This is for a Discussion board post.

Disruptive mood dysregulation disorder (DMDD) is actually relatively new and has evolved in consideration of childhood disorders. I have shared a presentation below that provides information on this more unknown disorder. Please take some time to review the presentation below and share your thoughts.

Dr. Kapoor, M.D

exploring disruptive, dysregulation mood disorder, a new diagnosis.

Birth of DMDD:

dramatic increase in the rate of BD in children and adolescents between mid-1990s and 2000s

The proportion of BP diagnosis of all psychiatric inpatient discharges, rose from 10% to 34% in children and from 10 to 49% in adolescents in eight years.

Reasons for increase:

Youth bipolar disorder was previously underdiagnosed

The way the diagnostic criteria were applied, leading to misdiagnosis

To get mental health services

Bipolar diagnosis:

a distinct period of abnormally and persistently elevated expensive or irritable mood(A symptoms)

Accompanied by a number of cognitive behavioral and physical symptoms( B symptoms)

-Distractibility

-Impulsivity

-Grandiosity

-Flight of ideas

-Agitation

-Sleep decreased

-Talkativeness

Bipolar disorder

core definition of bipolar comprises of episodic irritability

Vs.

some researchers in 1990s suggested that mania in youth presents as a non-episodic, persistent, chronic and severe irritability

Concepts of irritability

Irritability

irritability is defined as low threshold to experience anger in response to frustration.

It is the most common symptom of pediatric population

It is part of the clinical presentation of several disorders

DSM-IV provides no definition of irritability, despite inclusion in at least six diagnosis in children.

No DSM- IV category captures symptomatology of severely impairing, non-episodic irritability.

Chronic irritability

the constructs of episodic and chronic irritability are separable and remain stable over time

The correlation between episodic and chronic irritability is much lower. 0.34 an early and 0.26 in late adolescence.

Severe non-episodic irritability as a developmental presentation of mania

expect to develop into bipolar disorder on longitudinal studies

Expect to have a family history of bipolar disorder

Expect to have similar pathophysiological abnormalities

Defined a syndrome, termed, severe mood, dysregulation SMD

Inclusion criteria

1. Age 7 through 17 years with onset of the syndrome before age 12

2. Abnormal mood (specifically anger or sadness) present, at least half of the day most days and of sufficient severity to be noticeable by people in the child's environment

3. Hyper arousal (define by at least three of the following: insomnia, agitation, distractibility, racing thoughts, or flight of ideas, pressured, speech, and intrusiveness)

4. Compared to pierce the child exhibit markedly increased reactivity to negative emotional stimuli that is manifest, verbally or behaviorally. Such events occur on average at least three times a week.

5. The symptoms in 2, 3 and 4 are currently present and have been present for at least 12 months without any symptom free periods exceeding 2 months

6. The symptoms are severely impairing in at least one (home school or with Peers) and our at least mildly impairing in a second setting.

Exclusion criteria

exhibit any of these cardinal manic symptoms

Elevated or expensive mood

Grandiosity or inflated self-esteem

Episodically decreasing need for sleep

symptoms occur in distinct period lasting more than one day

Meets criteria for schizophrenia, schizoaffective disorder, pervasive developmental disorder, or post traumatic stress disorder.

Meets criteria for substance abuse disorder in the past 3 months

IQ < 70

Symptoms are due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition

Studies:

Since 2002, NIMH studied 146 youth

Used module that is appended to the schedule for affective disorders, and schizophrenia- present and lifetime version (K - SADS- PL)

Administered by master's/ doctoral level clinicians

Results:

main age at study entry is 11.7 years but parents report a mean age at onset nearly 7 years earlier.

The main children's global assessment scale (CGAS)score was 45.8 (SD=6.9), compared with a mean score of, 46.5(SD equals 12.4) for 107 youths with bipolar disorder recruited over the same. Indicating that youth with severe mood dysregulation are as severely impaired as those with bipolar disorder.

Approximately 60% of the youths with severe mood dysregulation had a community diagnosis of bipolar disorder at the time of recruitment

Results

• 84.9% met DSM - IV criteria for lifetime oppositional defiant disorder.
• 86.3% met criteria for lifetime ADHD.
• 58.2% met criteria for lifetime anxiety disorder.
• 16.4% for lifetime major depressive disorder, although youths were not included in the severe mood dysregulation sample if their irritability could be attributed solely to a major depressive episode or an anxiety disorder.

Longitudinal studies:

• assessed rates of mood episodes in 84 youths with SMD and 93 youth with DSMIV bipolar disorder over a medium of 28.4 months.
• Only one patient (1.2%) with SMD, but 58(62.4%) with bipolar, exhibited, at least one manic/hypomanic/ mixed episode.

Post HOC analysis data done on community samples

• Brotman et Al, found that youths who met the criteria for SMD at a mean age of 10.6 years or seven times more likely to meet criteria for a unipolar depressive disorder at a mean age of 18.3 years. The lifetime prevalence of SMD in children ages 9-19 was 3.3% (sample size: 1420)
• Stringaless et Al reported chronic irritability and adolescents predicted major depressive disorder at age 33, as well as generalized anxiety disorder, and dysthymia sample (size: 631)

Family history/heritability:

• study compared prenatal diagnosis in samples of youth, with SMD and bipolar disorder
• Prevalence of parental bipolar disorder: 33.3% in the pediatric bipolar disorder compared to 2.7% in SMD sample.

