IACAPAP Textbook of Child and Adolescent Mental Health

Chapter

E.3

MOOD DISORDERSDISRUPTIVE MOOD
DYSREGULATION DISORDER
2016 edition

Florian Daniel Zepf, Caroline Sarah Biskup,
Martin Holtmann, & Kevin Runions

Florian Daniel Zepf

Chair and Winthrop Professorof Child and Adolescent
Psychiatry, Centre & Disciplineof Child and Adolescent
Psychiatry, Psychosomatics
and Psychotherapy; Universityof Western Australia. Clinical
Director & Head of Departmentof Specialized Child andAdolescent Mental HealthServices. The University ofWestern Australia, Perth,
Australia
Conflict of interest: unrestrictedawards from the American
Psychiatric Association, The
American Psychiatric Institutefor Research and Education,
and AstraZeneca (the Young
Minds in Psychiatry Award).
Research support from theGerman Federal Ministry for
Economics and Technology,
This publication is intended for professionals training or practising in mental health and not for the general public. The opinions
expressed are those of the authors and do not necessarily represent the views of the Editor or IACAPAP. This publication seeks todescribe the best treatments and practices based on the scientific evidence available at the time of writing as evaluated by the authorsand may change as a result of new research. Readers need to apply this knowledge to patients in accordance with the guidelines andlaws of their country of practice. Some medications may not be available in some countries and readers should consult the specific drug
information since not all dosages and unwanted effects are mentioned. Organizations, publications and websites are cited or linked toillustrate issues or as a source of further information. This does not mean that authors, the Editor or IACAPAP endorse their content or
recommendations, which should be critically assessed by the reader. Websites may also change or cease to exist.
©IACAPAP 2016. This is an open-access publication under the Creative Commons Attribution Non-commercial License. Use,
distribution and reproduction in any medium are allowed without prior permission provided the original work is properly cited andthe use is non-commercial.
Suggested citation: Zepf FD, Biskup CS, Holtmann M, Runions K. Disruptive mood dysregulation disorder. In Rey JM (ed),
IACAPAP e-Textbook of Child and Adolescent Mental Health. Geneva: International Association for Child and Adolescent Psychiatryand Allied Professions, 2016.

Mood dysregulation

E.3

1

IACAPAP Textbook of Child and Adolescent Mental HealthAlthough irritability and temper outbursts are by no means uncommon in
the young, their chronicity and intensity beyond developmental norms canprove challenging for patients, parents, and those who work with children.
Severe irritability is one of the most common reasons for presentation to mental
health services (Stringaris, 2011), and emotional and behavioral dysregulation arecommonly observed amongst young people referred to services. These symptoms
can be present in a range of disorders including oppositional defiant disorder(ODD), attention-deficit/hyperactivity disorder (ADHD), bipolar and depressive
disorders (Bertocci et al, 2014; Brotman et al, 2006; Stringaris & Goodman,2009). The new diagnostic category of disruptive mood dysregulation disorder(DMDD) was introduced in DSM-5 to address this problem. Although DMDD
has been controversial as indexed by discussions in the media as well as among
clinicians and researchers, a growing body of evidence suggests that this condition
has a distinct etiology, divergent developmental outcomes, and differences inneurobiology from pediatric bipolar disorder, ADHD, and ODD.

CLINICAL PRESENTATION AND DIAGNOSISDMDD as a diagnostic category was introduced after controversy about
the diagnosis of pediatric bipolar disorder that had led to the identification of the
syndrome, initially called “severe mood dysregulation”. Severe mood dysregulation
as a clinical phenotype was described by Leibenluft et al in 2003, who defined
it as chronic (non-episodic) and severe irritability and hyperarousal without theeuphoric and grandiose characteristics that are the hallmark of bipolar disorder.
DMDD was introduced in DSM-5 to make available a diagnosis that would
account for severe temper outbursts out of proportion to the context, that are notconsistent with the child’s developmental level, and that occur on average three ormore times per week. A chart review study noted that patients with DMDD had a
median of 4 temper tantrums per week (Tufan et al, 2016). Between tantrums, thechild must show chronic irritability—angry outbursts, annoyance, and touchiness(Stringaris, 2011). Table E.3.1 summarizes the diagnostic criteria for DMDD,
included in the depressive disorders chapter in DSM-5.
Unlike children and adolescents with bipolar disorder—who present with
distinct periods of depressed mood and of mania or hypomania—patients with
DMDD do not show well defined episodes. According to DSM-5, an episode ischaracterized by a distinct period of mood change distinguishable from the persons’usual mood, lasting at least one week for mania or four days for hypomania.
These discrete episodes are separated by periods of euthymia or sub-syndromal
symptoms. DMDD, on the contrary, requires persistency of the abnormal moodstate. According to DSM-5, a diagnosis of DMDD cannot be made before 6 orafter 10 years of age. Prior to the age of 6 temper outbursts are normal (Wakschlag
et al, 2012) and the boundaries of clinically concerning temper tantrums areunclear. Importantly, DSM-5 criteria indicate that a DMDD diagnosis cannot bemade concurrently with ODD, bipolar disorder, or intermittent explosive disorder.

