Disruptive Mood Dysregulation Disorder (Children and Adolescents)

Children and adolescents as well as adults can get depressed, displaying persistent sadness and loss of interest in once-pleasurable activities, including a sense of discouragement and feelings of hopelessness. More often, however, children display a mood of irritability rather than one of sadness. Chronic, unrelenting moods of irritability and anger punctuated with severe and recurrent temper tantrums are the distinctive features of disruptive mood dysregulation disorder. Experts estimate that the condition affects 2 to 5 percent of children and is more common among males than among females. As with other depressive conditions, disruptive mood dysregulation disorder can have far-reaching effects on the functioning and adjustment of young people. It is associated with high levels of social impairment and school suspensions. Psychotherapy is often a highly effective form of treatment, and depending on the severity of the symptoms, medication may also be prescribed.

Definition

Disruptive mood dysregulation disorder has its onset in children under the age of 10, and consists of chronic, severe, persistent irritability. The extreme irritability manifests both in a pervasive irritable or angry mood and in frequent, developmentally inappropriate temper outbursts displayed verbally in rages and/or behaviorally in physical aggression toward people or property. The disorder impairs functioning in at least two of the three settings in which children typically spend their time—with parents, teachers, or peers—and it does so severely in at least one of those settings. A relatively newly defined condition, the diagnosis of disruptive mood dysregulation disorder is intended to accurately distinguish some children who were previously diagnosed with pediatric bipolar disorder, in which irritability tends to be episodic. Disruptive mood dysregulation disorder is more common than bipolar disorder before adolescence, and symptoms tend to decrease as an adolescent moves into adulthood. Longitudinal studies show that severe mood dysregulation in childhood correlates with later depression.

Symptoms

As catalogued by the DSM-5, the signs and symptoms of disruptive mood dysregulation disorder include:

  • Severe recurrent temper outbursts manifested verbally in verbal rages and/or behaviorally in physical aggression toward people or property
  • The temper outbursts are inconsistent with the child's developmental level 
  • Outbursts generally occur three or more times a week
  • Between temper outbursts the child is irritable or angry most of time
  • The symptoms have been present for at least 12 months, and the child has not had a period of longer than three consecutive months without symptoms
  • The symptoms manifest in at least two out of three of the child's usual settings—home, school, with peers—and are severe in at least one of them
  • The symptoms begin before age 10, and diagnosis is not made for the first time prior to age 6 or after age 18
  • The symptoms are not attributable to major depression, mania, autism spectrum disorder, oppositional defiant disorder, or other mental health condition.

The symptoms of DMDD may overlap with those of attention deficit/hyperactivity disorder (ADHD) and oppositional defiant disorder.

Causes

There is no single known cause of depression. Rather, it likely results from a combination of genetic, biological, environmental, and psychological factors.

Brain-imaging technologies, such as magnetic resonance imaging (MRI), have shown that the brains of people who have depression look different than those of people without depression. The parts of the brain responsible for regulating mood, thinking, sleep, appetite, and behavior appear to function abnormally. In addition, important neurotransmitters—chemicals that brain cells use to communicate with each other—appear to function abnormally. In addition, researchers have identified errors in the way the brains of children with DMDD process facial cues of others. But these findings do not reveal why the condition has occurred.

Some types of depression tend to run in families, suggesting a genetic link. However, depression can occur in people without family histories of depression as well. Genetics research indicates that risk for depression results from the influence of multiple genes acting together with environmental or other factors. 

In addition, trauma, loss of a loved one, a difficult relationship, or any stressful situation may trigger a depressive episode. Subsequent depressive episodes may occur with or without an obvious trigger.

Treatment

Depression is a treatable disorder, even in the most severe cases. As with many illnesses, the earlier that treatment can begin, the more effective it is and the greater the likelihood that recurrence can be prevented.

The first step to getting appropriate treatment is to visit a doctor. Certain medications, and some medical conditions such as viruses or a thyroid disorder, can cause the same symptoms as depression. A doctor can rule out such possibilities by conducting a physical examination, interview, and lab tests. Once a medical condition is ruled out as a cause, the doctor can conduct a psychological evaluation or refer the patient to a mental health professional.

