A relatively new psychiatric disorder known as disruptive mood dysregulation disorder, or DMDD for short, may be the proper diagnosis if you’re dealing with a teen with a combination of mood symptoms and highly disruptive and intense behaviors. Frequent anger outbursts combined with persistent, severe, and chronic irritability are the primary symptoms of DMDD. Classified as a mood disorder, DMDD is diagnosed between the ages of 6 and 18, and often occurs with other disorders such as ADHD and major depression.
This brief guide is designed to help you identify the signs of DMDD in your adolescent child and know the appropriate steps to take for initial diagnosis and treatment, as well as what to do if things escalate or standard treatment approaches aren’t enough.
Adolescent DMDD – Statistics and Facts
- DMDD affects between 2% to 5% of children
- DMDD occurs more frequently in boys than girls
- An estimated 50 to 60% of psychiatric admissions are due to behavioral outbursts, which is one of the prominent symptoms of DMDD
- Studies suggest that less than 4 out of 10 children with ODD also meet the criteria for DMDD, while 7 out of 10 with DMDD also meet the criteria for ODD.
- Youth with DMDD have an increased risk for both depression and anxiety in adulthood.
- DMDD symptoms can be just as severe as bipolar symptoms in children and adolescents with either disorder
- One study of 179 ADHD children found that 22% also had DMDD. The children with both ADHD and DMDD had a nearly 90% prevalence of ODD and a 41% prevalence of an anxiety disorder.
- The study mentioned above also found that ADHD children with DMDD were more likely to engage in bullying and have less self-control than ADHD children without DMDD.
Disruptive mood dysregulation disorder frequently co-occurs with other mental health disorders in children and adolescents. The most common comorbid disorders include:
- Attention-deficit hyperactivity disorder (ADHD)
- Oppositional defiant disorder (ODD)*
- Anxiety disorders
- Major depression
- Autism spectrum disorders
*When symptoms meet the criteria for both ODD and DMDD, clinicians must diagnosis the individual with DMDD; an additional diagnosis of ODD is not assigned.
Comorbidity (two or more disorders occurring at the same time) is very common in DMDD. Since there is not yet a definitive course of treatment for the disorder, it’s especially critical for treatment providers to use caution when determining the best course of treatment.
Again, working with an experienced mental health professional, preferably a psychologist or psychiatrist who specializes in treating children and adolescents, will increase the chances of an accurate diagnosis for your teen. A misdiagnosis will likely result in a course of treatment that will either be frustratingly ineffective or potentially make matters worse.
Risk Factors for DMDD
Disruptive mood dysregulation disorder is a relatively new diagnosis, first appearing in the latest edition (2013) of the DSM, the DSM-5. The DSM is the manual used by mental health professionals to diagnose psychiatric disorders. At this time, no one knows what specific risk factors are associated with the development of DMDD in children and adolescents.
DMDD vs Bipolar Disorder
Many mental health clinicians have thought pediatric bipolar disorder was being diagnosed far too often over the past several decades. The hallmark feature of bipolar disorder is a history of at least one manic or hypomanic (less severe than manic) episode, in which one’s mood is grandiose, euphoric, or irritable combined with a decreased need for sleep and a high level of energy or goal-directed behaviors. These episodes must last at least 4 days (in hypomania) and at least 7 days (in mania) days.
While irritability is often a symptom of bipolar disorder, it’s always a symptom – and a very persistent, stable one – in DMDD. The irritability isn’t persistent in bipolar disorder, as it comes and goes with the mood episodes. Persistent irritability is also a common symptom in children and teens with major depressive disorder, which is one of the reasons DMDD is usually more closely associated with major depression than bipolar disorder.
Atypical antipsychotic medications, which often come with potentially serious side effects, are often used in the treatment of bipolar disorder in children and adolescents. This is one of the reasons it’s crucial to work with an experienced, qualified mental health professional when determining your teen’s diagnosis and best course of treatment.
That being said; the angry, excessively disruptive outbursts often seen in children and teens with DMDD are strongly correlated with a high occurrence of bipolar disorder in their parents or other first-degree relatives.