the European Union, theGerman Society for Social
Pediatrics and Adolescent
Medicine, the Paul and Ursula
Klein Foundation, the Dr.
August Scheidel Foundation,
the Telethon Perth Children’s
Hospital Research Fund
(TPCHRF), and the IZKF of
RWTH Aachen University,
travel support from the
GlaxoSmithKline Foundation.
Unrestricted educational
grant, travel support andspeaker honoraria from Shire
Pharmaceuticals; editorial feesfrom Co-Action Publishing(Sweden); support from theRaine Foundation for Medical
Research (Raine Visiting
Professorship).

Caroline Sarah Biskup

Clinic for Child and Adolescent
Psychiatry, Psychosomatics
and Psychotherapy, RWTH
Aachen University Hospital,
Aachen, Germany
Conflict of interest: none
disclosed

Martin Holtmann

LWL-University Hospitalfor Child and Adolescent
Psychiatry, Ruhr-University
Bochum, Hamm, Germany
Conflict of interest: advisory
or consultancy role for Lilly,
Shire and Medice; conference
attendance support or paid
for public speaking by BristolMyers Squibb, Lilly, Medice,
Neuroconn, and Shire.

Kevin Runions

Centre & Discipline of Childand Adolescent Psychiatry,
Psychosomatics andPsychotherapy; Schoolof Psychiatry & Clinical
Neurosciences and School ofPaediatrics & Child Health, The
University of Western Australia,
Perth, Australia; Telethon Kids
Institute, Perth, Australia
Conflict of interest: none
disclosed

Although this diagnostic category appears to have face validity, there isdebate about its clinical validity and usefulness. A justification for introducing
this diagnosis may have been to resolve the controversy and possible misuse of thepediatric bipolar disorder diagnosis, particularly in the US, and to codify the severe

Mood dysregulation

E.3

2

IACAPAP Textbook of Child and Adolescent Mental Health

Table E.3.1 DSM-5 diagnostic criteria for disruptive mooddysregulation disorder
Severe recurrent temper outbursts in response to common stressors, which are:•On average, three or more times per week•
Temper outbursts are inconsistent with developmental level•
Between outbursts, mood is persistently irritable or angry, most of the day andnearly every day.
Onset of symptoms must be before the age of 10
Symptoms must have been present for 12 or more months
Symptoms must not be absent for three or more consecutive months
Children must be between 6 and 18 years of age
Symptoms should be present in at least two of three settings (home, school, social
situations) and are severe in at least one setting
Symptoms are not better explained by another medical disorder, are not the
manifestation of substance abuse or medical condition, criteria for manic/hypomanic
episode have not been met for more than one day and behaviors do not occur solely
during an episode of major depressive disordermood dysregulation construct (McGough, 2014). However, the concept has been
criticized for lacking established diagnostic reliability and research evidence—much of what is known about DMDD is derived from studies examining severemood dysregulation. It has been argued that DMDD should not be incorporated
in ICD-11. In its place, it has been proposed to add a specifier to ODD indicating
whether there is chronic irritability (Lochman et al, 2015).
Some researchers have used the Child Behavior Checklist (CBCL)(Achenbach, 1991) to capture a phenotype showing broad overlap between the
behaviors observed in DMDD and severe mood dysregulation (e.g., Diler et al,
2009; Holtmann et al, 2008; Volk & Todd, 2007). This CBCL “dysregulation”
profile encapsulates a mixed phenotype of severe behavioral and affective
dysregulation, including irritability, aggression, “affective storms”, hyperarousal,
and mood instability. This profile is characterized by simultaneous extreme scoreson the CBCL syndrome scales “anxious/depressed”, “attention problems”, and“aggressive behavior”. Much of our current understanding of DMDD relies oninference from research on this construct.

