I’m sure you’ve experienced it…
The screaming, the whining, the tantruming, and even the aggression.
Disruptive behavior and dysregulated mood are very common problems in children, and they are just as challenging as they are common.
Disruptive mood dysregulation disorder (DMDD) is a relatively new diagnosis that was included in the diagnostic and statistical manual of the American psychiatric Association in the most recent iteration, DSM5.
But what is DMDD?
Diagnostic Criteria for DMDD
Here is a paraphrase of the criteria as listed in DSM-5:
- Severe and recurrent temper outbursts
- The outbursts are not consistent with developmental level
- Temper outburst occur three times or more per week
- The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day.
So to summarize: DMDD is a disorder that includes severe temper outbursts where a child is also irritable or angry almost all the time.
DMDD is considered a mood disorder, with an emphasis on the fact that it leads to disruptive behavior, as opposed to something like major depressive disorder where there is a disturbance in mood but not necessarily a problem with behavior.
So disruptive mood dysregulation disorder (DMDD) is a new diagnosis that sort of bridges the gap between behavioral disorders such as oppositional defiant disorder (ODD) or intermittent explosive disorder, where there is an issue with behavior but not necessarily mood, and mood disorders such as bipolar disorder and major depressive disorder. Hence the combination of severe temper outbursts with the irritable or angry mood in between outbursts. This combination is contained in the name: Disruptive Mood Dysregulation Disorder.
I think it’s important to understand the context in which this diagnosis arose.
Over the past couple decades, there has been a large debate over how to describe and categorize children who have significant issues with mood dysregulation that leads to behavioral issues.
In the past, largely in the 1990s, many of these children were diagnosed with pediatric bipolar disorder. There has been a large debate over how to apply the diagnosis of bipolar disorder to children, and whether the criteria should be loosened or broadened when speaking about children.
One of the main criteria for bipolar disorder is mood dysregulation, which can include irritability. Irritability is when somebody gets angry, irritated, or aggressive in response to triggers that would not be expected to create that level of response.
However, there are many other criteria that need to be met in order to get a diagnosis of bipolar disorder in adulthood. The question is: in children with prominent irritability, should we label this mood issue as the early stages of bipolar disorder or not?
This question is not just academic.
Children and adults who are diagnosed with bipolar disorder are often placed on heavy-duty medications such as lithium, valproic acid, or antipsychotics, all of which can have some pretty serious side effects, including weight gain and obesity, high cholesterol, and diabetes. In turn, obesity, high cholesterol, and diabetes can lead to even more serious issues down the line, such as heart disease.
If children truly need these medications, then the benefits may outweigh the risks. However, the decision to diagnose a child with bipolar disorder may end up having serious long-term effects, and these effects must be taken seriously.
The diagnosis of DMDD was created in order to capture many of these children who have prominent irritability but who do not seem to meet criteria for bipolar disorder.
The debate continues to this day, though many proponents of the DMDD diagnosis note that long-term studies that followed irritable children showed that they are more likely to develop major depressive disorder than bipolar disorder.
This diagnostic difficulty is complicated by the fact that depression itself in children and adolescents often presents with irritability and anger more than depression itself. There is a broad issue in general with extending the diagnoses that are ordinarily applied to adults to children, and it is not always clear how best to categorize issues of mood dysregulation and anger in children.
The problem is, at least in my opinion, the advent of the diagnosis DMDD has not really helped this problem as much as had been hoped.
The treatment for DMDD is often many of the same medications used for bipolar disorder: lithium, valproic acid, and antipsychotics such as quetiapine, olanzapine, or risperidone. So children who are diagnosed with DMDD may develop some of the same negative long-term side effects if they receive these medications.
I think it’s important to call attention to the relatively specific time component of the diagnosis. If we look back at the diagnostic criteria of the DSM, we see that in order to meet criteria for DMDD, technically a child must be irritable most of the day, most days of the week.
Children who have explosive tempers, who are argumentative, or even who are aggressive, really do not meet criteria for DMDD if they are not irritable most of the time. In my experience, many of the children who I have seen who have received diagnoses of DMDD in the past do not seem to meet this time criteria.
It seems to me that the diagnosis of DMDD has, in many ways, replaced the diagnosis of pediatric bipolar disorder as a sort of catch-all diagnosis to categorize a wide variety of children who have serious issues with temper and mood regulation.
If, strictly speaking, a child does not meet criteria for DMDD based on the time course, what diagnosis would apply?
