A Guide to DSM-5

Bret S. Stetka, MD; Christoph U. Correll, MD

May 21, 2013

Disruptive Mood Dysregulation Disorder (DMDD)

The Change

This new diagnostic category includes children exhibiting persistent irritability and severe behavioral outbursts 3 or more times per week for more than 1 year. The mood in between temper outbursts is persistently negative (irritable, angry, or sad), which is observable by others, and the tantrums and negative mood are present in at least 2 settings. To meet criteria for the new diagnosis, onset of illness has to be before age 10 years and in a child with a chronological or developmental age of at least 6 years.

DMDD is intended to capture children with frequent temper tantrums and irritability, in part to prevent the overdiagnosis of bipolar disorder in youth with prepubertal onset of these symptoms. Often, such presentations result in a diagnosis of bipolar disorder or oppositional defiant disorder.^[4]

The Implications

Critics of this update cite the modest body of research into the validity of DMDD as a viable diagnostic entity,^[5] as well as the worry that such a diagnosis could increase the number of children diagnosed with mental illness and subsequent exposure to psychotropic medications with potential long-term side effects.

Furthermore, a recent study by Axelson and colleagues^[6] concluded that "In this clinical sample, DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders. These findings raise concerns about the diagnostic utility of DMDD in clinical populations." In a follow-up editorial,^[7] Dr. Axelson wrote, "One can conclude that at this time, not enough scientific data about these kids are available to create a new diagnosis. However, we should all agree on the vital importance of this problem and the need to expand our efforts to better understand the complex construct of irritability so that we can improve the assessment, diagnosis, and treatment of some of our sickest children."

Although the validity and specificity of the new DMDD diagnosis remain in question, the hope is that the rise in bipolar disorder diagnoses for nonepisodic mood dysregulation and aggression with prepubertal onset may decrease. Whether this new diagnosis will also lead to a more judicious use of psychotropic medications and increased utilization of behavioral, psychosocial, and family interventions remains to be seen, but the addition of DMDD in DSM-5 will hopefully encourage such research.