The doctor or mental health professional will conduct a complete diagnostic evaluation. He or she should discuss any family history of depression or other mental health condition, and get a complete history of symptoms—when they started, how long they have lasted, their severity, when they manifest, and if they have occurred before, how they were treated. The doctor may also ask if the young person is using alcohol or other agents, and whether the patient is thinking about harming him- or herself or about death.

Given the complex nature of disruptive mood dysregulation disorder, and its negative impact on family functioning, a combination of therapeutic approaches may be prescribed. They include individualized psychotherapy for the child, medication with psychostimulants such as those used to treat ADHD, and parent training. Treatment may also include targeted interventions involving the school environment.

Cognitive-behavioral therapy (CBT) has been proven effective in treating depression and many other conditions. Studies show that CBT helps people change negative styles of thinking and behaving. For those with DMDD, CBT may be aimed at teaching children how to regulate their moods and improve their frustration tolerance. Children may be taught coping skills for regulating anger and to identify and defuse cognitive distortions about the attitudes and intentions of others that underlie hostility.

Few studies have been conducted of pharmacologic treatment targeted directly at DMDD, and standardized guidelines for treating the condition do not yet exist. Treatment recommendations are typically based on knowledge of medications for associated symptoms, such as irritability and aggression.

Psychostimulants such as those used in treatment of attention deficit hyperactivity disorder are often used to treat children with DMDD, and they are typically combined with behavioral management. Stimulant treatment has been proved effective in reducing anger and hostility and explosive outbursts. Stimulant treatment may also increase frustration tolerance and decrease aggression.

The chronic irritability component of DMDD is linked to depressive disorder. Agents approved for treatment of major depression in pediatric populations include the selective serotonin reuptake inhibitors (SSRIs) escitalopram, fluoxetine, fluvoxamine, and sertraline. The serotonin and norepinephrine reuptake inhibitor (SNRI) duloxetine is also FDA-approved for use in pediatric patients.

Parent management training is aimed at providing parents with specific strategies to enhance effective discipline and communication.

References

  • American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition
  • National Institute of Mental Health
  • National Institutes of Health, U.S. Department of Health and Human Services
  • American Academy of Child & Adolescent Psychiatry, Depression in Children and Teens, No. 4, Updated October 2018
  • Tourian L, LeBoeuf A, Breton JJ, et al. Treatment Options for the Cardinal Symptoms of Disruptive Mood Dysregulation Disorder. Journal of the Canadian Academy of Child and Adolescent Psychiatry. 2015 winter; 41-54. 
  • Tsuang MT, Bar JL, Stone WS, Faraone SV. Gene-environment interactions in mental disorders. World Psychiatry, 2004 June; 3(2): 73-83.
  • March J, Silva S, Petrycki S, Curry J, Wells K, Fairbank J, Burns B, Domino M, McNulty S, Vitiello B, Severe J. Treatment for Adolescents with Depression Study (TADS) team. Fluoxetine, cognitive-behavioral therapy, and their combination for adolescents with depression: Treatment for Adolescents with Depression Study (TADS) randomized controlled trial. Journal of the American Medical Association, 2004; 292(7): 807-820.
  • Cyranowski JM, Frank E, Young E, Shear MK. Adolescent onset of the gender difference in lifetime rates of major depression. Archives of General Psychiatry, 2000; 57: 21-27.
  • Roy AK, V Lopes, RG Klein. Disruptive Mood Dysregulation Disorder: A new diagnostic approach to chronic irritability in youth. American Journal of Psychiatry. 2014; 171: 918-924.
  • Drew E. Winters, Sadaaki Fukui, Ellen Leibenluft, and Leslie A. Hulvershorn.Journal of Child and Adolescent Psychopharmacology. 2018 June   
  • Bridge JA, Iyengar S, Salary CB, Barbe RP, Birmaher B, Pincus HA, Ren L, Brent DA. Clinical response and risk for reported suicidal ideation and suicide attempts in pediatric antidepressant treatment, a meta-analysis of randomized controlled trials. Journal of the American Medical Association, 2007; 297(15): 1683-1696.

Last reviewed 02/26/2019