Child Psychiatry Consult

When is it bipolar disorder and when is it DMDD?


Case 1 discussion

Joseph most likely has bipolar I disorder, although a substance-induced mania will have to be ruled out. His symptoms are classic for what we think of as “narrow phenotypic” mania – elated and irritable mood, grandiosity, flight of ideas, decreased need for sleep, hypertalkativeness, increase in goal-directed activity, severe distractibility, and excessive involvement in activities that are likely to have painful consequences. These episodes are a clear change from baseline. Here, Joseph has been previously depressed, but never had symptoms like this that came, went, and then returned. If these manic symptoms continue for 1 week or longer, or are so severe as to require him to be hospitalized, these are a manic episode, which, essentially, makes the diagnosis of bipolar I disorder. Most clinicians have seen mania in late adolescence and early adulthood and can distinguish when these episodes occur in childhood. There is less ambiguity about this diagnosis when it occurs with frank mania.

Case 2 summary

Henry is a 12-year-old boy. His parents say that he’s been difficult since he was “in the womb.” Starting at about the age of 4 years, they started to notice that he would frequently become moody – lasting almost all day in a way that was noticed by everyone. He remains almost constantly irritable. He responds extremely to negative emotional stimuli, like when he got so upset about striking out at a Little League game last year that he had a 15-minute temper outburst that couldn’t be stopped. When his father removed him from the field to the car, he kicked out a window. These types of events are not uncommon, occurring four to five times per week, and are associated with verbal and physical aggression. There have been no symptom-free periods since age 4 years. There have been no clear episodes, and nothing that could be described as elation.

Case 2 discussion

Henry would very likely meet the criteria for the DSM-5 diagnosis of disruptive mood dysregulation disorder. DMDD requires that there be severe and recurrent temper outbursts that can be verbal or physical and are grossly out of proportion to the situation, happening at least three times a week for the past year. In between these outbursts, the child’s mood is angry or irritable, most of the day, nearly every day with no time longer than 3 months in the last year without symptoms. There cannot be symptoms of mania or hypomania. DMDD should be distinguished from oppositional-defiant disorder (ODD), which cannot be diagnosed concurrently. ODD has similar characteristics, but the temper outbursts are not as severe, frequent, or chronic. The mood symptoms in DMDD predominate, while oppositionality predominates in ODD. Note the chronicity of irritable mood in DMDD. This is the distinguishing characteristic of the disorder – chronic, nonepisodic irritability.

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