EPIDEMIOLOGY
Most of what we know about DMDD has been inferred from researchon severe mood dysregulation, although the upper age limit placed on its onset
differs between DMDD (10 years) and severe mood dysregulation (12 years). A
longitudinal study on severe mood dysregulation indicated that 97% of youths
who met diagnostic criteria for this condition also met criteria for DMDD; theremainder only failed to meet the criteria due to an age of onset of 10 or 11
years (Deveney et al, 2015). Moreover, a diagnosis of severe mood dysregulation
requires symptoms of hyperarousal, whereas DMDD does not, with the provisothat clinicians can assign a concurrent diagnosis of ADHD if warranted.

Mood dysregulation

E.3

Severe irritability is one of
the most common reasonsfor presentation to mental
health services

3

IACAPAP Textbook of Child and Adolescent Mental HealthA 3-month DMDD prevalence of 8.2% was observed in 6-year-old
American children with no sex or ethnicity differences (Dougherty et al, 2014). A
study by Copeland et al (2013) illustrates the prevalence of DMDD symptomology
in a large epidemiological sample including preschool and school age cohorts.
Among school age children, nearly half had shown severe temper outbursts during
the 3 months prior to assessment. Applying the frequency criterion reduced theprevalence to 6-7%; applying the duration criterion dropped the rate to 1.5-2.8%.
When all DMDD criteria were applied, prevalence was about 1%.
Research using the CBCL “dysregulation profile” results in comparable
estimates of prevalence: 1-2% in epidemiological samples (Volk & Todd, 2007;
Holtmann et al, 2007; Hudziak et al, 2005), 6-7% in child psychiatric clinicalsamples, and 13-20% in children with ADHD (Holtmann et al, 2008).

COURSE AND OUTCOME
Few studies have examined the stability of DMDD over time. Stability may
be higher in childhood than adolescence: over 80% of children who meet criteria
for DMDD at age 9 also met criteria when they were 6 years old (Dougherty et
al, 2016). By contrast, a study of 200 adolescents diagnosed with severe mooddysregulation found that less than half met criteria at follow-up (Deveney et al,2015).
Children diagnosed with DMDD at age 6 are at increased risk for depressive
disorders and ADHD at age 9; the risk of disruptive behavior disorder symptoms
was also elevated for these children (Doughterty et al, 2016). Childhood DMDD
status also predicts subsequent peer relationship problems, increased peer exclusionand victimization (i.e., being bullied), and more use of relational aggression(Dougherty et al, 2016). In later childhood, DMDD diagnosis in 10 to 16 year
olds predicted a range of subsequent problems in young adulthood (Copeland etal, 2014). Compared to non-cases and a psychiatric comparison group, those who
met criteria for DMDD were at greater risk as young adults for serious illness,sexually transmitted diseases, other non-substance-related psychiatric disorders,nicotine use, police contact, poverty, not achieving a high school diploma, and nocollege attendance.
Although the DMDD diagnosis arose out of research on bipolar disorder(see Assessment and Differential Diagnosis, below) patients with DMDD or severemood dysregulation do not show increased risk for later bipolar illness (Brotman
et al, 2006; Stringaris et al, 2009), but have an increased risk of depressive disorder(Krieger et al, 2013)—thus the classification of DMDD in the depressive disorders
chapter in DSM-5. This is also supported by studies concluding that children
with severe temper outbursts seldom show symptoms of bipolar disorder (Royet al, 2013, Mikita & Stringaris, 2013). Similarly, severe mood dysregulation isassociated with depressive and anxiety symptoms in later adulthood (Brotman
et al, 2006; Stringaris et al, 2009). Bipolar disorder is found less frequently infamilies of children with severe mood dysregulation than in families of children
with bipolar disorder in both community and clinical populations (Brotman
et al, 2007; Leibenluft, 2011). A 2-year follow-up of youths with severe mooddysregulation showed that they had lower rates of manic, hypomanic or mixed
episodes than patients with bipolar disorder (Stringaris et al, 2010).

Mood dysregulation

E.3

4

IACAPAP Textbook of Child and Adolescent Mental HealthLong-term follow-up of children captured by the CBCL “dysregulation” profile suggests that young adults with a positive CBCL “dysregulation” profile in childhood are at increased risk for substance use, conductand mood disorders, suicidal ideation, and suicide attempts but not for
bipolar disorder. In addition, they showed a marked impairment in overall functioning (Althoff et al, 2010; Holtmann et al, 2011a). The CBCL
“dysregulation” profile may be a valuable tool to identify patients withsevere mood problems. High scores may indicate poor outcomes, such as
substance use, suicidality, and functional impairment (Holtmann et al,
2011; Jucksch et al, 2011).