FMRI

• The difference in blood oxygenation level to generate a brain map corresponding to blood flow to active neurons.
• Map the functional activity of the brain noninvasively. adding to the structural mapping, provided by MRI.

Pathophysiology

• both groups have deficits in face, emotion, labeling, and experience, more frustration, then normally developing children
• Brain mechanism appears to be different between the two groups

The long battle to rethink mental illness in children

• decade of suffering for an 11-year-old boy, who, although diagnosed with bipolar disorder at age 4 has never been successfully treated for his extreme explosive rages
• 12-year-old girl whose emotions careen quickly between giddiness and fury. "It's like walking around with an arm full of explosives" says her mother. "you hope that you don't trip."
• Too many severely impaired children, like this are falling through the cracks because they suffer from a disorder that has not yet been defined

Need to fill in the cracks

• the road to mental health, begins with an accurate diagnosis
• Bipolar diagnosis mean, high functional impairment
• Limit the use of unnecessary antipsychotics

Midpresentation summary

• SMD has very low familial traits
• SMD on a long run can have unipolar depression, not bipolar
• SMD Pathophysiology looks different from bipolar

DSM - 5 task force

• Two operationalize, severe irritability reliability with a High threshold far beyond that of any current DSM - IV diagnosis
• To exclude hyper arousal symptoms
• To exclude preschoolers in patients, who symptoms did not begin until adolescence, because irritability may fluctuate during these developmental transitions
• To exclude youths, even with brief episodes of mania, such as those meeting criteria for episodic bipolar disorder, not otherwise specified

Process...

• comprehensive review of the scientific literature
• For discussion by work group, members review by the DSM -5 task force
• Scientific review committee
• Clinical and public health committee
• Finally approval by the American psychiatric association's board of trustees

DMDD (DSM-5) criteria:

• A. Severe recurrent temper outburst, manifested verbally(e.g verbal rages) and/or behaviorally(e.g physical aggression toward people or property) bats are grossly out of proportion in intensity, or duration to the situation or provocation
• B. The temper outburst are inconsistent with developmental level.
• C. The temper outburst occurred on average three or more times per week.
• D. The mood between temper outburst is persistently, irritable or angry most of the day nearly every day, and is observable by others.(e.g parents teachers Peers)
• E. Criteria A -D have been present for 12 or more months throughout that time the individual has not had a period lasting three or more consecutive months without all of the symptoms in criteria A-D.
• F. Criteria A and D are present in at least two or three settings ( i.e. at home, at school, with Peers) and or severe in at least one of these
• G. The diagnosis should not be made for the first time before age 6 years or after age 18.
• H. By history or, the Aj at onset of criteria A-E is before 10 years.
• I. There has never been a distinct period lasting more than one day, during which the full symptom criteria, except duration for a manic or hypo manic episode have been met
• J. The behaviors do not occur exclusively during an episode of major depressive disorder, and are not better explained by another mental disorder.
• K. The symptoms are not attributable to the physiological effects of a substance or two in other medical or neurological condition.

DMDD

• severe, persistent, non-episodic irritability
• Absence of grandiosity/elevated /expansive mood
• No psychosis present
• Diagnosis should not be made before six years or after 18 years.

Bipolar disorder

• distinct period of mania or depression.
• Presence of elevated/expansive mood and grandiosity
• Psychosis may be present
• Diagnosis can be made at any age mean age for manic depressive symptoms is 18 years for bipolar 1

DMDD

• mood disorder
• Irritability is required for diagnosis
• Extreme aggression is more common
• May or may not be there

ODD

• disruptive disorder
• Irritability not required for diagnosis
• Less common
• Manifest as a pattern of defiance and resistive behavior towards authority figures

• due to high degree of overlap between ODD & DMDD when criteria for both disorders are met then ODD should be dropped in favor of DMDD

Rationale

• more severe disorder
• Access to more services

DMDD

• mood disorder
• Not a diagnostic feature of DMDD
• May or may not be there

Conduct disorder

• disruptive disorder
• Characterized by lack of empathy and conscience
• Serious violations of rules

Treatment

• lots of research needed
• Some success on the lines of treatment of oppositional, defiant disorder

Lithium

• only placebo controlled trial in children with SMD found no benefit of lithium over placebo
• Lithium may not result in significant clinical or Neurometabolic alterations in SMD youths further SMD treatment trials are warranted, given its prevalence

Cognitive interventions

• 9 week group-based psychological treatment.
• Mean age(8.7+2 years)
• Improved child Global Assessment Scale (CGAS: pretreatment 47.8; post treatment 66.43+ 10.7)
• These findings provide preliminary evidence for behavioral cognitive interventions.

NIMH trial

• a treatment of trial of severe mood. Dysregulation is underway.
• Compares a stimulant plus capital pram to stimulate plus placebo
• The study builds on the longitudinal data reviewed above suggesting that severe mood dysregulation is on a Pathophysiologic continuum, with unipolar depressive and anxiety disorders
• Also built on data suggesting that both stimulants and SSRIs might be effective in treating irritability and/or aggression

Future

• to find clinical and biological markers that distinguish DMDD from health individuals, and from other psychiatric disorders
• Discovering Pathophysiology has the second goal of guiding diagnosis and treatment
• DMDD is a new diagnosis which tries to fill in the cracks
• Longitudinal studies have found the DMDD may present as depression and anxiety disorder, not bipolar disorder
• With the knowledge of this diagnosis on necessary use of antipsychotics can be avoided

End of presentation