Disruptive Mood Dysregulation Disorder
Disruptive mood dysregulation disorder (DMDD) is a mental health condition that may be diagnosed in children and adolescents who are frequently angry and hostile. Children and adolescents with the condition typically have temper tantrums or angry outbursts several days per week for at least one year. Those with the condition also have severe irritability that goes beyond a “bad mood.”
Although the condition only applies to children and adolescents between the ages of 6 and 18, patients are commonly diagnosed with DMDD between the ages of 6 and 10. (Older children who are diagnosed with DMDD must have experienced initial symptoms by age 10.)
Disruptive mood dysregulation disorder is a recently recognized condition—it was first included in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), the reference book of mental health conditions used by the American Psychiatric Association (APA), in 2013. Because the condition is relatively new, experts don’t know how many people have it.
Psychotherapy and medications may help to treat patients with disruptive mood dysregulation disorder. However, because the condition has been recognized only recently, there are no treatments that specifically target it.
What is disruptive mood dysregulation disorder?
Disruptive mood dysregulation disorder is a pediatric mental health condition that involves regular occurrences of tantrums and/or verbal outbursts, along with chronic, severe irritability. It affects children and adolescents ages 6 to 18.
Before the American Psychiatric Association (APA) recognized DMDD as a standalone mental health condition, it was categorized as a type of pediatric bipolar disorder (even though patients did not experience the symptoms required for a bipolar disorder diagnosis).
Children who have frequent tantrums or outbursts at least three times a week, which are not age-appropriate and longer or more intense than the situation merits, may have the condition. The tantrums or outbursts must occur in two or more settings, such as at home, in school, and/or among peers. Patients with the condition may physically attack others and/or destroy property.
Children with DMDD generally have a negative or hostile baseline mood. They are typically angry or irritable on most days, usually for most of the day. The negative mood, along with frequent tantrums or outbursts, must be present for 12 months for doctors to diagnose disruptive mood dysregulation disorder.
What causes disruptive mood dysregulation disorder?
Experts don’t yet know what causes this mental health disorder in some children and adolescents.
What are the symptoms of disruptive mood dysregulation disorder?
Children and adolescents who experience DMDD may:
- Have behavioral tantrums or verbal outbursts that are more intense and last longer than what seems appropriate for the situation
- Have behavioral tantrums or verbal outbursts that are inappropriate for the child’s or adolescent’s age or maturity level
- Have behavioral tantrums or verbal outbursts at least three times a week
- Feel angry, irritable, or cranky most days, for the majority of the day
- Experience tantrums, anger, and/or irritability at a high level of intensity for 12 months or longer
- Have difficulty functioning well in two or more settings (at home, at school, and/or with peers) due to tantrums, outbursts, anger, and/or irritability
What are the risk factors for disruptive mood dysregulation disorder?
Children and adolescents may be at increased risk of DMDD if they have:
- Oppositional defiant disorder, a condition in which a child exhibits defiant or disobedient behavior
- Attention-deficit/hyperactivity disorder (ADHD), a neurodevelopmental condition in which a child may have difficulty paying attention or controlling impulsive behaviors
- An anxiety disorder
- Major depressive disorder, a condition characterized by diminished interests and a depressed mood
- A family history of depression
- A prior diagnosis of pediatric bipolar disorder (without meeting all of the criteria)
- Difficulty understanding emotional facial expressions
Certain lifestyle factors may also increase the risk of disruptive mood dysregulation disorder, including:
- Psychological abuse or neglect
- Having a parent with a psychiatric disorder
- Early trauma
How is disruptive mood dysregulation disorder diagnosed?
A diagnosis of DMDD cannot be made from a physical exam, and there are no diagnostic tests to confirm the condition. Instead, doctors will learn about the patient’s symptoms and behavioral history from their parents and teachers. These details help doctors to make an accurate assessment and diagnosis.
During an assessment, the doctor will also rule out other conditions, including depression, anxiety, and post-traumatic stress disorder (PTSD).