ASSESSMENT & DIFFERENTIAL DIAGNOSISAs noted in the introduction, the core symptoms of DMDD – irritability
and temper outbursts – are often present in individuals suffering from bipolar
disorder, ADHD, and ODD among others. Moreover, DMDD commonly
overlaps with other disorders. For example, Copeland et al (2013) noted a 63 to
92% overlap with other diagnoses; Fristad and her colleagues (2016) highlighted
the high overlap of baseline demographic and clinical variables with Bipolar
Disorder Not Otherwise Specified. Thus assessment and differential diagnosis ofchildren with DMDD is difficult.
A chart review found an average age of onset of 4.9 years (Tufan et al, 2016).
This study also provides insights into the diagnostic challenges: consensus could
not be reached in more than 20% of patients. The more common reasons for thiswere whether symptoms occurred in more than one setting and whether there wasanger or other negative moods between tantrums. Other sources of disagreement
related to the frequency of tantrums, tantrum severity, and duration of symptoms.
Holtmann and his colleagues (2011b) established that a 5-item subset from theStrengths & Difficulties Questionnaire could be a valid screening measure.

DMDD and Bipolar Disorder
The assignment of a bipolar disorder diagnosis to children and adolescentswith chronic irritability but without distinct episodes of mania has been
controversial. The debate is not only academic: broadening the diagnostic construct
resulted in dramatic changes in clinical practice. For example, between 1993 and2003 the number of adults diagnosed with bipolar disorder in the US doubled,
but increased 40 times in people younger than 20 years (Blader & Carlson,
2007; Moreno et al, 2007); this shift was accompanied by a large increase in theprescription of antipsychotic drugs to youth (Olfson et al, 2006). Data suggestthat widening of the bipolar construct in the US was the explanation: for example,
James et al (2014) noted a 70-fold difference in hospital discharges for bipolar
disorder in the US and the UK, indicating different diagnostic practices.
According to the guidelines of the British National Institute for Healthand Clinical Excellence, a diagnosis of bipolar disorder in children should only
be made if the patient has a history of manic or hypomanic episodes in line with
relevant diagnostic criteria, including duration and frequency of such episodes(Baroni et al, 2009). That is, bipolar disorder should not be diagnosed in theabsence of episodes characterized by a distinct change in mood and concurrent

Mood dysregulation

E.3

Who are thechildren withsevere mooddysregulation?
“These explosive
children are not new.
A closer look at thetraditional diagnoses
that apply to this groupof youth gives us further
insight. Although there isno significant differencein the rates of ADHD
between children withnarrow phenotype
bipolar disorder andthose with severemood dysregulation(60.6% and 86.7%,
respectively), morethan twice the numberof children with severemood dysregulation
have oppositional defiant
disorder (39.4% versus
83.3%) […] If we recastchildren with severemood dysregulation as
children with prominent
combined ADHD and
oppositional defiant
disorder, we find wehave considerable
knowledge about themalready. For instance,
follow-up studies do notreport inordinate rates
of narrow phenotype
bipolar disorder inchildren with ADHD plus
oppositional defiant
disorder. However,conduct disorder (CD)and later antisocial
behavior/criminality andsubstance abuse are
the unfortunate legacies
of combined ADHD and
oppositional defiant
disorder” (Carlson,2007).

5

IACAPAP Textbook of Child and Adolescent Mental Healthchanges in behavior and cognition. The traditional view, and the view represented
in DSM-5, is that bipolar disorder can occur in pre-pubertal children but very
rarely, becoming increasingly prevalent during adolescence, and that symptoms inthe young are largely the same as in adults.

DMDD and the Disruptive Behavior Disorders
The presence of irritability and temper outburst have led some researchersand clinicians to argue that there is no clear demarcation between DMDD, ODD
and conduct disorder (Axelson, 2013). Proponents of this view maintain thatbipolar disorder is often misdiagnosed as, or co-morbid with, ADHD (Biederman
et al, 1998). ADHD does seem to have a considerable symptom overlap withbipolar disorder in children and adolescents as can be seen in Figure E.3.1 (Zepf,
2009), though irritability in bipolar disorder is episodic, unlike in DMDD where
it is chronic.
Lochman et al (2015) argue that ICD-11 should not incorporate the
DMDD category, proposing instead to make a diagnosis of ODD and add a
specifier indicating chronic irritability or anger instead. This argument is bolsteredby findings that 92% of children aged 6-12 years in a general population sample
who met DMDD criteria also met criteria for ODD, and 66% of those with ODD
also had DMDD symptoms (Mayes et al, 2016). Deveney et al (2015) reported
that over 80% of their sample of adolescents meeting criteria for severe mooddysregulation also met criteria for ODD or ADHD. However, other data indicatethat DMDD and ODD show a more modest overlap (55%) and that DMDD
predicts impairment over and above that due to ODD (Dougherty et al, 2014).

