Learning Objectives:
Examine why DMDD was established as a stand-alone diagnosis in DSM-5, review the diagnostic criteria for DMDD, along with the differential diagnosis from other common conditions and explore what we know about treating kids with DMDD
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Understanding DMDDTreating kids with protracted anger outbursts and irritability
1. Understanding DMDD
Treating kids with protracted
anger outbursts and irritability
Stephen Grcevich, MD
Associate Professor of Psychiatry – NEOMED
Presented for Stark MHAR Board
November 10, 2021
2. Learning
Objectives
• Examine why DMDD was
established as a stand-
alone diagnosis in DSM-5
• Review the diagnostic
criteria for DMDD, along
with the differential
diagnosis from other
common conditions
• Explore what we know
about treating kids with
DMDD
3. Where did DMDD come from?
• NIMH began to explore a broad phenotype of
adolescents with chronic, impairing irritability -
severe mood dysregulation (SMD)
• SMD required recurrent temper outbursts, persistent
negative mood, and the presence of at least three
“hyperarousal” symptoms…pressured speech, racing
thoughts/flight of ideas, intrusiveness, distractibility,
insomnia, agitation
Leibenluft E. Am J Psychiatry. 2011 February ; 168(2): 129–142
4. A large group of kids
experience:
• Irritability as their
predominant mood state
• Problems with emotional
self-regulation often
resulting in aggression
• Problems with attention,
concentration, academic
performance
• “At-risk” behaviors…self-
injury, substance use,
suicidal threats
5. The impetus for a new
diagnostic category
“The introduction of the
DMDD diagnosis was
designed to address the
problematic over-diagnosis of
bipolar disorder and the
associated rise in
antipsychotic and
polypharmacy use in youths.”
Robert Findling, MD
Findling RL et al. J Am Acad Child Adolesc Psychiatry 2021
– in press
6. DSM-5 Diagnostic Criteria for DMDD:
• A. Characterized by severe recurrent temper outbursts manifested verbally or
behaviorally in response to common stressors grossly out of proportion in
proportion in intensity or duration to the situation or provocation
• B. Outbursts are inconsistent with developmental level
• C.Temper outbursts occur, on average, three or more times per week.
• D. Mood between temper outbursts is persistently negative (irritable, angry,
and/or sad) and observable by others.
• A-D criteria present for at least 12 months, with no period of > 3 months in
which ALL of the criteria met
DSM-5, American Psychiatric Association, 2013
7. DSM-5 Diagnostic Criteria for DMDD
(Continued):
• Present in at least two of three settings (home, school, peers), severe in at
least one of the three
• Cannot be initially diagnosed prior to age 6 or after age 18
• Age of onset before 10 years
• No period of > 1 day when symptoms of mania or hypomania present
• Behavior not exclusively present during a major depressive disorder, not
better explained by another mental disorder
• Not attributable to the physiological effects of substances or another
medical/neurologic condition.
DSM-5, American Psychiatric Association, 2013
8. What do kids with
DMDD look like?
• Most have ADHD (86.3%) and
ODD (84.2%)
• 60% at NIMH were diagnosed
in community with bipolar
disorder
• Elevated prevalence of lifetime
anxiety disorders (58.2%),
major depression (16.4%)
• 7X greater risk of depression at
age 18
• Chronic irritability in
adolescence predicts MDD,
GAD, dysthymia at age 33
Leibenluft E. Am J Psychiatry 2011; 168(2):129-42
10. Distinguishing between Bipolar
Disorder and DMDD
Bipolar Disorder
• Episodic irritability
• Distinct change from baseline
mood
• Mood episodes >7 days (mania)
or >4 days (hypomania)
• Grandiosity common
DMDD:
• Chronic irritability
• Persistent mood state
• Severe outbursts typically last
minutes to hours (30 minutes to
4 hours)
• Poor self image
12. Distinguishing between DMDD and
Oppositional Defiant Disorder (ODD):
ODD
• Mood symptoms rare
• Doesn’t require “severe”
impairment in at least one
setting
• 85% of kids with ODD do not
meet criteria for DMDD
DMDD
• Persistently irritable
• “Severe” impairment required
in at least one setting
• Most kids (84%) with DMDD
meet criteria for ODD
13. What does the research say about
treating DMDD…
• NO FDA-approved treatments exist for DMDD.
• One open-label study suggested stimulants improved irritability in
kids with ADHD + DMDD
• 71% irritability improved, 19% irritability worsened
• DB/RC trial: citalopram + MPH vs. placebo + MPH
• 35% response to citalopram + MPH, 6% to PBO + MPH, but no difference in
functional impairment between groups
• Open-label aripiprazole + MPH significantly improved irritability,
externalizing symptoms, depression, anxiety, attention, social
problems
Winters DE et al. J Child Adolesc Psychopharmacol. 2018 Jun;28(5):298-305
Towbin K et al. J Am Acad Child Adolesc Psychiatry. 2020 Mar;59(3):350-361
Pan PY et al. J Child Adolesc Psychopharmacol. 2018 Dec;28(10):682-689
14. How DMDD is
being treated
• Greater use of ADHD
meds (60.2 vs. 34.4%),
antipsychotics (58.9 vs.