Obviously, the answer would depend on the particular situation, but several other options include:
- Oppositional defiant disorder (ODD)
- Intermittent explosive disorder
- Conduct disorder
- Major depressive disorder
- Bipolar disorder
Oppositional defiant disorder is defined as issues with mood and behavior including getting easily annoyed, being vindictive, being spiteful, and exhibiting oppositional and defiant behavior.
Conduct disorder is a more serious condition that includes behavior that violates the rights of others or foundational expectations of society, such as truancy, stealing, lying, aggression with weapons, etc.
Intermittent explosive disorder is a condition where a child has explosive temper tantrums at least twice a week but does not seem to have serious mood dysregulation between the episodes. It’s similar to DMDD but lacks the anger and irritability between the episodes.
A major distinguishing factor, then, between a mood disorder such as DMDD or major depressive disorder, is the time course. In conditions such as oppositional defiant disorder and intermittent explosive disorder, in between episodes of anger, the mood is relatively calm. In contrast, in disruptive mood dysregulation disorder there is prominent irritability most of the time.
The truth is, at least in my opinion, diagnoses in psychiatry are not necessarily the most important aspect informing treatment. Let me explain why.
This is a much larger topic, which I have covered in a different article, but I will briefly mention this point here as well.
Diagnoses in psychiatry are what are called descriptive diagnoses. That means that the diagnoses are based on a description of a cluster of symptoms. As in the example of disruptive mood dysregulation disorder or oppositional defiant disorder, the diagnoses are based on clustering different symptoms of anger, aggression, and mood dysregulation, as well as behavior, into conglomerates that are then named as a specific diagnosis.
However, it is important to understand that these diagnoses are not necessarily specific “illnesses“ in the way that diagnoses in some other field of medicine are. For instance if a person developed a cough that produce phlegm, he or she may go to the doctor, who will in turn recommend a chest x-ray which diagnoses pneumonia, and a culture of the phlegm or sputum will show that the pneumonia is caused by a particular bacteria. We can demonstrate that that particular bacteria will be killed by a specific antibiotic, the doctor prescribes that antibiotic to the patient, and the pneumonia goes away.
In this case, pneumonia is more than a descriptive diagnosis of the symptom cluster. We can say that the patient had a bacterial pneumonia caused by a particular bacteria that is sensitive to a particular antibiotic. Then the treatment is aimed at that specific pathology.
A descriptive diagnosis in the case of pneumonia would be something like “cough, shortness of breath, chest pain, phlegm disorder.” The truth is, that descriptive disorder is accurate, but the problem is that it tells us nothing about the underlying cause. In fact, many other conditions can cause chest pain, shortness of breath, and sputum production. A pulmonary embolism, which is a clot in the lungs, can cause those symptoms, and so can a heart attack.
It would seem ridiculous to us today to take all patients with chest pain and shortness of breath and place them into one descriptive diagnostic category and then study all of them as a group to find the underlying causes and effective treatment.
The truth is, that’s how medicine functioned in the past before we had better test such as x-rays, MRI, and sputum cultures.
But the DSM is based on such descriptive diagnoses. In fact, in the introduction to the DSM, the authors explicitly discuss the fact that these diagnoses are descriptive and do not necessarily describe real disease entities.
What this means is that oppositional defiant disorder, intermittent explosive disorder, disruptive mood speculation disorder, and the like may each be caused by many, many different underlying problems. In my opinion, disruptive mood dysregulation disorder is not necessarily a specific disease entity in the way that cancer or pneumonia are. Rather, it is a description of severe issues with mood dysregulation and behavioral problems that might have many different underlying causes.
In addition, it is not always clear that each DSM diagnosis is definitely separate from all the other diagnoses. In fact, it seems to be more common that somebody with one disorder has at least one other disorder. One could question whether oppositional defiant disorder, intermittent explosive disorder, conduct disorder, and disruptive mood dysregulation disorder (DMDD) are necessarily different entities with no overlap. It is possible that we are slicing similar issues up into different clusters that are not necessarily entirely distinct.
The real question is, why are these children so angry, and why can’t they modulate or control their anger? I think that when we describe diagnoses on the level of symptom clusters and then attribute the disorder to brain pathology, we miss the point that children are human beings with complicated and understandable reasons for being upset or even enraged. The brain pathology may explain why the angry reaction is so intense and why they are unable to control it, but it doesn’t necessarily explain why they are reacting that way in the first place.
Sources of anger or even rage in children include:
- A history of trauma such as neglect or abuse
- Resentment of parents
- Resentment of siblings
- Feeling unloved
- Feeling misunderstood
- Not getting what they want or think they need
Many of these issues may seem familiar to you because ultimately these causes of anger in children are similar to the causes of anger in adults. However, because children are not able to understand their feelings and express them in words the way adults do (at least most adults!), they act their feelings out.