Click on the picture to viewa brief video interview
with Ellen Leibenluft MDon bipolar disorder inchildhood summarizing therelationship between chronic
irritability and chronic mooddysregulation problems,and how these problems
differ from bipolar disorder inchildren

ETIOLOGY AND RISK FACTORSThe literature on developmental predictors of DMDD is in its infancy.
Dougherty et al (2014) examined at age 3 predictors of DMDD at age 6. They notedthat only temperamental “surgency” (a construct reflecting high levels of activity,
reward seeking, low shyness, and impulsivity) and parental lifetime substance use
disorder predicted DMDD status at age 6. In one study, participants with a CBCL
“dysregulation” phenotype exhibited an increase in C-reactive protein and albumin
concentrations, raising the possibility of an inflammatory diathesis (Holtmann etal, 2013).
To date, few studies have been conducted shing light on family or othersocial or ecological factors that might contribute to the development of DMDD.
The chart review by Tufan and colleagues (2016) indicated that over a threequarter of patients with DMDD had family histories involving parental mental
health problems, including major depressive disorders, ADHD and anxiety
disorder (56%, 25%, and 17% respectively). Although maternal depression has
been linked to irritability in children with ODD (Krieger et al, 2013), no studies
have found evidence for a role in DMDD of parental depression or other parental
psychopathology (e.g., Axelson et al, 2012). Parents of children with DMDD havebeen shown to be more hostile and critical in their interactions with their children,
but this may reflect bidirectional parent-child processes (Dougherty et al, 2014).
A history of lifetime substance use disorder has also been implicated. Compared

Mood dysregulation

E.3

6

IACAPAP Textbook of Child and Adolescent Mental Health

Figure E.3.1: Diagnostic overlap in manic episodes and ADHD
DSM-IV symptoms of ADHD that can also be observed in a manic episodeDSM-IV symptoms of a manic episode that can also be observed in ADHD

Zepf, 2009, adapted with permission from Wingo & Ghaemi, ©2007, Physicians Postgraduate Press and Kent & Craddock, Journal of
Affective Disorders, 73:211-221,©2003, with permission from Elsevier.

Mood dysregulation

E.3

7

IACAPAP Textbook of Child and Adolescent Mental Healthwith children diagnosed with bipolar disorder not otherwise specified, children
with DMDD are less likely to have a parent with bipolar disorder (Fristad et al,2016).
Interpersonal trauma and exposure to traumatic events are widely
acknowledged as being associated with affective dysregulation generally (Dvir etal, 2014), but to date no studies have examined trauma or related events including
abuse and neglect as risk factors for DMDD. Child maltreatment and physicalabuse are known risk factors for the sorts of affective processing biases observedwith severe mood dysregulation and DMDD (see next section) (Leibenluft &Stoddard, 2013). However, empirical studies have not yet focused on whether
these factors are particularly implicated in DMDD. Clearly, further research isneeded to establish a better picture of the etiology of DMDD.

Social-Affective and Cognitive Neuroscience
There is a burgeoning body of research examining social and emotional
information processing and emotion regulation and the underlying
neurobiology of severe mood dysregulation, particularly in comparison
with other diagnoses such as bipolar disorder. Much of this research has
focused on response to emotion-laden stimuli, primarily to the humanface. Severe mood dysregulation and bipolar disorder share common social
cognitive deficits in processing affective information from the human face,showing less accuracy in labelling expressions and less sensitivity in facial
emotion recognition relative to healthy controls. There is some evidenceof biased processing of threatening faces in particular (Hommer et al,2014). Functional magnetic resonance imaging research with severe mooddysregulation patients shows differential neural activation of the posterior
cingulate cortex, posterior insula, and inferior parietal lobe in relation to
fearful faces (Thomas et al, 2013). Future research need to examine whether
these biases are specific to DMDD/severe mood dysregulation or reflect comorbid psychopathology such as ODD.
Compared to individuals with bipolar disorder, those with DMDD
show diminished cognitive flexibility as assessed with a reversal learning task
(Adleman et al, 2012), and poor motor inhibition (Deveney et al, 2012).
These characteristics are shared with patients with ADHD, however, andthis overlap may account for these features (Uran & Kiliç, 2015).
In summary, at this stage it can be concluded that underlying brain
mechanisms related to the symptomatology of severe mood dysregulation
are different between patients with severe mood dysregulation, bipolar
disorder, and healthy people, which may be of importance to develop
pharmacological interventions.

