is a disorder that can be managed by addressing the causes of irritability and providing coping mechanisms through forms of psychotherapy.
Causes of DMDD
The exact causes of DMDD are still subject to further research. However, the best predictive factor associated with a risk of developing DMDD is other family members having the disorder, suggesting that genetics plays a role in its development.
One study identified as ‘The Pittsburgh Bipolar Offspring Study’, found that:
- Children of parents with bipolar disorder (BD) were 8x more likely to meet DMDD criteria than children of parents that did not have BD
- Children of parents with BD were much more likely to display chronic irritability
- Children who met DMDD criteria were more likely to have a parent who suffered from both BD and attention-deficit hyperactivity disorder (ADHD)
- Nearly all of the children of a BD parent who met DMDD criteria also met the criteria for either conduct disorder (CD), oppositional defiant disorder (ODD) and ADHD
This study focused exclusively on the link between parents with BD and their children meeting the DMDD criteria. However, other risk factors include:
- Genetics - A family history of other mood disorders, such as anxiety and depression, increases the risk of DMDD.
- Environment - Children exposed to chaotic home life, with substance abuse, neglect, or inconsistent attention, are also more likely to develop DMDD.
Signs and symptoms of DMDD
Irritability is a common feature of many childhood psychiatric disorders and is a key symptom in bipolar disease (BD), severe mood dysregulation (SMD), oppositional defiant disorder (ODD) and ADHD. However, DMDD was introduced as a new diagnosis to better characterise children with chronic irritability who may be misdiagnosed with BD. The outbursts of DMDD are much more frequent and intense than those of the previously mentioned disorders.
Key symptoms include:
- Severe irritability: Though irritability in childhood is common, severe irritability is characterised by severe/frequent outbursts of frustration to minor triggers. This occurs almost every day.
- Severe temper outbursts: Verbal or behavioural outbursts lasting 1-5 minutes occurring 3 or more times a week that have been ongoing for almost 12 months.
- Functional/social impairment: Symptoms of DMDD can make it difficult to avoid conflict with loved ones, maintain healthy relationships with peers and actively participate in social settings.
- Later manifestations of DMDD: Young adults or adolescents diagnosed with DMDD may begin to exhibit symptoms of depression, anxiety, or other mood disorders.
Management and treatment for DMDD
There are currently no forms of treatment specifically designated to treat DMDD. However, the chronic irritability symptom does have treatments available based on research on other forms of behavioural disorders. The main forms of treatment/management are:
- Pharmacological treatment - Use of psychostimulants and antidepressants for treating chronic and persistent irritability and anger in children and adolescents. These have shown a well-documented improvement in individuals with ADHD and modulating their aggressive behaviours.
- Forms of psychotherapy - Cognitive behavioural therapy (CBT) is a form of therapy which can help children and teenagers recognise the triggers of their behaviours and equip them with skills to cope with their feelings. For DMDD, researchers are looking to employ the use of dialectical behaviour therapy (DBT-C), which helps children learn to regulate their emotions and avoid extreme/prolonged outbursts.
- Parent training - Parents' understanding of how to respond to children diagnosed with DMDD is just as important as treating the children. Parent training teaches caregivers effective ways to respond to temper outbursts and irritable behaviour by focusing on the importance of predictability and rewarding positive behaviour.
The introduction of DMDD into the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been considered controversial as there is an absence of research to demonstrate that it is its own, separate condition. Many of the symptoms of DMDD overlap with the diagnosis of other mood/behavioural disorders. The chronic irritability and temper outbursts of DMDD are common in autism spectrum disorders, and many children with DMDD find a strong overlap with symptoms of ODD. Therefore, DMDD is characterised by high rates of appearing with other psychiatric disorders. However, the diagnosis of DMDD generally aligns with the following criteria:
- A: Severe, out-of-proportion temper outbursts
- B: Temper outbursts are inconsistent with developmental level
- C: Temper outbursts occur 3 or more times a week
- D: The mood between temper outbursts is irritable or angry most of the day, every day, and is observable by others.
- E: Criteria A, B, C, D have been present for 12 months or more, with any break in symptoms lasting less than 3 months
- F: Criteria A and D are present in 2 to 3 settings (home, with friends, at school) and are severe in at least 1 setting.
- G: No diagnosis made before the age of 6 or after 18, as temper tantrums are normal for young children
- Criteria H: The diagnosis of DMDD must ensure that the behaviours do not only occur during an episode of major depressive disorder and cannot be explained by other mental disorders such as autism spectrum disorder.
