Disruptive Mood Dysregulation in Children and Adolescents

ICD-10 code: F34.81

Disruptive mood dysregulation disorder (DMDD) is part of a cluster of diagnoses called the depressive disorders.  Depressive disorders are a group of psychiatric conditions that include:

  • Major depressive disorder
  • Persistent depressive disorder (dysthymia)
  • Disruptive mood dysregulation disorder (children only)

The depressive disorders are characterized primarily by mood disturbance (sad, empty, or irritable mood).  Individuals with depressive disorders often experience significant somatic changes, such as disruptions in sleep (insomnia or hypersomnia), eating (overeating or loss of appetite), or energy level.  Changes in cognition, such as difficulty concentrating, indecisiveness, and morbid ideation (such as thoughts of death) are also common.  

Individuals with major depressive disorder experience pervasive sadness or anhedonia (loss of interest) along with significant changes in somatic and/or cognitive functioning.  To be diagnosed, these problems must be present nearly every day for at least two weeks.  Individuals with persistent depressive disorder (dysthymia) experience similar symptoms, including sad mood and problems with somatic and/or cognitive functioning that occur most days for at least two years. Disruptive mood dysregulation disorder is diagnosed in children under 12 years old who experience persistent irritability and extreme behavioral dyscontrol.

These disorders can go undetected in youth because they are internalizing disorders, whereas many other childhood disorders are associated with externalizing symptoms, which are more likely to draw attention from parents and teachers. The exception is disruptive mood dysregulation disorder, which is characterized by temper outbursts; this may be related to an inability to effectively express internal distress and is likely to result in misdiagnosis as oppositional defiant disorder or bipolar disorder.  

Major depressive disorder (MDD) is an episodic illness; though some people experience only one episode, the majority will experience recurrent episodes. This may be particularly true for children; youth who become depressed often continue to struggle with depressed mood as adults. In contrast, both disruptive mood dysregulation disorder (DMDD) and persistent depressive disorder (PDD) are more chronic illnesses. Youth who meet criteria for DMDD or PDD must experience symptoms for at least one year with no more than two months (cumulative) symptom-free. Though DMDD and PDD can be longer lasting than an episode of major depression, the symptoms are usually not as severe. DMDD is characterized by persistent irritability and temper tantrums. PDD is more similar to major depression symptomatically – youth with this illness experience sad / depressed mood along with physical and cognitive symptoms.

All of the depressive disorders represent a change in functioning; though PDD and DMDD have a more chronic presentation, all three illnesses are episodic (although PDD and DMDD are defined by prolonged periods of low/irritable mood, these are also episodic; there must be a change of functioning at the onset of illness and the expectation is that symptoms will eventually remit) and, in most cases, there will be fluctuations in the severity of symptoms, due to time or treatment Many people with depressive disorders also experience significant somatic symptoms, and youth may complain of headaches or stomach aches, along with exhibiting low energy. Additionally, many youth with a depressive disorder diagnosis experience hopelessness and suicidal thoughts. The risk of suicide is a significant concern in this population and should be monitored closely.

What is disruptive mood dysregulation disorder?

DMDD is a psychiatric disorder that was introduced with DSM-5. Because it is such a new diagnosis, much of what we know about it is based on research done on severe mood dysregulation, a diagnostic category from which DMDD evolved – and from analysis of data on youth who, based on reported symptoms likely would have met criteria for DMDD had the diagnosis existed at the time of their interview. Prevalence for DMDD is estimated at approximately 1-5% of youth.

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Understanding Disruptive Mood Dysregulation Disorder

The symptoms of disruptive mood dysregulation overlap significantly with the symptoms of other childhood disorders, particularly ODD. Diagnosis of DMDD requires very careful attention to be paid to the duration and exclusion criteria; studies have suggested that, without very stringent application of every criterion, the prevalence of DMDD (particularly in clinical samples) can balloon. There are no longitudinal data on DMDD, so little is known about the trajectory of the illness; however, the prevalence is expected to be higher in school-aged children (as compared to adolescents) and in boys (relative to girls).

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How is disruptive mood dysregulation disorder treated?

There are currently no published guidelines for the treatment of DMDD. Based on studies of treatment for similar presentations (e.g., severe temper tantrums) atypical antipsychotics and stimulant medication (e.g., methylphenidate) may be helpful, whereas lithium is not. Data are inconsistent as to whether combination therapy is more effective than atypical antipsychotic medication or stimulant alone.

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