TREATMENT
Because DMDD is such a recent inclusion in the taxonomy, there are few
clinical trials that could inform clinical practice. Therefore, most of the
management recommendations are extrapolated from studies dealing withrelated disorders such as severe mood dysregulation, ODD, and depression(Roy et al, 2014).

Mood dysregulation

E.3

8

IACAPAP Textbook of Child and Adolescent Mental HealthBehavioral therapy
Scott and O’Connor (2012) investigated the effects of parent training andcognitive behavior therapy in children aged 4-6 years presenting with the emotion
dysregulation (defined as irritable and/or hurtful) subtypes of ODD as comparedto patients with ODD without such a profile. Although the children were too
young to meet diagnostic criteria for either severe mood dysregulation or DMDD,
the study showed that young children with emotion dysregulation were moresensitive to changed parenting and showed stronger treatment effects than children
without these symptoms.

Pharmacological treatment
Given the high comorbidity of DMDD with ADHD, stimulants have beenstudied as a possible treatment (Posner et al, 2014). Medications that improve
irritability and depressed mood may be valuable – all used “off label”. Second
generation antipsychotics such as risperidone have also been used. A double-blind
RCT of lithium treatment did not reduce symptoms in hospitalized patients withsevere mood dysregulation (Dickstein et al, 2009). Krieger and colleagues (2011)
reported a significant reduction in irritability in an open-label study of risperidone.
Carlson et al (2010) found similar results. This is consistent with the widely known
finding that risperidone can reduce aggressive behavior and irritability in the young.
However, these early findings should be seen with extreme caution considering thepotentially serious side effects of antipsychotics in the young and the fact that they
do not specifically refer to patients with DMDD. Preliminary studies suggest thatadolescents with ODD/CD and symptoms suggestive of DMDD show a reductionof symptoms when treated with divalproex (Donovan et al, 2000), a commonlyused treatment for bipolar disorder. Discussion with parents and patients as well as
careful monitoring of side effects is essential when prescribing these medications.

Click on the image to access“Facts for families” about
DMDD

Other interventions
Educational approaches are highly relevant. Clinicians, teachers and parents
need to work closely together to address and meet these patients’ special needs(e.g., consistency, classroom support, more time to complete school tests, etc.).
Teachers should also be made aware of the adverse effects of medication if it isprescribed. Patients and families should receive education about the disorder,
comorbid symptoms and related impairments, as well as strategies for managing
them. Finally, changes in lifestyle can be addressed together with the help of allied
health professionals. Such changes may include strategies for dealing with crises
and identifying potential stressors and triggers. A plan to manage emergencies(e.g., suicidal behavior, extreme loss of control) needs to be put in place. Moreover,parenting programs and family therapy need to be considered as many of thesechildren come from problematic families with poor parenting and communication
skills; often parents themselves suffer from psychiatric disorders. In that case areferral should be considered. This is an ideal situation. However, in many countries
these resources won’t be available; clinicians may need to rely on psychoeducation,school teachers, extended family and other supports.

Mood dysregulation

E.3

9

IACAPAP Textbook of Child and Adolescent Mental Health

M was 7.5 years of age when his parents became increasingly aware and worried becauseof his frequent temper outbursts, which seemed to happen without a noticeable or minor
trigger, such as after arguing with his older sister over which TV channel they would watch.
These outbursts had increased in intensity and frequency over time, with verbal and physicalaggression towards his classmates as well as objects. Between these outbursts M mostly
showed a negative mood. He once mentioned to his friends and parents that he wasthinking about what would happen if he was no longer alive. His peers wondered why M wasalways so cranky and irritable; minor provocations leading to aggressive reactions far outof proportion. The mentioned outbursts happened on average 3-4 times per week; initially,
however, frequency had been lower. Outbursts led to fights at school, and soon teachersbegan to contact the parents to come and discuss M’s behavioral problems. Before the current
presentation M had been taken to a community health center because teachers had raised
the possibility that M was suffering from ADHD. However, the diagnostic process was lengthy
as M frequently refused to participate in an evaluation and only rarely showed up for clinicalappointments.
A diagnosis of disruptive mood dysregulation disorder was made. Diagnoses of major
depression and conduct disorder were ruled out based on self-, parent and teacher reports.
Treatment with risperidone was initiated based upon clinical experience because of thefrequent temper outbursts. In addition, M received behavioral psychotherapy with a local
psychologist in order to identify potential triggers and stressors leading to temper outbursts
and negative mood, and to develop strategies to cope with stressful situations that could
easily impact M’s mood. Further, M and his parents had several meetings with teachers andcommunity health workers to plan strategies for prevention and constructive managementof his temper outbursts (such as time-out strategies, understanding and avoiding triggers
for aggression and management/coping strategies for stressful situations), frequency andintensity of M’s outbursts gradually decreased; he became more cooperative and willingto participate in further treatment and assessment, which lead to the diagnosis of ADHD.
Subsequently, treatment with methylphenidate was initiated leading to a further improvementof his scholastic performance and, with only a short latency, to a further improvement of
his outbursts. M currently being treated with methylphenidate alone; risperidone had been
discontinued after approximately six months. Treatment for ADHD symptoms needed to becontinued, but his mood dysregulation problems had improved significantly.

