Commentary

Diagnostic Labels and Kids: A Call for Context


 

The proliferation of diagnostic labels within the DSM for childhood emotional and behavioral symptoms has become something of an alphabet soup. It can be argued that the atheoretical, decontextualized, symptom focused model of the DSM-III (IV, and now 5), while giving a reliable descriptive nomenclature, has moved child psychiatry away from its traditional biopsychosocial systemic and integrative model (Med. J. Australia 2009;191:674-6). The literature, different international emphases in conference themes, and discussion with colleagues suggest that this problem is more acute in the United States than elsewhere. But the problem affects child psychiatry globally. (The ICD-10, used in many other countries, considers contextual factors on "Z codes" but in many respects replicates the problems of informational reductionism inherent in the DSM-IV.)

By Dr. Peter I. Parry

The latest proposed label for the DSM-5 is disruptive mood dysregulation disorder (DMDD). This proposed diagnosis has a brief but interesting and controversial history. Earlier iterations of DMDD have been termed severe mood dysregulation (SMD) and temper dysregulation disorder with dysphoria (TDD). Published articles on these constructs have only appeared within the last 5 years.

The DSM-5 Childhood and Adolescent Disorders Work Group described its main justification for introducing DMDD as the "dramatic ... marked upsurge" in bipolar disorder diagnoses among children. Yet, pediatric bipolar disorder (PBD) remains mainly confined to the United States. Why? What explains what Dr. Derrick Silove, professor in the school of psychiatry, University of North South Wales, Randwick, Australia, described several years ago as an "extreme biological model of mental disorders" that seems to have pervaded our specialty in the United States? (Aust. N. Z. J. Psychiatry 1990;1190:461-3).

Early History of PBD

The diagnosis of PBD arose from two U.S. research centers in the mid-1990s. Researchers at Washington University in St. Louis proposed a "narrow phenotype" PBD, in which children had euphoric as well as irritable and sad moods, mainly manifesting as several "ultradian" mood episodes per day. In contrast, researchers at Harvard University described a "broad phenotype" PBD, where children present with chronic irritability. The diagnosis increased markedly in the United States, with a 4,000% increase documented between 1994-1995 and 2002-2003 (Arch. Gen. Psychiatry 2007;64:1032-9).

The criticism of PBD has been strident. Deaths and side effects from polypharmacy in very young children made headlines from 2006 onward. The former chairperson of the DSM-IV task force, Dr. Allen Frances, noted in one fairly recent article that PBD fell outside DSM-IV criteria and described it as a "fad diagnosis" in "epidemic" proportions.

DMDD was proposed mainly from the research of Dr. Ellen Leibenluft of the National Institute of Mental Health and the DSM-5 Work Group, as an alternative construct to "broad phenotype" PBD (Am. J. Psychiatry 2011;168:129-42). Subsequent longitudinal research showed that children with "broad phenotype" PBD/DMDD failed to progress to adult bipolar disorder. Controversy also continues over "narrow phenotype" PBD.

The draft criteria for DMDD stipulate "severe recurrent temper outbursts in response to common stressors ... grossly out of proportion in intensity or duration to the situation ... inconsistent with developmental level ... occurring three or more times per week." The mood between outbursts is "persistently negative (irritable, angry, and/or sad)." The outbursts and/or mood must be present in at least two settings and the problem must have lasted for at least 12 months. The child must be aged 6-10 years.

Exclusion criteria include psychotic and mood disorder, pervasive developmental disorder, post-traumatic stress disorder, and separation anxiety disorder, as well as, it would seem, "narrow phenotype" PBD – as elevated expansive mood lasting more than 1 day is an exclusion criteria.

The diagnosis can be comorbid with the disruptive behavior disorders – attention-deficit/hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD).

The DMDD diagnosis has been welcomed by some who see it as mitigating overdiagnosis of PBD and highlighting the emotional aspect of children with severe temper tantrums. However, it has been criticized by proponents of "broad phenotype" PBD, others who would prefer it as a subtype of ODD, and the parent advocacy organization Child and Adolescent Bipolar Foundation – whose director has expressed concerns that it would lead to parents being blamed for being "unable to control their bratty kids"(Science 2010;327;1192-3). Some see the DMDD diagnosis as the same beast with a different name.

Lukewarm Reception for DMDD

Dr. Frances has criticized DMDD as being little better than PBD – "another monster" that is "too risky to be included in the DSM-5, because, once in general use, it would undoubtedly be misapplied to many kids with normal temper tantrums – who don’t require any diagnosis and should be kept away from potentially harmful medications."

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