Disruptive mood dysregulation disorder (DMDD)

Disruptive mood dysregulation disorder (DMDD) is a severe childhood mood disorder characterized by ongoing and persistent extreme irritability and anger, typically with debilitating temper tantrums occurring multiple times per week. A diagnosis of DMDD only applies to children between the ages of six and eighteen, and only to those whose symptoms start before the age of ten. There is no available research or information about this condition in adulthood. Treatment for DMDD typically includes a combination of medication and psychotherapy. Because this disorder is a relatively new diagnosis within the field of psychiatry, however, little is known about the long-term effectiveness of various treatments, particularly since DMDD often is diagnosed alongside other existing psychological disorders. As children age and develop additional coping skills, however, symptoms of DMDD do typically decrease.

Background

The fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; 2013), is the first edition to carry a listing for DMDD. Prior to the addition of DMDD to the DSM-5, children with these characteristics usually were diagnosed with pediatric bipolar disorder. According to the Journal of the American Academy of Physician Assistants, before the DSM-5 added DMDD in 2013, diagnoses of pediatric bipolar disorder had increased by 500 percent over the preceding ten years. Unlike bipolar disorder, DMDD is not episodic or cyclical. In addition, children with DMDD do not show an increased likelihood of developing bipolar disorder as adults. DMDD is more prevalent among boys than girls, which is not true of pediatric bipolar disorder. According to PsychCentral, researchers estimate that between 2 and 5 percent of children have DMDD, but more research is needed to determine its actual prevalence since many children with DMDD are likely misdiagnosed with pediatric bipolar disorder. The 2022 text revision of DSM-5, DSM-5-TR, updated the age range criterion for DMDD to six to eighteen years.

Researchers largely remain unsure about the risk factors for DMDD—what makes one child more likely to develop it while another one does not. Researchers have found that when a child has a parent suffering from bipolar disorder, that child may be more likely to develop DMDD. In fact, any type of family history of bipolar disorder appears to increase the risk of developing DMDD in childhood. Some research also suggests that children with DMDD may lack the ability to accurately perceive facial expressions, which may cause them to perceive a neutral face as an angry face—which then triggers them to respond in turn. Psychologists are conducting trials using computer training, which in theory will teach children to better identify facial expressions and regulate their own responses accordingly.

Another factor that disrupts diagnosis is the question of whom to believe in a diagnostic setting—for example, if the parent and child differ significantly in their descriptions of incidents or day-to-day life or if the psychologist does not directly observe the issues in the child. In some cases, a researcher may not even interview or interact with the child directly, which leads to the possibility that other issues, such as hallucinations or even sexual abuse, may remain unidentified in the child.

Overview

For a child to be diagnosed with DMDD, they must experience symptoms consistently for at least twelve months. The key symptoms for diagnosis include irritability or anger nearly all day, every day, in every situation, with outbursts that are significantly out of proportion to the current situation or to the child's level of development three or more times per week. Temper outbursts may include verbal rages (such as screaming and yelling) and/or physical aggression toward other people or belongings. DMDD is not situational—that is, if a child experiences irritability and anger consistently at home, but not at school or with peers, it is not DMDD. If a child experiences breaks in their irritability that last for three months or more, the diagnosis of DMDD will not apply. Children with DMDD typically have significant problems functioning in their lives, whether they are at home or at school, which is one of the reasons this disorder requires treatment from a professional.

The key component of DMDD is that the child has chronic, consistent issues with mood regulation. Disorders that are similar to DMDD but are more episodic or situational—that is, they do not always occur—include intermittent explosive disorder or oppositional defiant disorder. Children with autism may struggle to express and regulate their moods. In addition, DMDD may co-occur with other psychological disorders including attention deficit hyperactivity disorder (ADHD), anxiety, major depression, conduct disorder, or even substance abuse, which can also make it more difficult to diagnose.

Children with DMDD are much more likely to develop depression and anxiety later in life. They struggle to learn in school and to make friends and often have a very low quality of life. Treatment for the disorder typically includes medication—which may include stimulants, such as those used to treat ADHD; antidepressants, or even antipsychotics, if the child has become physically aggressive. However, all medications—particularly psychotropic ones—carry risks of side effects, and many are not approved for usage in children, so research is ongoing to determine the best methods of treatment. In addition to medication, DMDD patients typically undergo some form of psychotherapy, often for both the child and the child's parents or caregivers, who must learn how to handle the disorder in day-to-day life. The most common type of therapeutic treatment used in this disorder is cognitive behavioral therapy, or CBT, which teaches children skills for managing their moods and emotions and changing the perceptions that may be contributing to their anger or tantrums. Parents will then learn better strategies to respond to the child's behavior, reward positive behavior, and learn to anticipate the situations that are more likely to cause an outburst and potentially redirect the child to a different situation or a healthier method of expression. According to the Child Mind Institute in 2024, practitioners have effectively treated DMDD with a combination of dialectical behavior therapy for children and parent management training.

Bibliography

Althoff, Robert R., et al. "Disruptive Mood Dysregulation Disorder at Ages 13–18: Results from the National Comorbidity Survey—Adolescent Supplement." Journal of Child and Adolescent Psychopharmacology, vol. 26, no. 2, 2016, pp. 107–13.

Carlson, Gabrielle A. "Disruptive Mood Dysregulation Disorder." Long-Term Outcomes in Psychopathology Research: Rethinking the Scientific Agenda, edited by Evelyn J. Bromet, Oxford UP, 2016.

"Disruptive Mood Dysregulation Disorder: The Basics." National Institute of Mental Health, NIH, 2023, www.nimh.nih.gov/health/publications/disruptive-mood-dysregulation-disorder. Accessed 29 Jan. 2025.

"DSM-5-TR and Diagnoses for Children." American Psychiatric Association, 2022, www.psychiatry.org/getmedia/178f173b-f4a1-433b-aef3-7b2fb513436b/APA-DSM5TR-DiagnosesforChildren.pdf. Accessed 29 Jan. 2025.

Ditzell, Jeffrey, and Lela Moore. "Symptoms of Disruptive Mood Dysregulation Disorder." PsychCentral, 28 Sept. 2021, psychcentral.com/disorders/disruptive-mood-dysregulation-disorder. Accessed 29 Jan. 2025.

Noller, Diana T. "Distinguishing Disruptive Mood Dysregulation Disorder from Pediatric Bipolar Disorder." Journal of the American Academy of Physician Assistants, vol. 29, no. 6, June 2016, pp. 25–28.

Shuldiner, Marc. "Quick Guide to Disruptive Mood Dysregulation Disorder." Child Mind Institute, 3 Dec. 2024, childmind.org/guide/disruptive-mood-dysregulation-disorder-a-quick-guide/. Accessed 29 Jan. 2025.

Sparks, Garrett, et al. "Disruptive Mood Dysregulation Disorder and Chronic Irritability in Youth at Familial Risk for Bipolar Disorder." Adolescent Psychiatry, vol. 53, no. 4, 2014, pp. 408–16.