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Disruptive mood dysregulation disorder diagnosis criteria


DMDD Diagnosis: DSM 5 Criteria for Disruptive Mood Dysregulation Disorder

Jenna Jarrold

Assigning the disruptive mood dysregulation disorder (DMDD) diagnosis in a child has not always been an option.  In fact, this is a relatively new diagnosis, added to the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5) in 2013.  

The addition of DMDD to the DSM-5 was, in part, to address the over-diagnosis and overtreatment of bipolar disorder in children.  Since disruptive mood dysregulation disorder is a newly recognized mental health disorder, there are no specific assessment tools used for diagnosis.  Thus, even for trained medical and mental health professionals, it can be difficult to determine whether a child should be assigned a DMDD diagnosis or that of another psychiatric disorder.  Yet, the difficulty in diagnosing is not only due to the lack of assessment tools; disruptive mood dysregulation disorder symptoms can look similar to those found in other psychiatric disorders in children (i. e. – depression, posttraumatic stress disorder, oppositional defiant disorder, bipolar disorder, etc.)  Nonetheless, an accurate diagnosis is possible, as there are specific disruptive mood dysregulation disorder criteria a child must meet to receive the DMDD diagnosis.

DMDD Diagnosis: Criteria

In general, a clinician considering disruptive mood dysregulation disorder will look for severe temper outbursts and consistent irritability and anger in between the outbursts.  Prior to making a diagnosis of DMDD, the clinician will rule out any other possible causes or contributing factors to the presenting DMDD symptoms.  The diagnostic criteria a child must meet in order to receive a DMDD diagnosis is:

  1. Recurrent and severe temper tantrums or outbursts
    • The tantrums/outbursts may be expressed verbally and/or behaviorally (physical aggression towards other people or property).
    • The tantrums/outbursts are considered out of proportion (in duration and intensity) to the situation or triggering event
    • The tantrums/outbursts are inconsistent with the child’s developmental level
    • The tantrums/outbursts occur three or more times per week, on average
  2. Persistent irritability or anger
    • The irritable/angry mood occurs nearly every day, for most of the day
    • The irritable/angry mood is observable by others (peers, parents, teachers, etc. )
  3. The recurrent temper tantrums and persistent irritability/anger have been present for 12 months or longer
    • Throughout the 12 months of ongoing temper tantrums and irritability/anger, the child has not had a period lasting 3 or more consecutive months without all of the diagnostic symptoms.
  4. Symptoms are present in at least two of three primary settings, either home, school, or in social situations.
    • Symptoms are severe in at least one of the three primary settings.
  5. DMDD diagnosis should not be assigned before age 6 or after age 18.
  6. The age of onset of disruptive mood dysregulation disorder is before 10 years old.
  7. The symptoms are not better explained by another mental illness, such as depression, posttraumatic stress disorder, or autism (DMDD and Autism: How Are the Two Related?).  

Disruptive Mood Dysregulation Disorder Controversy

The addition of DMDD to the DSM-5 is helpful in many ways, but it comes with controversy as well.   Many are concerned this new mental health disorder will lower the threshold for diagnosing children who are perhaps just going through a difficult time (What are the Causes of DMDD?). There is fear DMDD will be over-diagnosed (as was previously the case with bipolar disorder), as tantrums and bad moods are not uncommon in children.  Yet being inaccurately diagnosed with DMDD prevents professionals from identifying what might truly be going on with a child.

article references

APA Reference
Jarrold, J. (2018, July 22). DMDD Diagnosis: DSM 5 Criteria for Disruptive Mood Dysregulation Disorder, HealthyPlace. Retrieved on 2023, April 21 from https://www.healthyplace.com/parenting/dmdd/dmdd-diagnosis-dsm-5-criteria-for-disruptive-mood-dysregulation-disorder

Last Updated: May 25, 2019

Medically reviewed by Harry Croft, MD

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Disruptive Mood Dysregulation Disorder (DMDD)

Table of Contents

  • Disruptive Mood Dysregulation Disorder (DMDD)

    • Primer

    • DSM-5 Diagnostic Criteria

      • Signs and Symptoms

    • Screening and Rating Scales

    • Controversy and Criticism

    • Pathophysiology

    • Differential Diagnosis

    • Investigations

    • Treatment

    • Resources

      • For Patients

      • For Providers

Primer

Disruptive Mood Dysregulation Disorder (DMDD) is a new controversial DSM-5 diagnosis for children with chronic and severe persistent irritability and severe anger outbursts. DMDD was created for patients previously diagnosed with the also controversial diagnosis of childhood (pediatric) bipolar disorder and concerns about over-diagnosis and over-treatment with antipsychotics. Although DMDD is officially classified as a mood disorder under the DSM-5, it often co-presents during childhood with other non-mood diagnoses such as conduct disorder and oppositional defiant disorder.

