- Describe symptoms, characteristics, and treatment methods related to disruptive mood dysregulation disorder
Disruptive mood dysregulation disorder (DMDD) is a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. Disruptive mood dysregulation disorder (DMDD) symptoms go beyond being a “moody” child—children with disruptive mood dysregulation disorder (DMDD) experience severe impairment that requires clinical attention. DMDD is a fairly new diagnosis, appearing for the first time in the DSM-5, published in 2013.
Signs and Symptoms
DMDD symptoms typically begin before the age of 10, but the diagnosis is not given to children under six or adolescents over 18. A child with DMDD experiences
- irritable or angry mood most of the day, nearly every day;
- severe temper outbursts (verbal or behavioral) at an average of three or more times per week that are out of keeping with the situation and the child’s developmental level; and
- trouble functioning due to irritability in more than one place (e.g., home, school, or with peers).
To be diagnosed with DMDD, a child must have these symptoms steadily for 12 or more months. The core features of DMDD—temper outbursts and chronic irritability—are sometimes seen in children and adolescents with other psychiatric conditions. Differentiating DMDD from these other conditions can be difficult. Three disorders that most closely resemble DMDD are attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and bipolar disorder in children. Additionally, in both community and clinical samples DMDD is highly comorbid with internalizing and externalizing disorders, particularly with ODD, and long-term functional outcome is likely poor.
There are not good estimates of the prevalence of DMDD, but as of 2015, primary studies have found a rate of 0.8 to 3.3%. Epidemiological studies show that approximately 3.2% of children in the community have chronic problems with irritability and temper, the essential features of DMDD. These problems are probably more common among clinic-referred youths. Parents report that approximately 30% of children hospitalized for psychiatric problems meet diagnostic criteria for DMDD; 15% meet criteria based on the observations of hospital staff.
This video explains more about the history of the diagnosis of disruptive mood dysregulation disorder.
The causes of DMDD are unknown, but researchers are exploring risk factors and brain mechanisms of this disorder. Functional MRI studies suggest that under-activity of the amygdala, the brain area that plays a role in the interpretation and expression of emotions and novel stimuli, is associated with these deficits. Deficits in interpreting social cues may predispose children to instances of anger and aggression in social settings with little provocation. For example, youths with DMDD may selectively attend to negative social cues (e.g., others scowling or teasing) and minimize all other information about the events. They may also misinterpret the emotional displays of others, believing others’ benign actions to be hostile or threatening. Consequently, they may be more likely than their peers to act in impulsive and angry ways.
Youth with DMDD have difficulty attending, processing, and responding to negative emotional stimuli and social experiences in their everyday lives. For example, some studies have shown youths with DMDD to have problems interpreting the social cues and emotional expressions of others. These youths may be especially bad at judging others’ negative emotional displays, such as feelings of sadness, fearfulness, and anger.
Treatment and Therapies
DMDD is a new diagnosis. Therefore, treatment is often based on what has been helpful for other disorders that share the symptoms of irritability and temper tantrums. These disorders include attention deficit hyperactivity disorder (ADHD), anxiety disorders, oppositional defiant disorder, and major depressive disorder.
DMDD can impair a child’s quality of life and school performance and disrupt relationships with their family and peers. Children with DMDD may find it hard to participate in activities or make friends. Having DMDD also increases the risk of developing depression or anxiety disorders in adulthood.
While researchers are still determining which treatments work best, two major types of treatment are currently used to treat DMDD symptoms: medication and psychological treatments like psychotherapy, parent training, and computer-based training. Psychological treatments should be considered first, with medication added later if necessary, or psychological treatments can be provided along with medication from the beginning. It is important for parents or caregivers to work closely with the doctor to make a treatment decision that is best for their child.
Many medications used to treat children and adolescents with mental illness are effective in relieving symptoms. However, some of these medications have not been studied in depth and/or do not have U.S. Food and Drug Administration (FDA) approval for use with children or adolescents. All medications have side effects and the need for continuing them should be reviewed frequently with the child’s doctor.
For basic information about these and other mental health medications, you can visit the National Institute of Mental Health (NIMH) Mental Health Medications webpage. For the most up-to-date information on medications, side effects, and warnings, visit the FDA website.
Stimulants are medications that are commonly used to treat ADHD. There is evidence that, in children with irritability and ADHD, stimulant medications also decrease irritability.
Stimulants should not be used in individuals with serious heart problems. According to the FDA, people on stimulant medications should be periodically monitored for changes in heart rate and blood pressure.
Antidepressant medication is sometimes used to treat the irritability and mood problems associated with DMDD. Ongoing studies are testing whether these medicines are effective for this problem. It is important to note that although antidepressants are safe and effective for many people, they carry a risk of suicidal thoughts and behavior in children and teens. A “black box” warning—the most serious type of warning that a prescription can carry—has been added to the labels of these medications to alert parents and patients to this risk. For this reason, a child taking an antidepressant should be monitored closely, especially when they first start taking the medication.
An atypical antipsychotic medication may be prescribed for children with very severe temper outbursts that involve physical aggression toward people or property. Risperidone and aripiprazole are FDA-approved for the treatment of irritability associated with autism and are sometimes used to treat DMDD. Atypical antipsychotic medications are associated with many significant side effects, including suicidal ideation/behaviors, weight gain, metabolic abnormalities, sedation, movement disorders, hormone changes, and others.
CBT, a type of psychotherapy, is commonly used to teach children and teens how to deal with thoughts and feelings that contribute to their feeling depressed or anxious. Clinicians can use similar techniques to teach children to more effectively regulate their mood and to increase their tolerance for frustration. The therapy also teaches coping skills for regulating anger and ways to identify and re-label the distorted perceptions that contribute to outbursts. Other research psychotherapies are being explored at the National Institute of Mental Health (NIMH).
Parent training aims to help parents interact with a child in a way that will reduce aggression and irritable behavior and improve the parent-child relationship. Multiple studies show that such interventions can be effective. Specifically, parent training teaches parents more effective ways to respond to irritable behavior, such as anticipating events that might lead a child to have a temper outburst and working ahead to avert the outburst. Training also focuses on the importance of predictability, being consistent with children, and rewarding positive behavior.
Evidence suggests that irritable youth with DMDD may be prone to misperceiving ambiguous facial expressions as angry. There is preliminary evidence that computer-based training designed to correct this problem may help youth with DMDD or severe irritability.
Key Takeaways: Disruptive mood dysregulation disorder
disruptive mood dysregulation disorder (DMDD): a childhood condition marked by extreme irritability; anger; and frequent, intense temper outbursts