DISRUPTIVE MOOD

DYSREGULATION
DISORDER (DMDD)
DSM-V 296.99 (F34.8)
DISRUPTIVE MOOD DYSREGULATION DISORDER : BACKGROUND

▪ Disorder in children & adolescents ▪ Resemble

▪ Persistently irritable or angry ▫ ADHD*
mood + frequent temper ▫ ODD*
outbursts ▫ Anxiety Disorders*
▫ Disproportionate to situation ▫ Childhood Bipolar
▫ More severe than typical Disorder*
reaction of same-aged peers

*Diagnostic and statistical manual of mental disorders(DSM, 5th ed.). Washington, DC: American Psychiatric
5
Association. 2013. ISBN 9780890425541
DSM-5 296.99 (F34.8)
Disruptive Mood Dysregulation Disorder
 “
“Some of these children were
previously diagnosed with bipolar
disorder, even though they often did
not have all the signs and symptoms.”
- American Academy of Child and Adolescent Psychiatry (2018)

7
CRITERIA FOR DIAGNOSIS

A. 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 provocation.
B. The temper outbursts are inconsistent with developmental level.
C. The temper outbursts occur, on average, three or more times per week.
D. The mood between temper outbursts in persistently irritable or angry most of the day, nearly
every day, and is observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has
not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of the three settings (i.e., at home, at school, with
peers) and are severe in at least one of these.

*Diagnostic and statistical manual of mental disorders(DSM, 5th ed.). Washington, DC: American Psychiatric
8
Association. 2013. ISBN 9780890425541
CRITERIA FOR DIAGNOSIS

G. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
H. By history or observation, the age of onset of Criteria A-E is before 10 years.
I. There has never been a distinct period lasting more than 1 day during which the full symptom
criteria, except duration, for a manic or hypomanic episode have been met.
J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not
better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress
disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).
K. The symptoms are not attributable to the physiological effects of a substance or to another
medical or neurological condition.

*Diagnostic and statistical manual of mental disorders(DSM, 5th ed.). Washington, DC: American Psychiatric
9
Association. 2013. ISBN 9780890425541
IN A NUTSHELL

Observed by others to be present in

2 settings for > 1 year & not without
for > 3 months:
▪ Persistently irritable / angry
▪ Severe, recurrent outbursts
▫ Inconsistent with
developmental level
▫ > 3 / week

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WHAT
HAPPENS
IN DMDD?
Pathophysiology of DMDD

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WHAT HAPPENS IN DMDD

1. Excessive arousal • Prolonged recovery

Frustration / 2. State-dependent from frustration /
Irritation impairments in irritation
attentional flexibility • Relationship impairment

1. Impairments in • Increased frequency and

Distress
emotional regulation recurrence of outbursts

1. Difficulty identifying negative emotions • Increased reactive

2. Experience greater fear when viewing neutral faces aggression

Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation disorder: current
insights. Neuropsychiatr Dis Treat. 2016;12:2115. doi: 10.2147/NDT.S100312. 12
DO WE NEED
TO TREAT
DMDD?
What are the treatment
options?

13
DMDD AT AGE 6

▪ Predicted current ▪ Predicted greater ▪ More likely to

and lifetime functional receive
Attention Deficit impairment educational
Hyperactivity ▪ Poorer peer support services,
Disorder (ADHD) relations OPD treatment,
& Disruptive psychotropic
▪ More frequent
Behavior Disorder treatment
peer victimization
(DBD)
▪ Teacher-reported
aggression

Disruptive Mood Dysregulation Disorder at Age Six and Clinical and Functional Outcomes Three Years Later
Psychol Med. 2016 Apr; 46(5): 1103–1114. Published online 2016 Jan 20. doi: 10.1017/S0033291715002809 14
TREATMENT FOR DMDD

Pharmacological treatments Psychological treatments

1. Stimulants 1. Psychotherapy
2. Anti-depressants 2. Parent Training
3. Atypical Antipsychotic 3. Computer-based training

Source: U.S. Department of Health and Human Services

The National Institute of Mental Health Information Resource Center 15
 “
“Preliminary evidence suggests that
youth with ADHD and DMDD or with
ADHD and recurrent aggression
respond positively to CNS stimulants”
- Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation
disorder: current insights. Neuropsychiatr Dis Treat. 2016;12:2115. doi:
10.2147/NDT.S100312