One of the most important aspects of diagnosing DMDD is that the symptoms should be present across most environments of the child: at home, amongst friends, in school and with teachers. Parents who may suspect that their child is exhibiting symptoms of DMDD should consult with teachers or other key figures in the child’s life to get an understanding of whether their behaviour exists within different environments. This will be important when describing your child’s behaviour to a healthcare provider and in allowing them to make informed and accurate evaluations.
What age do children grow out of DMDD?
While it is still unclear if children can grow out of DMDD, children or teenagers diagnosed with DMDD may display a different set of symptoms as they grow and develop. Some adolescents with DMDD may experience fewer tantrums but exhibit symptoms of depression or anxiety.
Is DMDD on the autism spectrum?
Though not strictly on the autism spectrum, children diagnosed with DMDD do commonly display symptoms of autism.
How can I prevent DMDD?
DMDD is not a disorder which can necessarily be prevented, but it can be managed by recognising the early onset of symptoms. This can help to minimise the stress experienced by the child and allow them to flourish in their functional and social lives. Management of DMDD is mostly conducted via forms of talking therapy. Therapists work with the child to understand their triggers and equip them with coping mechanisms. Simultaneously, parent training can prove vital in ensuring that the approach to their child’s temper outbursts/irritability does not worsen their symptoms.
How common is DMDD?
Due to the relative novelty of DMDD and the lack of consensus that DMDD is its own condition, it is not clear how widespread the disorder is. However, according to the DSM-5, between 2-5% of children and teenagers are thought to have the disorder. Furthermore, individuals who are assigned male at birth (AMAB) are more greatly represented within clinical trials, though it is not clear whether this is because individuals who are AMAB are at a greater risk of developing the disease or whether individuals who are assigned female at birth(AFAB) are simply overlooked or underrepresented.
When should I see a doctor?
Caregivers who suspect their children may be exhibiting symptoms of DMDD should monitor and record their children’s behaviour according to the outlined signs and symptoms. It is also important that consultations with teachers are made to get a wider understanding of the child’s behaviour outside of the home.
DMDD is a behavioural disorder usually occurring in children between the ages of 6-10. The most common symptoms of DMDD are chronic and severe irritability along with frequent, intense temper outbursts. These symptoms make it difficult for children with DMDD to maintain healthy relationships with family and friends and to engage positively in social activities. Due to the relatively new introduction of the disorder, more research needs to be conducted into the causes and prevalence of DMDD. However, research conducted so far suggests a strong association between DMDD and a family history of bipolar disorder or other mood disorders. Though the onset of DMDD cannot be prevented, forms of talking therapy, parent training and, in some cases, administration of medication are the most effective ways of managing the symptoms of DMDD and allowing children to thrive in their social and functional development.
- Mayes SD, Waxmonsky J, Calhoun SL, Kokotovich C, Mathiowetz C, Baweja R. Disruptive mood dysregulation disorder (Dmdd) symptoms in children with autism, ADHD, and neurotypical development and impact of co-occurring ODD, depression, and anxiety. Research in Autism Spectrum Disorders [Internet]. 2015 Oct [cited 2023 Jun 9];18:64–72. Available from: https://linkinghub.elsevier.com/retrieve/pii/S1750946715000823
- Disruptive mood dysregulation disorder: the basics [Internet]. National Institute of Mental Health (NIMH). [cited 2023 Jun 9]. Available from: https://www.nimh.nih.gov/health/publications/disruptive-mood-dysregulation-disorder
- Sparks GM, Axelson DA, Yu H, Ha W, Ballester J, Diler RS, et al. Disruptive mood dysregulation disorder and chronic irritability in youth at familial risk for bipolar disorder. Journal of the American Academy of Child & Adolescent Psychiatry [Internet]. 2014 Apr [cited 2023 Jun 9];53(4):408–16. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0890856714000495
- Leibenluft E. Irritability in children: what we know and what we need to learn. World Psychiatry [Internet]. 2017 Feb [cited 2023 Jun 9];16(1):100–1. Available from: https://onlinelibrary.wiley.com/doi/10.1002/wps.20397
- Bruno A, Celebre L, Torre G, Pandolfo G, Mento C, Cedro C, et al. Focus on disruptive mood dysregulation disorder: a review of the literature. Psychiatry Research [Internet]. 2019 Sep [cited 2023 Jun 9];279:323–30. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0165178119300290
- Pan LA, Goldstein TR, Rooks BT, Hickey M, Fan JY, Merranko J, et al. The relationship between stressful life events and axis i diagnoses among adolescent offspring of probands with bipolar and non-bipolar psychiatric disorders and healthy controls: the Pittsburgh bipolar offspring study(Bios). J Clin Psychiatry [Internet]. 2017 Mar 29 [cited 2023 Jun 9];78(3):e234–43. Available from: http://www.psychiatrist.com/jcp/article/pages/2017/v78n03/v78n0302.aspx