Disruptive Mood Dysregulation Disorder (DMDD)…A necessary response to the “bipolar” epidemic

shutterstock_134142485In Part Three of our new blog series…Dissecting the DSM-5…What it Means for Kids and Families we’ll look at one of the most controversial  diagnoses in the new diagnostic manual for mental disorders: Disruptive Mood Dysregulation Disorder (DMDD).

One of the most common reasons parents bring their kids to a practice like ours is for help in managing severe anger outbursts. We do very thorough assessments when kids have problems with irritability and anger because there are so many potential conditions that can predispose them to or precipitate meltdowns associated with aggressive or potentially self-injurious behavior. It’s not uncommon for us to see kids who have two or more conditions contributing to aggressive outbursts…in many instances, the treatment used to address aggression associated with one condition can precipitate aggression associated with a comorbid condition.

Over the last 15-20 years, kids with irritability as their predominant mood state along with protracted aggressive outbursts/meltdowns began receiving diagnoses of bipolar disorder at rates that alarmed many (myself included) in the mental health community…a 4,000% increase in prevalence of bipolar disorder over a ten year period!

Most kids receiving the bipolar disorder diagnosis didn’t fit the traditional diagnostic criteria in terms of duration of mood episodes (a distinct period of elevated, expansive or irritable mood lasting at least a week).

Medications shown or thought to be effective for bipolar disorder in children and teens have been associated with the potential for very serious side effects…significant weight gain, elevation in lipid and cholesterol levels, diabetes or prediabetic conditions, elevated prolactin levels and tardive dyskinesia in the case of second-generation antipsychotics, renal and thyroid toxicity with lithium, and polycystic ovary disease and weight gain with sodium valproate. For more information, see this post on safety issues with antipsychotic medication.

Why was there such an uptick in the frequency with which the bipolar diagnosis was applied to children from the mid-1990s on?

  • For some time, there was a lack of consensus among researchers in the field as to the appropriate diagnostic criteria for bipolar disorder in children and teens, or whether bipolar disorder presented differently in kids as opposed to adults.
  • Many clinicians were prone to misinterpret the research that was being published on pediatric bipolar disorder at the time from several very prestigious academic medical centers.
  • Lots of parents of kids with chronic irritability and aggression latched onto the diagnosis of bipolar disorder following the publication of a very influential book, The Bipolar Child.
  • In a reimbursement-driven mental health system in which treatment for most conditions is limited to brief psychiatric visits for medication management and weekly outpatient psychotherapy with clinicians of  wildly inconsistent training backgrounds and experience, the bipolar diagnosis provided a rationalization for the use of medication that occasionally provided temporary relief from crisis situations for families of kids with serious mental illnesses in the absence of a better continuum of services for kids with chronic irritability and aggressive behavior.

Emotional girlA number of researchers, most notably Dr. Ellen Leibenluft and her team at the National Institute of Mental Health began to do longitudinal studies with kids who presented with irritability as their predominant mood state and severe difficulties with emotional and behavioral self-regulation. What they found laid the foundation for the new diagnostic classification in the DSM-5 of DMDD (listed below)…

  • Presentation characterized by severe recurrent temper/aggression outbursts in response to common stressors
  • Outbursts are manifest verbally and/or behaviorally, in the form of verbal rages or physical aggression towards people or property
  • The child’s reaction is grossly out of proportion in intensity or duration to the situation or provocation
  • The child’s outbursts are inconsistent with their developmental level
  • Temper outbursts occur, on average, three or more times per week in two or more different settings (home, school, peers) and severe in at least one setting
  • Mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
  • Negative mood is observable by others (e.g., parents, teachers, peers).
  • Age of onset prior to ten years
  • Symptoms present for at least twelve months

Compared to kids who fit the traditional diagnosis of bipolar disorder…

  1. The kids with DMDD had serious mental illness…their functional impairment was typically as severe (if not more severe) than kids who met criteria for bipolar disorder in the DSM-IV.
  2. Kids with DMDD exhibited measurable differences in neuroimaging studies and computer tasks measuring attention deployment in response to emotional stimuli frustration tolerance and cognitive flexibility.
  3. Kids with DMDD were at greater risk for developing depressive disorders and anxiety disorders as they grew older…kids with bipolar disorder become adults with bipolar disorder.

