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How Does DBT 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 published in the latest DSM-5 (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. Psychiatrists were misdiagnosing too many children with pediatric bipolar personality disorder, even though they did not display the manic phases of the illness. DMDD was created partly for these teens who could not fit into any of the existing diagnoses.

If you’ve done any research to find help for your adolescent with Disruptive Mood Dysregulation Disorder (DMDD), you might have found that a combination of medication, parent training, CBT and DBT can all treat DMDD.

So, how does DBT work for adolescents with DMDD?

What is DMDD?

Your child 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 your adolescent has these outbursts most of the day almost every day, and you always feel like you need to walk on eggshells in order to prevent setting them off, they 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. Your child may lash out with verbal and physical aggression as soon as you present 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 ODD, it is more severe in DMDD, and occurs more frequently. In DMDD, these disruptive outbursts occur must at least 3 times a week for at least a year, while in ODD they only need to occur once a week for at least 6 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 your son or daughter’s DMDD symptoms?

There are 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’re going to act out less. Teens learn how to assess whether their intense emotions are appropriate for the situation at hand. For example, anger may be appropriate when you are attacked or hurt by others, or when you are stopped from achieving an important goal of yours. But it doesn’t make sense to be so wrathful when someone accidentally bumps into you on your 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 your child 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 will teach your child 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 adolescents 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 adolescents 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 your child’s view of people, experiences, and himself.

DBT Works for DMDD

Dialectical Behavior Therapy is evidence-based: scientific studies have shown 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 adolescents 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.

Where to Get DBT Treatment For Your Teen With DMDD

Because DBT is a skills-based therapy, your adolescent will need to learn these skills from a DBT-trained therapist.

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 your child’s DMDD is more severe, an immersive program may be indicated for stabilization.

Depending on the level of your teen’s DMDD, these services can be offered at Residential (RTC), Partial Hospitalization (PHP) or Intensive Outpatient (IOP) programs.

Residential Treatment

If your adolescent needs full-time DMDD treatment, they’ll stay in a non-hospital treatment facility that specializes in treating adolescents with DMDD. Your child will be immersed in DBT with teens going through similar issues. Teens participate in skills groups with their milieu peers and receive in-the-moment client coaching, 24/7, whenever they need it. Every encounter can be a potential DBT-skills lesson—at breakfast, an outing, or bedtime—and counselors will direct the teens to apply DBT skills when appropriate. Residential treatment often lasts between 30 to 60 days, depending on the disorder and its severity.

Partial Hospitalization Program

In a Partial Hospitalization Program (PHP), teens attend programming at least five hours per day, five days a week. At this level of care, teens receive a full day of treatment but continue to live at home. Partial hospitalization is an effective alternative to residential or inpatient treatment when DMDD symptoms do not require 24/7 monitoring. It may be appropriate for those transitioning from an RTC or those who need more structure than an IOP.

Intensive Outpatient Program

An Intensive Outpatient Program (IOP) for DMDD is a less intensive option than PHP. At the intensive outpatient level of care, adolescents receive a half day of professional treatment. Most teens in IOP are able to attend school and live at home. Intensive outpatient is an effective alternative to residential or partial hospitalization programs. It may be appropriate for teenagers who need more structure than private practice psychotherapy for their DMDD. The number of hours in an Intensive Outpatient Program may vary, but generally, teens in IOP receive 3-4 hours of treatment up to four days a week.

Whether it’s a DBT therapist or teen rehab center; residential treatment, IOP or PHP, get in touch with a Dialectical Behavior Therapy program for DMDD today. Let your child start building, as they say in the DBT world, “a life worth living.”

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