DMDD vs Oppositional Defiant Disorder (ODD)
Both DMDD and ODD require the presence of temper outbursts and irritability. However, in DMDD these symptoms are more frequent and for a longer duration – they must occur at least 3 times a week for at least 12 months to meet the criteria. In ODD the diagnostic requirement is only once per week for at least 6 months. In DMDD, unlike ODD, symptoms must cause impairment in at least two settings (e.g. home and school) and be severe in at least one of those settings.
DMDD vs Intermittent Explosive Disorder (IED)
If the criteria for both DMDD and IED are met, then the diagnosis of DMDD is given. In IED, there is no requirement for irritable mood. Anger outbursts in IED need to occur only twice a week for at least 3 months – again, less frequently and for a shorter duration than in DMDD.
Looking for and Recognizing the Signs of DMDD
Early intervention and treatment play an important role in ensuring a positive outcome and reducing the risk of your teen developing other disorders as time goes on. That’s why it’s helpful to know what to look for so you can spot the signs of DMDD in your child.
Signs and symptoms of DMDD include:
- Presence of persistent irritable or angry mood practically throughout much of the day almost every day, and occurs between anger outbursts (see below)
- The irritability and anger are noticeable to others who interact with your teen, such as family members, friends, and teachers
- Explosive outbursts of rage or anger expressed either verbally (e.g. screaming or yelling) or physically (e.g. becoming physically aggressive towards others or towards property such as hitting, punching, throwing or breaking things)
- These outbursts are excessively disproportionate in terms of their duration and intensity with regards to the situation that triggered them
- The outbursts have been occurring for at least 12 consecutive months and an average of at least 3 times a week during that 12-month period (with no more than a 3-month period of relief from symptom occurrence)
- The anger or temper outbursts don’t fit with the child’s developmental age (i.e. they might be considered normal in a younger child)
- The symptoms mentioned above aren’t caused by alcohol, drugs, or any other substances
- The irritability and anger outbursts don’t occur exclusively in the presence of another psychiatric disorder and can’t be better explained by another psychiatric disorder or a neurological disorder
- The symptoms above first appeared prior to the age of 10
- Family members often feel as if they must “tiptoe” around the individual so as not to “set” him or her off
- Symptoms occur in more than one setting (e.g. both home and school); if they occur in only one setting then DMDD is not the proper diagnosis
- There are no indicators of mania or hypomania lasting for more than one day
Knowing the First Steps to Take
If you suspect your teen is showing signs of DMDD it’s essential that you take steps to address the situation sooner than later. With all mental health issues, early intervention often plays an important role in a better prognosis and treatment outcome. Following are the first steps to take:
1 – Talk to your teen. It can be challenging for any parent to attempt to have a conversation with a teen who’s almost always in an irritable mood and may fly off in an angry outburst at the slightest hint of provocation. Choose a time when you’re calm, and your teen is at least relatively calm, to address your concerns. Avoid bringing up the issue when you or your teen is angry or frustrated, or when your teen is acting out. Practice compassion and understanding when talking to your teen. Refrain from attacking, accusing, blaming, or getting defensive.
Prepare yourself for an angry or irritable response. Avoid pressuring or over-reacting. Assure your teen that you are concerned and genuinely want to help in any way you can, and that you are willing and available to listen any time he or she wants to talk (and be sure to keep that promise). Don’t expect your teen to be particularly open and forthcoming – mental health issues often cause shame, embarrassment, and anxiety in adolescents.
2 – Set up an appointment for an evaluation. One of the best places to start is with an initial exam by your family doctor or pediatrician. Your physician can rule out any underlying medical issues that may be playing a role in your child’s mood symptoms and outbursts. He or she should be able to give you a referral to a psychiatrist or psychologist who can provide a more thorough evaluation. If possible, find someone who specializes in working with children and adolescents rather than adults.
3 – Get your teen into treatment. Determining the best course of treatment for DMDD can be challenging since it’s still such a new disorder. Once your teen has been evaluated, treatment recommendations and options will be discussed with you. Treatment for DMDD may involve a combined approach including psychotherapy (both individual and family therapy) and medication. It is generally recommended that medication be used only in conjunction with psychotherapy and not as the sole treatment.