An obvious question comes to mind…Why would so many kids start turning up in mental health clinics and physician offices with severe anger outbursts and chronic irritability around the turn of the current century? The answer to that question may provide hints as to how kids who meet the criteria for DMDD will be most safely and effectively treated. Allow me to share a hypothesis…

We know that kids with the condition described as DMDD struggle with anxiety and depression as they grow older, and that most meet the diagnostic criteria for ADHD. They have difficulties with emotional self-regulation and impulse control, and they think too much…I’d use the terms “obsess,” “perseverate” and “ruminate” to describe this quality of their thinking. The parents give affirmative answers to the following  questions…

  • Does your child have a hard time making up their mind when they need to choose between two or three things?
  • When somebody says or does something that bothers your child, do they have a hard time letting it go?  
  • Does your child have a hard time transitioning from activities they like to do to activities they have to do?  

What else happened that had a big impact on mental health care for kids in the mid to late 1990s? From the Centers for Disease Control

The first national survey that asked parents about ADHD was completed in 1997. Since that time, there has been a clear upward trend in national estimates of parent-reported ADHD diagnoses. It is not possible to tell whether this increase represents a change in the number of children who have ADHD, or a change in the number of children who were diagnosed. Perhaps relatedly, the number of FDA-approved ADHD medications increased noticeably since the 1990s, after the introduction of long-acting formulations.

The late 1990s were the time when we began to see a big increase in the use of ADHD medication, especially longer-acting ADHD medications with effects extending beyond the bounds of the school day. The trend accelerated following FDA approval of Concerta in 2000, Adderall XR in 2001 and Strattera in 2002. One problem frequently seen with ADHD medication is that kids prone to obsessive, ruminative thinking and perseveration often become angry, moody, irritable and emotional in response to commonly used ADHD medications, especially at home where they don’t have the same intensity of cognitive stimulation serving as a distraction from bothersome thoughts. I’d suggest that many of these kids are mislabeled with bipolar disorder when clinicians fail to recognize that their ADHD medication is exacerbating other traits…traits that contribute to anger outbursts and aggressive behavior in the short run and predispose kids to anxiety or depression as they get older.

As a result, the way I’ve been approaching kids who meet the criteria for DMDD is to become significantly more conservative in the use of medications for ADHD and anxiety in the absence of research that informs how we might most effectively treat them. I’ll encourage parents to pursue cognitive-behavioral therapy to help with the rigid, obsessive thinking that frequently leads to protracted meltdowns. I’ll suggest more environmental or educational accommodations to try to decrease the need for ADHD medication that often exacerbates irritability. In my experience, I’ve found that many kids who meet the criteria for DMDD are very sensitive to behavioral activation from the serotonin-specific antidepressants that are approved to treat anxiety, depression and obsessive thinking in children and teens, resulting in the need to start with very low doses and monitor carefully for increases in restlessness, agitation or aggression.

Critics of the DSM-5, including the eminent psychiatrist Allen Francis, have raised concerns that inclusion of DMDD increases the risk of excessive use of medication, when the intent of the APA was to call attention to the practice of inappropriate diagnosis of pediatric bipolar disorder. Quoting from the DSM-5…

“In fact, disruptive mood dysregulation disorder was added to DSM-5 to address the considerable concern about the appropriate classification and treatment of children who present with chronic, persistent irritability relative to children who present with classic (i.e., episodic) bipolar disorder.

Other critics, including Dr. David Axelson have valid points in suggesting we lack sufficient scientific data to support a new diagnosis, and observing the criteria for DMDD lack good inter-rater reliability.

On the whole, I think we have more than enough data to recognize that there is a very large subset of kids who are inappropriately being diagnosed with bipolar disorder and unnecessarily exposed to medication treatments associated with substantial health risk. Because of biases introduced through differences in training and experience, the consistency with which clinicians would accurately apply any new criteria involving irritability and mood in children would be low, regardless of the breadth and depth of the scientific data supporting the new condition. Adding diagnostic criteria to the DSM-5 for DMDD is a significant plus for kids if the new guidelines help clinicians to be more thoughtful in  evaluating and treating kids with moodiness and irritability.

Here’s a download from the American Psychiatric Association on DMDD.

Updated June 28, 2014

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KM Logo UpdatedKey Ministry has assembled resources to help churches more effectively minister to children and adults with ADHD, anxiety disorders, Asperger’s Disorder, Bipolar Disorder, depression and trauma. Please share our resources with any pastors, church staff, volunteers or families looking to learn more about the influence these conditions can exert upon spiritual development in kids, and what churches can do to help!