Epidemiology

  • The epidemiology of DMDD is not well understood as it is a new diagnosis; it is estimated to have a prevalence between 2 to 5%.

  • Individuals presenting to clinical attention are most commonly male.

Prognosis

  • Approximately 50% of children with severe, chronic irritability will have a presentation that continues to meet criteria for DMDD 1 year later.

  • DMDD is not a “pre-bipolar” diagnosis, and the rates of conversion from severe, nonepisodic irritability to true bipolar disorder are very low.

  • In both DMDD and pediatric bipolar disorder, severe aggression, reckless behavior, suicidal ideation or suicide attempts, and psychiatric hospitalization can be common.

Comorbidity

  • DMDD has extremely high comorbidity with other psychiatric disorders and it would be rare for an individual to only have a diagnosis of DMDD.

  • The strongest overlap is with oppositional defiant disorder (ODD)

  • Individuals can present with a wide variety of concerns including disruptive behavior, mood, anxiety, and sometimes autism spectrum symptoms.

Risk Factors

DSM-5 Diagnostic Criteria

Criterion A

Severe recurrent temper outbursts manifested verbally (e.g. - verbal rages) and/or behaviourally (e.g. - physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

Criterion B

The temper outbursts are inconsistent with developmental level.

Criterion C

The temper outbursts occur, on average, 3 or more times per week.

Criterion D

The mood between temper outbursts in persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g. - parents, teachers, peers).

Criterion E

Criteria A, B, C, and D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A to D.

Criterion F

Criteria A and D are present in at least 2 of the 3 settings (i.e. - at home, at school, with peers) and are severe in at least 1 of these.

Criterion G

The diagnosis should not be made for the first time before age 6 years or after age 18 years

Criterion H

By history or observation, the age of onset of Criteria A to E is before 10 years.

Criterion I

There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

Criterion J

The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder.

Note:

  • The diagnosis of DMDD cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorders.

  • Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder.

  • If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned (as this indicates a diagnosis of bipolar disorder).

Criterion K

The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Signs and Symptoms

  • It is important to note that according to the DMDD diagnostic criteria, the age of onset of the primary symptoms must have occurred before age 10.

  • In addition, the diagnostic label can only be applied to individuals between age 6 to 18.

Screening and Rating Scales

  • There are no validated scales for DMDD.

  • National Institute for Mental Health (NIMH) research groups have used versions of the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children to diagnose DMDD.

Controversy and Criticism

See main article: Cognitive Biases, Misdiagnosis, Iatrogenesis, and Overdiagnosis

  • The inclusion of DMDD has been questioned because the diagnostic criteria failed the DSM-5 field trials. The agreement between clinicians using the DMDD was poor, with questionable agreement (kappa = 0.25).

  • There remains additional concern that the DMDD diagnosis too broadly includes symptoms from other diagnoses, including oppositional defiant disorder, ADHD, anxiety, and depression.

“DMDD will capture a wildly heterogeneous and diagnostically meaningless grab bag of difficult to handle kids. Some will be temperamental and irritable, but essentially normal and just going through a developmental stage they will eventually outgrow without a stigmatizing diagnosis and a harmful treatment. Others will have conduct or oppositional problems that gain nothing by being mislabeled as mood disorder. Yet others will have serious, but not yet clearly defined psychiatric disorders that require careful and patient monitoring before an accurate diagnosis can be made.”

– Allen Frances, MD, Chair of the DSM-IV Task Force

Pathophysiology

See also: Baweja, R. et al. (2016). Disruptive mood dysregulation disorder: current insights. Neuropsychiatric disease and treatment.

Differential Diagnosis

  • Bipolar I and Bipolar II disorder

    • The central feature differentiating disruptive mood dysregulation disorder and bipolar disorders in children involves the longitudinal course of the core symptoms. In children, as in adults, bipolar disorders are an episodic illness with discrete episodes of mood changes that can be differentiated from the child's typical presentation. For example, the mood change that occurs during a manic episode is distinctly different from the child's usual baseline mood.

    • Additionally, during a manic episode onset (just like adults), there are additional associated cognitive, behavioural, and physical symptoms (e.g. - grandiosity, distractibility, increased goal-directed activity)

    • Thus, in the case of a manic episode, parents and/or children should be able to identify a distinct time period during which the mood and behavior were markedly different from usual.