51.0%), antidepressants
(54.3 vs. 46.0%) in DMDD
vs. Bipolar Disorder
• Greater use of mood
stabilizers (32.6 vs.
27.3%), anxiolytics (19.3
vs. 14.8% in Bipolar
Disorder vs. DMDD
Findling RL et al. J Am Acad Child Adolesc Psychiatry 2021 – in press
15. Is DMDD really trauma
under another name?
“Unfortunately, the developers of this
diagnostic category (severe mood
dysregulation and its successor,
DMDD) have largely neglected the
clear association between trauma
exposure and these symptom clusters.
DMDD is usually treated in the same
way as an errant bipolar disorder
diagnosis, namely, with medications
presumed to reduce mood instability
and aggression. In fact, based on the
work of Findling et al., the introduction
of the DMDD diagnosis may have
exacerbated the overuse of these
medications.”
Havens JF et al. J Am Acad Child Adolesc
Psychiatry, 2021 Aug 4;S0890-8567(21)00485-8.
16. My experience in treating kids with DMDD
• They have difficulty with transitions…”cognitive rigidity”
• They tend to “ruminate”…indecisive, perseverate
• They may experience significant improvement in school from
ADHD medication, but often become more irritable, have more
meltdowns at home on medication
• They do better when they’re busy…inactivity increases irritability
• They’re prone to behavioral activation on SSRIs that is often
mistaken for mania, hypomania
17. How I’m treating DMDD in the presence of
insufficient data…
• Conservative use of ADHD medication…
• Coverage limited to school day in many/most instances
• Lots of CBT!
• Kids need strategies to help manage perseverative thinking
• Meltdowns related to perseveration on frustrations may respond to
SSRIs, clomipramine
• SSRI-related behavioral activation appears dose-dependent
• Titrate weekly in VERY small increments
• Aggressively dosing accommodations, school-based interventions
• SGAs last resort for severe aggression (aripiprazole, risperidone)
Differences between “SMD” as studied by the NIMH and DMDD in the DSM-5:
SMD required recurrent temper outbursts, persistent negative mood, and the presence of at least three “hyperarousal” symptoms…pressured speech, racing thoughts/flight of ideas, intrusiveness, distractibility, insomnia, agitation.
Age of onset was prior to age 12, maximum symptom-free period = 2 months
We’re not sure what these kids have! SMD?
Most have ADHD in late adolescence, depression in young adulthood
What are differences with SMD?
The name SMD would subsequently be changed to TDD and the hyperarousal criterion dropped. So what did we learn from research on SMD?
We learned that children with SMD are as severely impaired as those who suffer from classical (episodic) Bipolar Disorder. But there are important differences between those who met criteria for SMD and those who met criteria for Bipolar Disorder (BD).
The groups differed in their outcome, gender ratio, and possibly family history. Let me focus on just a few of the most significant findings here: Children with SMD/chronic irritability were at risk for later anxiety and unipolar depressive disorders — they did not turn out to be risk of developing BD. That finding, which was replicated by several studies, suggests that diagnosing children with non-episodic chronic irritability as having Bipolar Disorder may not only be inaccurate as opposed to premature, it may lead to offering these children ineffective or possibly harmful treatments.
In children and adults with classic (episodic) BD, the gender ratio is approximately even. That means that males and females are equally likely to have the disorder. In children with SMD, however, boys outnumbered girls by a ratio of about 3:1.SMD is a serious mood disorder and is as impairing as BD in the short-term and long-term.85% of children and teens diagnosed with SMD also met diagnostic criteria for ADHD and Oppositional Defiant Disorder (ODD). That is not surprising when you think about chronically irritable children look like and how disruptive their behavior can be. But SMD is more than just ADHD+ODD, as it involves mood. Furthermore, children with severe irritability frequently meet diagnostic criteria for an anxiety disorder and have a family history of depression.
What are differences with SMD?
The name SMD would subsequently be changed to TDD and the hyperarousal criterion dropped. So what did we learn from research on SMD?
We learned that children with SMD are as severely impaired as those who suffer from classical (episodic) Bipolar Disorder. But there are important differences between those who met criteria for SMD and those who met criteria for Bipolar Disorder (BD).
The groups differed in their outcome, gender ratio, and possibly family history. Let me focus on just a few of the most significant findings here: Children with SMD/chronic irritability were at risk for later anxiety and unipolar depressive disorders — they did not turn out to be risk of developing BD. That finding, which was replicated by several studies, suggests that diagnosing children with non-episodic chronic irritability as having Bipolar Disorder may not only be inaccurate as opposed to premature, it may lead to offering these children ineffective or possibly harmful treatments.
In children and adults with classic (episodic) BD, the gender ratio is approximately even. That means that males and females are equally likely to have the disorder. In children with SMD, however, boys outnumbered girls by a ratio of about 3:1.SMD is a serious mood disorder and is as impairing as BD in the short-term and long-term.85% of children and teens diagnosed with SMD also met diagnostic criteria for ADHD and Oppositional Defiant Disorder (ODD). That is not surprising when you think about chronically irritable children look like and how disruptive their behavior can be. But SMD is more than just ADHD+ODD, as it involves mood. Furthermore, children with severe irritability frequently meet diagnostic criteria for an anxiety disorder and have a family history of depression.