Since DMDD is still a fairly new diagnosis, treatment currently relies primarily on using approaches that are effective with other disorders with similar symptoms, particularly irritable moods and temper outbursts.
Individual therapy – Individual therapy can help teens learn to manage and express their feelings in a healthy manner and learn new, effective coping and problem-solving skills. Cognitive behavioral therapy may be particularly beneficial for teens with DMDD by helping teens identify negative thought patterns and self-talk that play a role in their irritability, low frustration tolerance, and intense anger outbursts.
Family therapy – Teens with DMDD have a highly negative impact on the entire family, which is where family therapy can be especially beneficial. When the whole family is involved a therapist can help everyone develop better coping skills, find healthier ways to respond and interact during difficult situations, and work together to create more supportive home environment.
Parent training – This type of therapy is focused on teaching parents to learn more effective predictable, and consistent ways to respond to their teen’s negative, disruptive behaviors and chronic irritability. It also helps parents learn to give more positive attention to desirable behaviors to reward and reinforce them. Parenting training is usually more effective with children with DMDD than adolescents with the disorder.
Medication – Medication is often used in the treatment of DMDD to help reduce irritability, aggressive behavior, anger outbursts, and other mood problems. Medications may be selected based on the presence of comorbid disorders and their symptoms. The three most common categories of medication used for DMDD are stimulants, antidepressants, and antipsychotics.
- Stimulants – Stimulant medications, such as methylphenidate (Ritalin) and dextroamphetamine (Dexedrine) are frequently used in the treatment of ADHD. In individuals with DMDD and comorbid ADHD, these medications have been found to reduce irritability. One of the more serious potential side effects of stimulants is an increased risk of heart problems. They are also controlled substances due to the risk of abuse and addiction.
- Antidepressants – Antidepressant medications are often used to treat mood disorders and anxiety. They may help reduce mood issues, sadness, and irritability in teens with DMDD. Keep in mind, however, that many antidepressants have been associated with a risk of causing suicidal thoughts and behaviors in children and adolescents.
- Antipsychotics – As the name suggests, antipsychotic medications were initially developed to treat psychotic disorders such as schizophrenia. Newer antipsychotic medications known as atypical antipsychotics, such as aripiprazole (Abilify) and risperidone (Risperdal) have been approved by the FDA to treat irritability in autistic individuals and have been used in the treatment of DMDD. Antipsychotics can also help reduce aggression and anger outbursts. These potent medications can cause serious side effects, including hormonal and metabolic changes, significant weight gain, sedation, and suicidal thoughts and behaviors.
All the medications listed above can cause potentially serious side effects. If prescribed for your teen for DMDD they should be monitored very closely by a qualified medical professional.
Computer-based training – Another type of intervention that is showing some promise in the treatment of severe irritability in DMDD is computer-based training. It may help children and teens who frequently misinterpret facial expressions in others as angry.
Supporting and Encouraging Your Child
Dealing with an adolescent with DMDD can be a constant challenge that takes a toll on even the best parents. It’s important for you to provide as much support and encouragement as possible. Following are some tips that will help both you and your teen:
- Educate yourself about DMDD so you can be more empathetic and understanding regarding what your teen is experiencing
- Strive to be patient, especially when symptoms escalate
- Pay close attention to triggers for outbursts as well as patterns in mood and behaviors. This will enable you to recognize early warning signs and either redirect and prevent the triggering situation or help your teen handle it more effectively
- Assist your teen as he or she learns to self-regulate intense emotions; don’t assume he or she can handle those emotions alone
- Help your teen find healthy, enjoyable ways to cope, relax, and manage stress; be a role model by managing your own stress in healthy ways
- Pay attention to negative self-statements (e.g. your child often states he or she is stupid, etc.) and help him or her replace them with healthier self-talk
- Provide structure, routine, and consistency in the home
- Focus on giving attention and praise to positive behaviors rather than criticizing or pointing out negative behaviors
- Set firm, clear rules and boundaries with your teen
- Provide consequences for inappropriate behavior that are consistent and predictable, so your teen knows what to expect
- Avoid nagging or lecturing your teen
- Keep stress levels and over-stimulation to a minimum in the home as much as you can
- Be willing and available to listen to your teen
- Be sure to keep any alcohol, medications, and weapons in the home locked in a safe place
- Make it a priority to spend quality one-on-one time with your teen
- Do your best to remain calm no matter how frustrated or overwhelmed you feel
- Actively participate in your teen’s treatment
What to Do When Things Escalate
Intense outbursts of anger, self-destructive, impulsive, or aggressive behavior, irritability, and suicidal thoughts and behavior can intensify at times in teens with DMDD, particularly if they are using alcohol or recreational drugs, under a lot of stress, experiencing medication side effects, and / or have another diagnosis such as major depression or ADHD. If things start to escalate and your teen is endangering himself / herself or others, immediate attention is critical to ensure everyone’s safety.