The doctor will ask about the frequency and intensity of a child’s tantrums (behavioral and/or verbal). They should ask how long each tantrum or outburst lasts and whether they culminate in aggression (such as shouting, slamming doors, destruction of property, or physical attacks on others). The doctor will also ask if tantrums or outbursts have occurred at least three times per week for at least 12 months and if they have been noted by people in at least two different venues, such as at home, in school, or among peers.
The doctor should also ask about the child’s baseline mood to find out how often they appear angry, irritable, or hostile. The doctor should find out whether parents, teachers, peers, or others have noticed the child’s overall hostile mood or chronic irritability.
A doctor may use different scales or checklists to determine whether a child’s irritability, temper, and aggression levels, as well as their ability to control their anger, may qualify as disruptive mood dysregulation disorder. However, no validated scales are designed to diagnose DMDD. Sometimes, doctors refer patients to a mental health professional to confirm their diagnosis.
How is disruptive mood dysregulation disorder treated?
Different types of psychotherapy (talk therapy), with or without medication, may be used to treat disruptive mood dysregulation disorder. At the moment, no treatments have been designed specifically for patients with the condition because the APA has only recently recognized it. Current treatments are primarily based on other childhood disorders associated with irritability, such as anxiety and ADHD.
Psychotherapy treatment options include:
- Cognitive behavioral therapy (CBT), which helps children/adolescents learn how to better manage the relationship between their thoughts, feelings, and behaviors to reduce the frequency and intensity of tantrums and outbursts
- Dialectical behavior therapy for children (DBT-C), which teaches children/adolescents how to better regulate their feelings with self-calming techniques, thereby helping to reduce the intensity or frequency of patients’ tantrums or outbursts
- Parent training, which teaches parents how to read and respond to children’s/adolescents’ behaviors before a tantrum or outburst begins, which may help to reduce their frequency
Medication therapy options may include:
- Stimulant medications, such as methylphenidate, which may help reduce feelings of irritability
- Antidepressant medications, such as selective serotonin reuptake inhibitors (SSRIs) or serotonin noradrenalin reuptake inhibitors (SNRIs), which may help reduce the intensity of negative moods and feelings of irritability
- Atypical antipsychotics, such as risperidone and aripiprazole, which may help reduce feelings of aggression and irritability
- Anticonvulsant medications, such as valproic acid, which may help decrease aggressive behaviors
Some doctors may be hesitant to prescribe medication to children and adolescents for disruptive mood dysregulation disorder—for instance, antidepressants may increase suicidal ideation among young patients.
What is the outlook for people with disruptive mood dysregulation disorder?
Treating disruptive mood dysregulation disorder may lead to improvements, resulting in a less irritable mood and fewer tantrums or outbursts.
In certain children and adolescents, DMDD symptoms fade over time. However, some people with disruptive mood dysregulation disorder during childhood or adolescence develop depression or anxiety in adulthood.
What makes Yale unique in its treatment of disruptive mood dysregulation disorder?
“Yale provides thorough multidisciplinary diagnostic evaluations for children and teens with mood disorders, including Disruptive Mood Dysregulation Disorder or DMDD,” says Yale Medicine psychiatrist Dorothy Stubbe, MD. “Because this is a relatively new diagnosis, a thorough assessment is required to identify the key diagnostic features, as well as assess for other potential diagnoses or co-occurring disorders.”
Children with DMDD are complex, and the treatment includes behavioral and psychotherapeutic interventions that involve the child, family, and school, she adds. “Yale offers a full spectrum of care options, depending upon the needs of the child—from outpatient therapy, to intensive outpatient day hospital treatment, to inpatient care for those children for whom the disorder has resulted in active safety concerns,” she says. “Medication is frequently an important component of this comprehensive treatment. Yale values the uniqueness of each patient and their family, and we pride ourselves in providing high-quality, culturally informed, and patient-focused care.”