    • Compare this with DMDD, where irritability is persistent and is present over many months to years. This is why the diagnosis of DMDD cannot be assigned to a child who has ever experienced a full-duration hypomanic or manic episode (irritable or euphoric) or who has ever had a manic or hypomanic episode lasting more than 1 day.

  • Oppositional defiant disorder (ODD)

    • While symptoms of ODD also occur in children with DMDD, the mood symptoms seen in DMDD are relatively rarer in ODD. The diagnosis of DMDD requires severe impairment in at least 1 setting (i.e. - home, school, or among peers) and mild to moderate impairment in a 2nd setting. Thus, a child that meets diagnosis for DMDD will very likely meet criteria for ODD, but not vice versa (only 15% of individuals with ODD would meet criteria for DMDD).

  • Attention-deficit/hyperactivity disorder, major depressive disorder, anxiety disorders, and autism spectrum disorder.

    • Unlike children with bipolar disorder or ODD, a child whose symptoms meet criteria for DMDD also can receive a comorbid diagnosis of ADHD, major depressive disorder, and/or anxiety disorder. However, children whose irritability is present only in the context of a major depressive episode or persistent depressive disorder (dysthymia) should receive one of those diagnoses and not a diagnosis of DMDD.

    • Children with autism spectrum disorder can also have temper outbursts and the child should not receive a DMDD diagnosis.

  • Intermittent explosive disorder (IED)

    • Children with IED present with episodes of severe temper outbursts, much like children with DMDD. However, unlike DMDD, IED does not require persistent irritability and/or disruption in mood between outbursts.

    • In addition, IED requires only 3 months of active symptoms, compared to the 12-month requirement for DMDD. Thus, these two diagnoses should never be made in the same child. For children with severe outbursts plus persistent irritability, the diagnosis of DMDD should be made over IED.

Investigations

Treatment

  • Management of DMDD should focus on helping children and adolescents improving emotional dysregulation through parental, school, and professional support. Social skills training may also be helpful.

  • There are no FDA-approved medications for use in DMDD.

Resources

For Patients

  • NIMH - Disruptive Mood Dysregulation Disorder: The Basics

For Providers

Articles

  • NYT Magazine: The Bipolar Puzzle

  • NPR: Children Labeled 'Bipolar' May Get A New Diagnosis

Research

  • Parker, Gordon, and Gabriela Tavella. "Disruptive Mood Dysregulation Disorder: A Critical Perspective." The Canadian Journal of Psychiatry 63, no. 12 (2018): 813-815.

References

1) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

2) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

3) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

4) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

5) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

6) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

7) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

8)Baweja, R., Mayes, S. D., Hameed, U., & Waxmonsky, J. G. (2016). Disruptive mood dysregulation disorder: current insights. Neuropsychiatric disease and treatment.

9) American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA.

Psychology of stress: theory and practice

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    Borderline Personality Disorder Test - Competent Parent

    Uncategorized

    The technique is a personality questionnaire developed on the basis of diagnostic criteria for borderline personality disorder according to DSM-III-R and DSM-IV in 2012 by a team of authors (T. Yu. Lasovskaya, S. V. Yaichnikov, Yu. V. Sarycheva, Ts. P. Korolenko).

    According to the DSM diagnostic criteria, the diagnosis of borderline personality disorder is carried out according to the following criteria:

    1. Pattern of unstable and intense interpersonal relationships , characterized by polar, negative or positive assessments. It is assumed that persons with borderline personality disorder are unable to see the true reasons for the behavior of others (for example, caring or helping) and the behavior is rated as absolutely positive if it is pleasurable, or as absolutely negative if it does not. This characteristic is important in diagnosing borderline personality disorder, as it reflects a psychological splitting mechanism that effectively alleviates strong feelings, such as anger.
    2. Impulsivity in at least two areas that are potentially self-injurious, eg spending money, sex, substance abuse, risky driving, overeating (does not include suicidal and self-injurious behavior). Impulsivity as a feature is characteristic of antisocial personality disorder, as well as states of mania (hypomania). However, it is only in borderline personality disorder that impulsivity has a connotation of direct or indirect self-harm (self-directedness), such as chemical addictions or bulimia. The criterion of impulsivity explains the difficulties described in early works in conducting psychotherapy for people with borderline personality disorder - frequent conflicts, interruption of therapy at the very beginning.
    3. Emotional instability : pronounced deviations from the isoline from the side of mood towards depression, irritability, anxiety, usually lasting from several hours to several days. The affective instability and propensity to depression in borderline disorder resemble those in individuals with emotion regulation problems such as depression and bipolar 2 disorder. Therefore, the meaning of this criterion should be clarified, namely: we are talking about increased emotional reactivity, where mood swings occur, but they occur more often, proceed softer and less long than in depression and bipolar disorder.
    4. Inadequate, intense anger or poor anger control (eg, frequent irascibility, persistent anger, attacking others). Kernberg considered anger to be a characteristic feature of borderline personality disorder and noted that the anger reaction is associated with a situation of excessive frustration. Anger is both a result of genetic predisposition and environmental influences and may lead to future acts of self-harm. Signs of self-harm as a result of the realization of anger, it would seem, are easily detected, for example, cuts, but they are not always possible to establish during a conversation with the patient. Many patients experience anger most of the time, but very rarely put it into action (the anger is hidden). Sometimes anger becomes apparent only after the patient's destructive actions. In some cases, indications of anger and its manifestations appear in the anamnesis or are revealed during active questioning on this topic. Anger is easily provoked in a purposeful confrontational interview.
    5. Repeated suicidal behavior , destructive behavior and other self-injurious behavior. Repeated suicide attempts and self-injurious behavior are reliable markers of borderline personality disorder.
    6. Identity disorder manifesting itself in at least two areas - self-esteem, self-image, sexual orientation, goal setting, career choice, type of friends preferred, values. This criterion was described by O. Kernberg when describing the construct of a borderline personal organization. Since DSM-III, the criterion has been modified to distinguish between situations where identification instability is a manifestation of the norm, such as during adolescence. This criterion, more than any other, is self-related and therefore specific to borderline personality disorder. This may be important in pathology, when the perception of the body image is impaired - body dysmorphic disorders and anorexia nervosa.
    7. Chronic feeling of emptiness (or boredom). Early analysts (Abraham and Freud) described the oral phase of development, noting that failure to complete it leads in adulthood to symptoms of depression, dependence, and emptiness in interpersonal relationships. This concept was developed and supplemented by M. Kline's theory of object relations, which showed that due to poor early relationships, a person becomes incapable of internalizing positive emotions during interpersonal communication (that is, inability to internalize feelings in oneself / oneself) and incapable of self-comfort. The feeling of emptiness in borderline personality disorder has somatic manifestations, localized in the abdomen or chest. This sign should be distinguished from fear or anxiety. Emptiness or boredom, which takes the form of intense mental pain, as a subjective experience of the patient, is extremely important for making a diagnosis of borderline personality disorder.
    8. Real or imagined fear of leaving . Masterson sees the fear of leaving as an important diagnostic feature of the borderline construct. However, this criterion needs some clarification, since it is necessary to differentiate it from the more pathological separation anxiety. Gunderson proposed to change the wording of this criterion, namely, to transform it into " lack of tolerance for loneliness ". It is believed that exposure in the early period, from 16 to 24 months of life, is important in the formation of the symptom
    9. Stress-related incoming paranoid ideas and dissociative symptoms .

    The short version contains 20 questions and is a convenient and valid tool for screening, daily diagnosis and verification of the diagnosis in psychiatric, general clinical and non-medical practice.

    1. I am often disappointed in people who seemed ideal to me

    Yes

    No

    2. I can be called a "risk guy" - I like everything that helps to feel the brightness of the world - drive a car at high speed, spend big money, experiment with alcohol or drugs

    Yes

    No

    3. I experience an unprecedented high of mood if I manage to win at least a small amount of money (for example, in cards or a casino)

    Yes

    No

    4. I have episodes when I can eat a large amount of food in a short time (sweets, cake) and in general everything that is in the refrigerator

    Yes

    No

    5. My mood is often good, even and stable

    Yes

    No

    6. Others notice that my mood can be very changeable - sometimes several times a day

    Yes

    No

    7. If I am really angry, I can easily insult a person or provoke a fight

    Yes

    No

    8. Sometimes I get very angry, which is difficult to contain

    Yes

    No

    9. At moments of difficult emotional experiences, I have thoughts of suicide or self-harm

    Yes

    No

    10.Sometimes I suddenly want to do something that may or may not end in my death, such as taking a large dose of medication

    Yes

    No

    11. From time to time such bad thoughts come into my head that it is better not to talk about them

    Yes

    No

    12. There were episodes in my life when I hurt myself (cut my hand with a razor, burned my skin with a cigarette, etc.

    Yes

    No

    13. Others notice that I can sometimes do rash things

    Yes

    No

    14.Sometimes it happened that I did not finish almost finished work, because it ceased to interest me

    Yes

    No

    15.

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