When things start to escalate you can:
- Contact your teen’s treatment provider immediately (some providers have a specific number for after-hour emergencies
- Enlist the help of a close family member or friend for support or assistance
- Call an emergency hotline
- Take your child to the nearest hospital emergency room (if you can do so safely)
- Call 911 (police or paramedics can transport your teen to the nearest ER if necessary)
When Individual Therapy isn’t Enough
Standard approaches to treatment such as individual therapy and medication aren’t always enough for teens with DMDD. A more intensive level of treatment may be warranted if any of the following are occurring:
- Your teen is refusing to comply with treatment recommendations and symptoms are getting worse
- Your teen is engaging in any form of self-harm behavior, such as burning or cutting
- Your teen is abusing alcohol or drugs (which can exacerbate mood symptoms, suicidal thoughts, and have adverse interactions with medications)
- Your teen is talking about, threatening, or planning suicide, or engaging in suicide gestures or attempts
- Your teen’s aggressive and disruptive behavior is putting him or her or others at risk of harm
- Your teen’s symptoms are making it difficult to function
More intensive levels of treatment include:
- Intensive outpatient treatment (IOP) / Psychiatric day treatment
- Dual Diagnosis Treatment
- Residential treatment
- Inpatient psychiatric treatment (usually short-term)
Intensive outpatient treatment or psychiatric day treatment can vary in terms of the amount of time spent each day at the treatment facility and how many times a week your teen is required to attend. These programs are typically the next step up from regular outpatient treatment.
Dual diagnosis treatment is typically needed if your teen has a substance use disorder in addition to DMDD. Alcohol or drug abuse can completely disrupt the effectiveness of individual therapy and other forms of treatment. A dual diagnosis program addresses your teen’s DMDD (and any co-occurring disorders) as well as his or her substance abuse or addiction simultaneously. Many residential treatment and intensive outpatient programs also offer dual diagnosis treatment.
Residential treatment requires having your teen live at a non-hospital treatment facility that specializes in treating adolescents with DMDD and other psychiatric disorders. Residential treatment usually lasts between 1 to 6 months. The length of treatment may be determined by a combination of factors, including severity of symptoms and the rate of progress.
Inpatient psychiatric treatment in a hospital setting is the highest and most intensive level of treatment for adolescents with DMDD. Short-term inpatient treatment is typical required if suicide risk is imminent or symptoms are significantly impairing your teen’s ability to function. Patients are monitored 24/7 by medical staff.
Taking Care of Yourself
Parenting a teen with DMDD can be exhausting, exasperating, and overwhelming. The very frequent angry outbursts and constant irritability can push any parent to the brink if proper self-care isn’t taking place. Granted, it may seem impossible to find any time for yourself let along actually relax when it seems you’re constantly putting out fires.
That’s why it’s especially critical for you to make self-care a priority, even if it’s just committing to a few minutes a day. If you’re exhausted and irritable yourself you’ll be depriving your teen of the stability, guidance, and unconditional support he or she so desperately needs.
A few things you can do include:
- Making sure you get adequate sleep and rest
- Seek support from a therapist, counselor, your church, or a local support group for parents (e.g. through your local NAMI chapter – National Alliance on Mental Illness – local chapters can be found online at NAMI.org)
- Finding healthy, enjoyable ways to manage your stress (e.g. yoga or running)
Don’t give up hope when it comes to your teen getting better. With proper treatment and support, teens with DMDD can get better and have a worthwhile future.