Dialing in the Diagnosis: What is Disruptive Mood Dysregulation Disorder?

Getting the correct diagnosis for your teen is an essential first step if they struggle with emotional, mood, behavioral, and/or substance use disorders. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is the go-to, authoritative bible mental health professionals use to identify and diagnose mental disorders in children, adolescents, and adults. It’s a comprehensive guide that includes detailed diagnostic criteria for almost any mental disorder a therapist might see. From conditions everyone has heard of like Obsessive-Compulsive disorder (OCD) to Major Depressive Disorder (MDD) to those most don’t know exist, like Clinical Lycanthropy – a rare condition during which individuals believe they transform into animals – the clinicians who author the DSM have a monumental task on their hands: accurately cataloguing, describing, and distilling the primary characteristics of all the possible disorders that might cause people emotional and behavioral problems.

The American Psychiatric Association oversees the complex and painstaking process. New disorders must meet a broad range of specific criteria and survive a rigorous professional peer-review process to make it into each new version. The first DSM, the DSM-I, published in 1952, contained 128 mental disorders. The most recent edition, the DSM-5, includes over 300. One of the new disorders included is of primary concern to parents of adolescents struggling with mental health issues and the therapists, psychiatrists, and counselors who help them. It’s called Disruptive Mood Dysregulation Disorder, or DMDD.

DMDD: A New Diagnosis for an Old Set of Behaviors

The problem with diagnosing mental and emotional disorders in children and adolescents is as old as parenting.

Modern medical science confirms these disorders do, in fact, occur in children and adolescents, but every parent looks at their children at some point or other and wonders to themselves, their partner, or a friend, if their child is developing issues that require professional intervention. Tantrums out of nowhere, hitting playmates, and eating everything in sight (that’s obviously not food) are common behaviors in toddlers. Moodiness, sadness, and uncharacterizable silliness – which can look like mania – are common in school age children. Defiance, opposition, novelty-seeking, and risk-taking are common in adolescents. In fact, most of these things are signs of typical, healthy development and behavior. Challenging to manage, certainly, but all part of the whole parenting deal. We all lived through these things ourselves when we were kids, so when we have kids, we knew exactly what we’re signing up for.

For the most part, we hold on tight during the rollercoaster ride and simply pray our kids will come back around when their brains finally finish developing and they get some life experience under their belts.

But what happens when your child displays behaviors you know are outside the range of typical?

Mental Illness : Age of Onset

Reliable research indicates about half of all lifetime cases of mental illness begin before age 14. For many years, mental health diagnoses in children were limited to conditions like anxiety, depression, and obsessive-compulsive disorder. Then in 1980, the DSM added criteria for diagnosing Bipolar Disorder (BD) in children. By 1987 the DSM also contained criteria for Oppositional Defiance Disorder (ODD). However, these new categories seemed inadequate in describing the range of behavioral and emotional pathologies present in children and adolescents. Clinicians knew they were missing something, and that neither BD, ODD, or other childhood diagnoses like ADD/ADHD adequately described what many witnessed. Dr. Gabrielle Carson defined the contours of cases that fell outside existing diagnoses:

“…the most common mood disturbance in manic children is severe irritability, with ‘affective storms’ of prolonged and aggressive temper outbursts. The type of irritability observed in manic children is very sever, persistent, and often violent. The outbursts often include threatening or attacking behavior toward family members, other children, adults, and teachers. In between the outbursts, these children are described as persistently irritable in mood.”

The rub here is that, according to clinicians such as Dr. Joseph Biederman:

“…the clinical descriptions of mania have been remarkably consistent over the years, if not centuries…consisting of a distinct episode of elevated mood…usually interspersed with episodes of major depression…[and] no diagnostic criteria have ever been proposed for stable, continuous mania.”

A Separate Category

In order to help parents and clinicians help children who develop behavioral symptoms that overlap with BP, ODD, MDD, and ADD/ADHD but do not precisely match any of them, researcher proposed a sub-category called SMD -Severe Mood Dysregulation. While compiling the DSM-5, SMD temporarily became Temper Dysregulation Disorder with Dysphoria (TDD), then the powers that be decided on a new name, Disruptive Mood Dysregulation Disorder (DMDD). In the words of research scientist Uma Rao:

“The rationale for the introduction…was partly to provide a home for these diagnostic orphans, and partly to address concerns about the potential for over-diagnosis and treatment of bipolar disorder.”