About Dr. G

Dr. Stephen Grcevich serves as President and Founder of Key Ministry, a non-profit organization providing free training, consultation, resources and support to help churches serve families of children with disabilities. Dr. Grcevich is a graduate of Northeastern Ohio Medical University (NEOMED), trained in General Psychiatry at the Cleveland Clinic Foundation and in Child and Adolescent Psychiatry at University Hospitals of Cleveland/Case Western Reserve University. He is a faculty member in Child and Adolescent Psychiatry at two medical schools, leads a group practice in suburban Cleveland (Family Center by the Falls), and continues to be involved in research evaluating the safety and effectiveness of medications prescribed to children for ADHD, anxiety and depression. He is a past recipient of the Exemplary Psychiatrist Award from the National Alliance on Mental Illness (NAMI). Dr. Grcevich was recently recognized by Sharecare as one of the top ten online influencers in children’s mental health. His blog for Key Ministry, www.church4everychild.org was ranked fourth among the top 100 children's ministry blogs in 2015 by Ministry to Children.
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10 Responses to Disruptive Mood Dysregulation Disorder (DMDD)…A necessary response to the “bipolar” epidemic

  1. Max Forrey says:

    Great article, Steve! As an educator, I agree with all you said. I would add from my personal viewpoint that this age of “relaxed parenting” with no boundaries, personal accountability or structure actually contributes to the anxiety level in many children.
    When kids have real structure, natural consequences/rewards and have a general knowledge of what to expect on any given day, anxiety decreases dramatically for many of them…even those
    who might otherwise be “diagnosed” by a clinician not looking for environmental causes, just a “quick fix”…(but wait, it was you and Leslie who taught ME about decreasing anxiety by creating this type of environment for MY kid…lol).

    Like

  2. Honey Hofmann says:

    Dear Steve
    As always your thoughts/reflections especially on DMDD are based on careful consideration of the research and supported by your extensive clinical experience with children and their families. I desperately miss being able to consult and collaborate with you in the care of kids. I am practicing now in Charlottesville VA and so often wish I could just refer some of my patients to your kind and competent care.
    Honey Hofmann

    Like

  3. drgrcevich says:

    Honey,

    Nice to hear from you! I hope Larry is enjoying his well-deserved retirement in Charlottesville. I wouldn’t mind having you back in Northeast Ohio…it’s becoming more and more of a challenge to find mental health professionals who are excellent with kids.

    Like

  4. mrsmontanez says:

    Amazing. Our doctor recently brought this diagnosis up at an appointment as something we will be potentially looking at for my son. I’ve been looking for information on it, and now I have it. We’ve been struggling for three years, trying to figure out what’s going on and what to do and this has given me a lot of insight. Thank you so much for this.
    Carrie Montanez

    Like

  5. Laurie Mershobn says:

    Being a parent of an early onset bipolar child (11yr old son), I do agree that it is very difficult to “tease” out all the symptoms and behaviors. So many disorders overlap; it really requires very strong assessment skills and experience, which from our experience, I feel a large percentage of child pdocs just don’t have w/this disease. It took 8 very long painful years of seeking help from developmental pediatricians, neurologists, and several well known pdocs here in the Dallas area, and our son being flipped in to mania w/full blown psychosis after being put on 2.5mg of Lexapro for 5 days, for us to finally “peg” what was going on w/our son. Being a trauma nurse myself, it has been incredible to see how this disease has changed since that initial 10 wk nightmare episode…. our son has had 3 full blown manic episodes w/psychosis in one year and when he is in a “good” state, he cycles like “clock work” every morning/late afternoon that literally stops 30min after he gets his . 0625mg dose of Risperdal. We do have him w/ped bipolar specialist( Kirti Saxena at Texas Childrens Hospital down in Houston) in conjunction w/ a pdoc at Childrens here in Dallas. With all this being said, it is just as devastating for this disease to be “missed” (maybe worse because of the potential long term effects the antidepressants and stimulants can have on the coarse of this disease) in the 1% of children who are afflicted w/this aweful disease.

    Like

  6. zazzzy says:

    Unfortunately, the recommended medication for DMDD kids is Risperidone, which undermines your argument.

    Like

    • drgrcevich says:

      There is no FDA-approved medication treatment for DMDD at this time. Who claims that the “recommended medication” for DMDD is risperidone?

      Like

  7. Mandi Hariton says:

    My son is getting ready to start Lamictal. He will start one a day for the first week then we up it to twice a day. Has anyone had any luck with this medicine?

    Like

  8. a.s says:

    now i know what is wrong with me when i was a kid

    Like

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