Summary
In the absence of research evidence, treatment of DMDD is currently guided
by clinical experience or based on limited evidence about the treatment of specificbehaviors such as persistent aggression or temper outbursts. Management needs tobe judicious to avoid doing harm rather than good (Roy et al, 2014, Tourian et al,2015). In summary, this would entail:
•
•

•
•
•
•
•

A careful evaluation of symptoms and potential causal factors such as
child maltreatment or neglect
Dealing with the factors that may be causing or maintain the symptoms.
That may include CBT, improving parenting skills through parenting
programs, psychoeducation, providing support to the family, or fostering
if the child is unsafe
Family therapy when family interactions are severely dysfunctional
Education and support to teachers
If symptoms of ADHD are significant, specific ADHD treatment can be
tried
Antipsychotics and sodium valproate may be used when there is lack of
response to other interventions
Temper outburst and aggression may benefit from methylphenidate inchildren with ADHD. Risperidone or valproate, with the appropriate
precautions, may also be helpful

Mood dysregulation

E.3

10

IACAPAP Textbook of Child and Adolescent Mental Health•••In spite of the fact that DMDD is considered to be related to major
depression, there is no evidence yet that antidepressants are useful
One important unresolved issue is for how long medication should beprescribed, particularly because some of these drugs have significant side
effects
In most cases, medication should be combined with CBT and parent
training for optimal results.

Key practitioner
messages•

CONCLUSIONS
Irrespective of whether the diagnosis of DMDD in its current
incarnation survives the test of time, children and adolescents sufferingfrom chronic irritability are highly impaired and hospitalized frequently.
Experienced clinicians are aware that many of these children come from very
disturbed families in which abuse, neglect and separation from attachment
figures is often the norm, sometimes ignored in taxonomic and researchstudies. This adds another layer of complexity, in particular because it
becomes very difficult to establish which behaviors are due to a “biological”
disorder and which are the results of, or a response to family dysfunction,or how one interacts with the other.

•
•

•

•

Do you have questions?
Comments?

Click here to go to the Textbook’s Facebook page to share your views about
the chapter with other readers, question the authors or editor and makecomments.

•

DMDD is a usefuldiagnosis for children
with severe, nonepisodic irritability.
Current evidence
suggests that such
irritability may
be related to thedepression dimension
Young people withsevere, non-episodic
irritability differ fromthose with bipolar
disorder in longitudinalcourse, family history,
and performance on
some, although not all,neuropsychologicalfeatures.
The diagnosis ofpediatric bipolar
disorder should bereserved for children
who have distinct
episodes of mania.
During such an
episode, the child’s
mood and behavior
must differ from theusual comportment
There is limited
empirical evidence
to guide treatment
decisions in thesepatients.

REFERENCES
Achenbach TM (1991) Manual for the Child Behavior
Checklist/4-18 and 1991 Profile. Burlington, VT:
University of Vermont, Department of Psychiatry.
Adleman NE, Fromm SJ, Razdan V et al. (2012) Cross-sectional
and longitudinal abnormalities in brain structure inchildren with severe mood dysregulation or bipolar
disorder. Journal of Child Psychology and Psychiatry, andallied Disciplines 53:1149-1156
Althoff RR, Verhulst FC, Rettew DC et al (2010). Adult
outcomes of childhood dysregulation: a 14-year
follow-up study. Journal of the American Academy ofChild and Adolescent Psychiatry 49: 1105-1116
Axelson D (2013) Taking disruptive mood dysregulation
disorder out for a test drive. The American Journal of
Psychiatry 170:136-139

Mood dysregulation

E.3

Axelson D, Findling RL, Fristad MA et al (2012). Examining
the proposed disruptive mood dysregulation disorderdiagnosis in children in the Longitudinal Assessmentof Manic Symptoms study. Journal of ClinicalPsychiatry 73:1343-1350.
Baroni A, Lunsford JR, Luckenbaugh DA et al (2009).
Practitioner review: the assessment of bipolar disorderin children and adolescents. Journal of Child Psychology
and Psychiatry 50:203-215
Bertocci MA, Bebko G, Olino T et al (2014). Behavioral
and emotional dysregulation trajectories marked by
prefrontal-amygdala function in symptomatic youth.
Psychological Medicine 44: 2603-2615.

