Child Psychiatry Consult

When is it bipolar disorder and when is it DMDD?



In the last 20 years there has been a marked rise in the number of children and adolescents receiving the diagnosis of bipolar disorder (BD) – a mood disorder that, classically, involves cycling between episodes of elevated mood and episodes of low mood (Arch. Gen. Psychiatry 2207;64:1032-9). The increase in diagnosis is partly explained by the inclusion of children with chronic irritability being diagnosed with BD. This has led to concern about the subsequent use of approved second-generation antipsychotics for chronically irritable children, with the resultant side effects.

Dr. Robert R. Althoff

Dr. Robert R. Althoff

A new diagnosis called disruptive mood dysregulation disorder (DMDD) was introduced into the DSM-5 to describe these chronically irritable children and, in part, to reduce the number of children receiving a bipolar diagnosis. So, how does one know whether a child has BD, DMDD, or something else? The two brief cases that follow distinguish the difference between BD and DMDD.

Case 1 summary

Joseph is a 15-year-old boy with a history of childhood depression. About 1 year ago, he began to appear more irritable and anxious. Despite his parents’ prohibition, he was going out at night and was intoxicated on several occasions when he came home – something he had never done before. After about 2 weeks of this, he began going to bed at midnight, but would be up again by 4 a.m. talking to himself, playing music, or exercising. He was hanging out with a different crowd. He began to talk about the possibility of becoming part of a motorcycle gang – at some point perhaps the leader of Hells Angels. Slowly, this resolved. However, these symptoms recurred about 1 month ago with progressive worsening, again, and 2 days ago he stopped sleeping at all. He has been locking himself in his room, talking rapidly and excessively about motorcycles, complaining that he “just needed to get his thoughts together.” He was very distractible and was not eating. His mother called his primary care clinician who advised her to bring him to the ED, which she could do only by police because he refused to leave the home, complaining of the “noises” outside.

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