This move was important for parents, doctors, and teens alike. After all, a mental health diagnosis is a medical diagnosis. And the wrong medical diagnosis can lead to treatment that hurts, rather than helps those who suffer from it. You wouldn’t want prescribe aspirin to an individual with blood-clotting problems, a mood-stabilizer to someone who is just going through a rough patch at work, or opiates to someone with a mild headache. Nor would you want your child to receive therapy or medication specifically designed for Bipolar Disorder if that’s not what’s really going on.

DMDD: The Symptoms

A helpful fact sheet on DMDD published in 2013 American Association of Child and Adolescent Psychiatry (AACAP) identifies the following primary symptoms:

  • Severe tantrums at least three times a week
  • Sad, irritable, or angry mood almost every day
  • Reactions out of proportion to stimuli
  • Trouble functioning in more than one place – i.e. the symptoms present at home, at school, and/or with peers

The AACAP also indicates three other criteria for a DMDD diagnosis:

  • The child must be at least six years old
  • The symptoms must be present for at least one year
  • The symptoms must be present before age ten

These specific criteria – particularly those regarding age and consistency of episodes – exist to differentiate between children with BP or ODD and children who may potentially fit the DMDD diagnosis. They also exist so as not to pathologize normal childhood behavior. Because, as everyone who’s ever had or met a child or an adolescent knows, they’re often moody and unpredictable. They can get extremely emotional about things adults might think are no big deal. On the flip side of that, the specificity of the criteria also form a bulwark against another mistake: normalizing pathological behavior. Parents who think it’s typical for a child to tantrum, act out aggressively, or display symptoms of sadness/depression every day need to understand those behaviors are nothing to worry about if they happen sometimes. When they happen all the time, though, there’s legitimate reason for concern and ample reason to seek professional help.

DMDD: The Treatment Options

It’s worth repeating. If you believe your child meets the criteria for DMDD, your first step should be to seek help – in the form of a full assessment – from a fully accredited and licensed mental health practitioner. This article can’t diagnose your child. WebMD can’t diagnose your child. Nor can a random Facebook friend who thinks everything can be cured with a hike in the woods and daily fish oil supplements. Hiking and fish oil are great. And we’re sure your friends want the best for you and your child. But only a mental health professional can offer you a real, medical diagnosis. To find a qualified therapist or psychiatrist for your child, your best bet is to use this Child and Adolescent Psychiatrist Finder provided by the AACAP.

DMDD also frequently occurs concurrently and symptoms overlap with other psychiatric problems, such as anxiety, depression, bipolar disorder, attention issues, and oppositional defiant disorder. A trained professional will be able to sort through the symptoms your child displays. They’ll get the diagnosis right and offer a viable course of treatment. Since DMDD is a new diagnosis, the National Institute of Mental Health points out that “treatment is often based on what has been helpful for other disorders that share the symptoms of irritability and temper tantrums.”

Common Elements of Treatment for DMDD 
  • Psychosocial Interventions
    • Parent training for parents of younger children
    • Cognitive Behavioral Therapy (CBT) older children
  • Medication
    • Stimulant treatment, shown to enhance child resilience, increase frustration tolerance, and reduce aggression
    • Anti-depressants, shown to help children suffering from depression
    • Atypical Anti-psychotics, shown to help reduce severe temper outbursts and physical aggression toward people and/or property
  • Combination Therapies
    • Modes of therapy which include a blend of lifestyle changes, family interventions, medication, and conventional talk-therapy such as CBT. Combined therapies help children more effectively than any one mode of therapy alone.

Source: Disruptive Mood Dysregulation Disorder (DMDD): A New Diagnostic Approach to Chronic Irritability in Youth

Every course treatment should be custom-tailored to the specific needs of your child, your family values, and what you’re comfortable with as a parent. If you visit a healthcare practitioner who reaches for the prescription pad immediately, or if you visit one who proudly proclaims, “I never medicate kids!” then it’s time to seek out a second opinion. In the 21st century, the best approach to helping anyone – not just kids – with mental health issues is a holistic approach. A course of therapy should address the whole person, and consider the biological, psychological, and social issues at play in their lives. Finally, follow your instincts as a parent. If something a professional recommends doesn’t feel right to you, then research the issue and get a second opinion. It’s more than worth the effort it takes to dial in the diagnosis and get it right the first time.