Disruptive Mood Dysregulation Disorder: A Critical Analysis

Introduction to DMDD and Its Core Features

Disruptive Mood Dysregulation Disorder (DMDD) is a childhood disorder characterized by chronic irritability that interferes with academic and social functioning. Frequent outbursts and temper tantrums — occurring approximately three times per week — are the most obvious behavioral externalizations of DMDD. However, to be diagnosed with the disorder, the child must also exhibit persistently poor mood or irritability between outbursts (National Institute of Mental Health, 2018). To differentiate DMDD from pediatric bipolar disorder, it is also essential that the child does not exhibit sustained mood elevation or nonepisodic mania (Baweja, Mayes, Hameed, et al., 2016). Moreover, the symptoms of DMDD persist in spite of changes to the child's environment and are evident both at home and at school. Symptoms must also not be temporary; they must have been present for a year or more.

While on the surface DMDD appears no different from any other psychiatric illness, it is in fact a nebulous disorder that closely resembles oppositional defiant disorder. Including DMDD in the DSM-5 could lead to the overly eager prescription of medications. The DMDD designation may also reflect a systematic denial of the role that poverty and other contextual variables might play in causing DMDD symptoms (Grau, Plener, Hohmann, et al., 2018).

Controversy Over DMDD's DSM-5 Inclusion

The American Psychiatric Association "controversially" listed DMDD in the DSM-5 in 2013 (Copeland, Angold, Costello, et al., 2013, p. 173). Reasons for the controversy include its significant overlap in symptomology with several other mood and behavior disruption disorders, such as oppositional defiant disorder (ODD), which is a more established childhood disorder classification (Freeman, Youngstrom, Youngstrom, et al., 2016). DMDD also has a comorbidity rate as high as 92%, making it appear as though DMDD symptoms are attributable more to a comorbid condition than to a separate mood disorder altogether (Copeland, Angold, Costello, et al., 2013). Other similar disorders already listed in the DSM include childhood bipolar disorder and attention deficit hyperactivity disorder (ADHD), the symptoms of which closely mirror those of DMDD.

The most important reason for the controversy over DMDD, however, is the lack of empirical evidence supporting its classification as a distinct disorder. As Baweja, Mayes, Hameed, et al. (2016) point out, there is "no consensus or even well-validated scales" for the assessment of DMDD (p. 2115). No neurobiological or genetic component has been identified, no reliable method of accurately assessing DMDD has been established, and no consistent means of distinguishing it from similar disorders has emerged — even several years after the disorder was added to the DSM-5 (Baweja, Mayes, Hameed, et al., 2016). Current assessments depend on psychiatric interviews and evaluations, which can be problematic and subjective. In spite of the practical and ethical problems surrounding the DMDD diagnosis, it remains in place partly to prevent children from being misdiagnosed with other mood disorders and to ensure that children with mood and behavioral disorders receive appropriate, evidence-based treatment.

Diagnostic Challenges and Prevalence Uncertainty

As a childhood-only disorder, diagnoses are offered only to individuals between the ages of 6 and 18 (National Institute of Mental Health, 2018). Symptoms include constant irritability and anger, frequent outbursts or tantrums, and difficulty functioning socially as a result of these mood and behavioral symptoms. Because the disorder has only been classified for a few years, prevalence rates remain inconclusive, with estimates ranging from 0.8% to 3.3% (Copeland, Angold, Costello, et al., 2013).

Another reason why DMDD remains a controversial classification is that as many as a third of all children could potentially be diagnosed with it under the current diagnostic criteria, with prevalence rates particularly high in community clinics (Freeman, Youngstrom, Youngstrom, et al., 2016). Diagnostic tools such as observations and interviews are not standardized, and what one clinician perceives as irritability or anger may be considered normal behavior by another. The diversity and range of these tools contribute to wide variation in both diagnosis and reported prevalence.

Conclusion

Children with mood disorders and their caregivers do need help. However, DMDD may not be the most appropriate means of helping children with behavioral regulation problems or mood disorders. Psychiatrists and psychologists should focus their attention on addressing the root causes of childhood psychological and mood disorders rather than fabricating new and potentially prejudicial pathologies.