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How Therapists Use DBT to Treat DMDD

Written by Evolve's Behavioral Health Content Team​:

Alyson Orcena, LMFT, Melissa Vallas, MD, Shikha Verma, MD, Ellen Bloch, LCSW, Lianne Tendler, LMFT, Megan Johnston, LMFT

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Disruptive mood dysregulation disorder, or DMDD, is a relatively new psychiatric disorder described in the latest edition of the Diagnostic and Statistical Manual of Behavioral Disorder (DSM-V, 2013). The diagnosis was created for children with behavioral symptoms that overlap with oppositional defiant disorder (ODD), bipolar disorder, and attention deficit hyperactivity disorder (ADHD), but do not exactly match any of them. DMDD was created partly for these teens who could not fit into any of the existing diagnoses.

If you have an adolescent client diagnosed with disruptive mood dysregulation disorder (DMDD), you might see that a combination of medication, parent training, Cognitive Behavioral Therapy (CBT) and Dialectical Behavior Therapy (DBT) can all be part of an effective treatment plan for DMDD.

In this article, we will focus on some of the ways DBT can help adolescents with DMDD.

What is DMDD?

A teen may have DMDD if they have a combination of mood symptoms and highly disruptive, intense behaviors that are not developmentally age appropriate. Adolescents with DMDD commonly explode in rage or anger, either physically and/or verbally. When upset or disappointed (and they do get upset fairly frequently), they may attack both people and objects. They may scream, yell, hit, kick, punch, throw, break things.

Additionally, other family members, friends, and teachers usually notice these displays of anger. If an adolescent has these outbursts most of the day almost every day, and a parent always feel like they need to walk on eggshells in order to prevent setting them off, the child may have DMDD.

While ups and downs in adolescent relationships are common, it’s exponentially more intense in those with DMDD. Tensions between parents and family members are high. The teen may lash out with verbal and physical aggression as soon as someone presents a boundary or say no to a request.

The Difference Between DMDD and ODD

While persistent irritability and excessively angry outbursts are also present in oppositional defiant disorder (ODD), they are more severe in DMDD, and occur more frequently. In DMDD, these disruptive outbursts occur must at least three times a week for at least a year, while in ODD they only need to occur once a week for at least six months. Also, in DMDD the irritability causes damage in more than one setting (e.g. home and school). To learn more about DMDD symptoms, check out our DMDD Parent Guide.

Dialectical Behavior Therapy for DMDD

So how exactly will DBT help treat a teen’s DMDD symptoms?

As a reminder, below are the five modules of Dialectical Behavior Therapy skills for adolescents:

1. Navigating up-and-down emotions (emotion regulation)
2. Managing relationships effectively (interpersonal effectiveness)
3. Tolerating difficult emotions safely and reduce suffering through reality acceptance (distress tolerance)
4. Increasing awareness and focus in the present moment (core mindfulness)
5. Finding balance between two extremes (walking the middle path)

Each module of DBT will help address the chronic anger, irritability, and temper outbursts that DMDD teens display.

Emotion Regulation Skills

When adolescents can regulate their emotions and learn how to manage disappointment, they act out less. Teens learn how to assess whether their intense emotions are appropriate for the situation at hand. For example, a client should understand that anger may be appropriate when they are attacked or hurt by others, or when they are stopped from achieving an important goal. But anger doesn’t make sense when someone accidentally bumps into them on their way to class.

When their emotions do not, actually, “fit the facts,” adolescents learn how to problem-solve wisely or temper their emotions. For example, they can take a time-out or engage in some deep breathing.

Distress Tolerance Skills

When a teen experiences a disappointment, it’s hard to deal with the pain. Teens with DMDD are often tempted to hurt others or themselves out of this pain.

Dialectical Behavior Therapy’s Distress Tolerance skills teach a teen physiological ways to safely and quickly tolerate their distress instead of acting or lashing out. Skills like Wise Mind A.C.C.E.P.T.S, Self-Soothe, I.M.P.R.O.V.E. the Moment, Pros and Cons, and T.I.P.P. are last-resort tricks to survive a crisis when you don’t want to make the situation worse. These tips include lowering your body temperature, distraction, imagery, exercise, relaxation, self-soothing, and more.

Mindfulness Skills

Mindfulness strategies are specifically helpful for adolescents with DMDD who have problems with keeping their cool. Concepts like urge surfing, validation, loving-kindness, and nonjudgmental observation teach teens to become more self-aware. When teens learn how to identify what happens when they become angry or lash out—the thoughts running through their head, and what happens to their body simultaneously—they become better at controlling their anger. Mindfulness also teaches adolescents how to switch from the hot, mood-dependent “Emotion Mind” to the more balanced “Wise Mind.”

Interpersonal Effectiveness Skills

Due to their frequent explosiveness, teens with DMDD typically have tumultuous relationships. DBT’s interpersonal effectiveness skills teach clients how to repair these strained relationships and how to prevent them, in the future, from getting broken.

When in conflict, adolescents with DMDD usually turn to attacks, screaming, threats, and lashing out. DBT teaches why and how these methods of communication generally fail. They also learn what works better instead: attempting to invoke empathy, speaking in a calm tone of voice, smiling when appropriate, imagining themselves in the other person’s shoes, and trying to be gentle, both in speech and action. By doing so, teens can keep their anger at bay, resolve conflict, or prevent it in the first place.

Walking the Middle Path Skills

Since clients with DMDD often have extreme emotions (like rage or aggression), DBT tries to help them find cognitive balance. This is where the dialectical part of DBT comes in: helping teens hold two ideas in their hands simultaneously. For example—instead of regarding a person with “hate”, or a situation as “terrible,” Dialectical Behavior Therapy encourages replacing those extremes with: Sometimes this person does things that upset me, and other times he/she does things that I like. This helps broaden a client’s view of people, experiences, and himself.

DBT Works for DMDD

Dialectical Behavior Therapy is evidence-based: scientific studies show it works.
Researchers have conducted numerous studies analyzing whether Dialectical Behavior Therapy is effective for DMDD. Their consensus? Yes. One foundational study (Perepletchikova, 2017) found that 90% of DMDD participants who received DBT saw an improvement in their symptoms, compared with only 45% in the control group who received Treatment As Usual. Additionally, none of the teens in the DBT group dropped out of treatment, whereas eight of the 22 participants in the control ultimately did. This suggests that DBT has a higher retention rate than other therapies.

Intensive DBT Treatment For Teens With DMDD

Individual therapists usually run adolescent DBT-skills groups in their outpatient practice, coupled with weekly individual sessions and coaching, over the course of a year. If a teen’s DMDD is more severe, an immersive program may be indicated for stabilization.

Depending on the severity of your client’s DMDD, a Residential (RTC), Partial Hospitalization (PHP) or Intensive Outpatient (IOP) program that offers a comprehensive DBT approach may be appropriate.

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