The problem, of course, is that the anger is of a much greater intensity than it should be, and these children do not have the ability to process the emotion. This issue could either be due to the severity and intensity of the feelings, or it could be due to a reduced capacity to deal with negative feelings.
Why would the feeling be so intense, and why would a child be unable to process negative feelings? As with everything in psychiatry, there are many, many possible answers, but I will describe a few possible answers.
The Causes of Disruptive Mood Dysregulation Disorder
Early adversity has been shown to lead to many negative outcomes in physical and mental health. Early trauma such as abuse or neglect can lead to increased reactivity in the brain, including a stronger response of the amygdala to stressful situations. Even if a child has not been abused, per se, many children with challenging behavior are embroiled in constant fighting with their parents.
These interactions lead to a high level of anxiety and stress in these children’s brains, and many of these children likely have an increase in their brain’s reactivity and fight-or-flight response.
That means that these children have their adrenaline pumping even under relatively ordinarily or low-stakes situations, as if they were under attack.
When the adrenaline is pumping and the amygdala is doing its thing, the higher part of the brain which ordinarily processes and inhibits strong emotions, the prefrontal cortex, gets flooded and goes off-line.
So a child in the midst of a tantrum is basically operating from the lower part of the brain, the primitive fight-or-flight part, without much neurological ability to dampen that response.
In fact, neuroimaging studies of mood disorders and anxiety disorders have shown that individuals suffering from these conditions have reduced connection between the lower and higher parts of the brain, as well as increased activity in the lower parts of the brain when under stress. I discuss these ideas in more depth here.
So far I’ve only spoken about the physical machinery of the brain. However, we have to also understand how the brain processes information at a higher level, including issues such as self-esteem, word-view, relationships with parents, conscience, and recognition of parental and societal ideals.
How are those high-level concepts such as self-esteem encoded in the brain? I don’t think we really know the answer to that question yet, but I think that these types of high-level functions are probably carried out by massive interconnections among many or almost all parts of the brain working together in complex patterns and rhythms.
Understanding the physical issues with the brain may explain why the response to stress is so intense and cannot be modulated. However, it doesn’t really explain why a child would experience being told “no” as a severe attack on his or her life that would necessitate a fight-or-flight response. Somehow, for certain children, what seem to be minor provocations are experienced as severe and intense threats.
Psychological Aspects of DMDD
In order to understand why some children experience minor provocations as serious injuries, we need to shift to the internal world of the child.
We need to look at aspects of the child’s mind including personality structure, self-esteem, self-conception, conceptions of others including the parents, and a developing sense of morality and conscience, as well as many other issues.
For instance, if a child views him or herself as unlovable and damaged, and views the parents as vindictive, callous, and controlling, then something as small as the end of a session of video games can be seen as a violent parental attack and the confirmation of just how unlovable the child is.
Wow! That’s quite an intense response, but the reality is that many children with behavioral issues do experience everyday life on these terms. That reality is often brought out in psychotherapy over many weeks and months, when these issues can gradually be understood.
I discussed the difference and interaction between biology and psychology in my article on nature vs. nurture.
Treatment for Disruptive Mood Dysregulation Disorder
The medical treatment for DMDD and the behavioral disorders including ODD, intermittent explosive disorder, and conduct disorder, are usually pretty similar because medications target symptoms, not specific diagnoses.
Medications such as mood stabilizers such as lithium and valproic acid, as well as antipsychotics, are used to control excessive anger and aggression. Stimulants are used to treat ADHD and its associated impulsivity, which can sometimes give children more control over their impulsive acting out.
Antidepressants can sometimes help when there is comorbid depression and anxiety; however, these medications can sometimes make the anger and aggression worse, so they are often avoided. Alpha agonists such as guanfacine are also used to dampen down the fight-or-flight response.
Medication Is Often Not Enough
However, a main point that I would like to emphasize is that the medications only reduce symptoms on the surface and take the edge off. They do not address the underlying issues of distortions in social-emotional development that go into how the child is experiencing him or herself and the world.
That’s because the medications work mostly on the level of the brain’s physical integrity, whereas the social-emotional issues are encoded more in the higher level complex interaction of the brain that is described by psychology.
Ultimately, studies for most disorders have shown that the combination of medication and psychotherapy has the best effect.
I use medication for most of my patients because it often does reduce symptoms and make them more manageable, but I do think it’s important to combine psychotherapy as well to address the underlying issues.