DMDD diagnosis will house only some children with rages



The DSM-5’s new diagnosis of disruptive mood dysregulation disorder was made to address the overdiagnosis of bipolar disorder by creating a diagnostic home for children with explosive rages, but only some of those children will qualify for the diagnosis, according to Dr. Gabrielle A. Carlson.

It "will relieve [only] some of the stress" on bipolar disorder, but "it won’t solve all the problems of false diagnosis," she said at a psychopharmacology update, sponsored by the American Academy of Child and Adolescent Psychiatry.

Dr. Gabrielle Carlson

When the DSM-5 is published in May, disruptive mood dysregulation disorder (DMDD) probably will require at least 12 months of very severe outbursts from trivial triggers that happen more than three times per week and are developmentally inappropriate; persistently irritable mood between outbursts most of the day every day; outbursts or negative mood in at least two separate settings; and onset before the age of 10, among other criteria.

"And there are a number of really important exclusionary criteria. You don’t see [DMDD] if there’s any hint of mania, if there’s major depressive disorder," or if there is dysthymia, psychosis, posttraumatic stress disorder (PTSD), pervasive developmental disorders, or separation anxiety, said Dr. Carlson, director of child and adolescent psychiatry at the State University of New York at Stony Brook.

"Here’s the problem: Many children with explosive outbursts have depression and dysthymia, or PTSD," or some other exclusionary problem, or don’t meet all of the DMDD requirements. "If we follow the rules," only about 25% of inpatient explosive children and a fifth of children on the outpatient side will have DMDD, she said, based on analyses of her own inpatient and outpatient services.

Having a diagnostic home and treatment focus for explosive children is probably a positive development, Dr. Carlson said, because rages are probably the "single most vexing problem we have in child psychiatry. On the other hand, [DMDD] is just as likely to be abused as bipolar disorder, because it doesn’t capture the vast majority of kids with explosive outbursts. In fact, it may well mask conditions we already know about and can treat. If you go rushing right to ‘whoa, explosive outbursts – DMDD,’ you’re not going to look for depression, you are not going to look for ADHD, you’re not going to look for stuff you can treat," Dr. Carlson said.

Remember that "kids [with explosive outbursts] are doing the best they can," she said. "They aren’t getting up in the morning saying, ‘I’m really going to try to anger my parents and teachers.’ "

It’s important to first "maximize treatment of the base condition, whether it’s ADHD, depression, or some other problem." If outbursts remain a symptom, consider adding an atypical or conventional antipsychotic or a mood stabilizer, she said. It might take a while to see benefit, so "keep a record of the frequency, duration, and intensity of outbursts" to show parents that progress is being made.

"Medication is for executive functioning and mood regulation. For language and social" problems, it’s about psychoeducation – trying to understand the rage triggers and how not to feed them. Parent training can help. In addition, "if a parent has a psychiatric disorder, get it treated." Parents will not be able to help their child – and follow through on treatment recommendations – if they don’t have their own issues under control.

Dr. Carlson disclosed research funding from Pfizer, GlaxoSmithKline, Schering-Plough, Bristol-Myers Squibb, and Otsuka.

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