16
 “
“Similarly, psychosocial techniques
derived from those employed for ADHD,
ODD, and depression have been found
to be efficacious”
- Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation
disorder: current insights. Neuropsychiatr Dis Treat. 2016;12:2115. doi:
10.2147/NDT.S100312

17
Lithium for DMDD

▪ To date, the only randomized, placebo-controlled trial

of medication in children with SMD
▪ Found no benefit of lithium over placebo for
treatment of DMDD

Randomized double-blind placebo-controlled trial of lithium in youths with severe mood dysregulation ; Dickstein DP,
Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E 18
J Child Adolesc Psychopharmacol. 2009 Feb; 19(1):61-73.
Risperidone for DMDD

▪ Open-label trial of risperidone (mean dose = 1.28 mg)

in youth with SMD done in 2011
▪ Showed significant reduction in irritability

An open-label trial of risperidone in children and adolescents with severe mood dysregulation. ; Krieger FV, Pheula GF,
Coelho R, Zeni T, Tramontina S, Zeni CP, Rohde LA ; J Child Adolesc Psychopharmacol. 2011 Jun; 21(3):237-43 19
NON PHARMACOLOGICAL TREATMENTS

Psychotherapy Parent Training Computer Based Training

▪ How to deal with ▪ How to interact with ▪ Teaches children how to
thoughts a child in a way that perceive ambiguous facial
▪ Teaches coping will reduce expressions
skills for regulating aggression and
anger irritable behavior
▪ Improve the parent-
child relationship

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 “
“Meeting the criteria for DMDD
should not stop the search for
triggers for the child’s irritability, as
DMDD does not identify an etiology
for the child’s distress.”
- Baweja R, Mayes SD, Hameed U, Waxmonsky JG. Disruptive mood dysregulation disorder:
current insights. Neuropsychiatr Dis Treat. 2016;12:2115. doi: 10.2147/NDT.S100312

21
PSYCHOTHERAPY FOR DMDD

▪ Emphasis on managing antecedents for temper

outbursts
▪ Training parents to be effective emotion regulation
coaches for their children
▪ Addressed impairments in affect identification
▪ Emphasis on soothing negative mood states prior to
problem solving
A Randomized Clinical Trial of an Integrative Group Therapy for Children With Severe Mood Dysregulation ; Waxmonsky
JG, Waschbusch DA, Belin P, Li T, Babocsai L, Humphery H, Pariseau ME, Babinski DE, Hoffman MT, Haak JL, Mazzant 22
JR, Fabiano GA, Pettit JW, Fallahazad N, Pelham WE ;J Am Acad Child Adolesc Psychiatry. 2016 Mar; 55(3):196-207.
PSYCHOTHERAPY FOR DMDD

▪ feasible and well received by families

▪ greater reduction in parent-rated irritability than
with CNS stimulants alone
▪ In those completing the majority of sessions,
additional improvement in mood symptoms were
seen

A Randomized Clinical Trial of an Integrative Group Therapy for Children With Severe Mood Dysregulation ; Waxmonsky
JG, Waschbusch DA, Belin P, Li T, Babocsai L, Humphery H, Pariseau ME, Babinski DE, Hoffman MT, Haak JL, Mazzant 23
JR, Fabiano GA, Pettit JW, Fallahazad N, Pelham WE ;J Am Acad Child Adolesc Psychiatry. 2016 Mar; 55(3):196-207.
ADULT OUTCOMES OF DMDD

▪ Significantly more likely to meet criteria for an adult

diagnosis than non-case comparison subjects
▪ Individuals with DMDD were most likely to meet
criteria for multiple adult disorders, with 10.3
greater odds than noncase comparison subjects and
5.9 greater odds than psychiatric comparison
subjects.
Adult Diagnostic and Functional Outcomes of DSM-5 Disruptive Mood Dysregulation Disorder ; William E.
Copeland, Ph.D., Lilly Shanahan, Ph.D., Helen Egger, M.D., Adrian Angold, M.R.C.Psych., and E. Jane Costello, Ph.D.
24
 “
“…they were more likely to have an
adult depressive or anxiety disorder
and more likely to meet criteria for
adult anxiety or depression relative to
psychiatric comparison subjects…”

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IN CLOSING

▪ DMDD was added to address concerns about the

misdiagnosis and consequent overtreatment of
bipolar disorder in children and adolescents
▪ DMDD symptoms are found in many psychiatric
disorders and rarely occur in isolation

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IN CLOSING

▪ Children who have persistent, explosive irritability

and recurrent temper outbursts are highly impaired
and in need of evidence-based treatments

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THANK YOU VERY MUCH!

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