11

IACAPAP Textbook of Child and Adolescent Mental Health

Biederman J, Klein RG, Pine DS et al (1998) Resolved: mania
is mistaken for ADHD in prepubertal children.
Journal of the American Academy of Child & Adolescent
Psychiatry 37:1091-1096

Dougherty LR, Smith VC, Bufferd SJ et al (2014). DSM-5
disruptive mood dysregulation disorder: correlates andpredictors in young children. Psychological Medicine
44:2339-2350

Blader JC, Carlson GA (2007). Increased rates of bipolar
disorder diagnoses among U.S. child, adolescent andadult inpatients, 1996-2004. Biological Psychiatry
62:107-114

Dougherty LR, Smith VC, Bufferd SJ et al (2016). Disruptive
mood dysregulation disorder at the age of 6 years
and clinical and functional outcomes 3 years later.
Psychological Medicine 46:1103-1114

Brotman MA, Kassem L, Reising MM et al (2007). Parental
diagnoses in youth with narrow phenotype bipolar
disorder or severe mood dysregulation. American
Journal of Psychiatry 164:1238-1241

Dvir Y, Ford JD, Hill M, Frazier JA (2014). Childhood
maltreatment, emotional dysregulation, andpsychiatric comorbidities. Harvard Review of
Psychiatry 22: 149-161

Brotman MA, Rich BA, Guyer AE et al (2010). Amygdala
activation during emotion processing of neutral faces
in children with severe mood dysregulation versus
ADHD or bipolar disorder. American Journal of
Psychiatry 167:61-69

Fristad MA, Wolfson H, Algorta GP et al (2016). Disruptive
mood dysregulation disorder and bipolar disorder
not otherwise specified: Fraternal or identical twins?
Journal of Child & Adolescent Psychopharmacology
26:138-146.

Brotman MA, Schmajuk M, Rich BA et al (2006). Prevalence,clinical correlates, and longitudinal course of severemood dysregulation in children. Biological Psychiatry
60: 991-997

Holtmann M, Becker A, Banaschewski T et al (2011b).
Psychometric validity of the Strengths and Difficulties
Questionnaire-Dysregulation Profile. Psychopathology
44: 53-59

Carlson GA, Potegal M, Margulies D et al (2010). Liquid
risperidone in the treatment of rages in psychiatrically
hospitalized children with possible bipolar disorder.
Bipolar Disorders 12:205-212

Holtmann M, Bolte S, Goth K et al (2007). Prevalence of theChild Behavior Checklist-pediatric bipolar disorderphenotype in a German general population sample.
Bipolar Disorders 9:895-900

Carlson GA (2007). Who are the children with severe mooddysregulation, a.k.a. “Rages”? American Journal of
Psychiatry 164:1140-1142

Holtmann M, Bölte S, Poustka F (2008). Rapid increase inrates of bipolar diagnosis in youth: “true” bipolarity
or misdiagnosed severe disruptive behavior disorders?
Archives of General Psychiatry, 65:477-477

Copeland WE, Angold A, Costello EJ et al (2013). Prevalence,
comorbidity, and correlates of DSM-5 proposed
disruptive mood dysregulation disorder. The American
Journal of Psychiatry 170:173-179
Copeland WE, Shanahan L, Egger H, et al (2014). Adult
diagnostic and functional outcomes of DSM-5
diruptive mood dysregulation disorder. American
Journal of Psychiatry 171: 668-674
Deveney CM, Connolly ME, Jenkins SE et al (2012).
Neural recruitment during failed motor inhibitiondifferentiates youths with bipolar disorder and severemood dysregulation. Biological Psychology 89:148-155.
Deveney CM, Hommer RE, Reeves E, et al. (2015). A
prospective study of severe irritability in youths: 2and 4-year follow-up. Depression & Anxiety 32:364372
Dickstein DP, Towbin KE, Van Der Veen JW et al (2009).
Randomized double-blind placebo-controlled trial oflithium in youths with severe mood dysregulation.
Journal of Child and Adolescent Psychopharmacology,
19:61-73.
Diler RS, Birmaher B, Axelson D et al (2009). The Child
Behavior Checklist (CBCL) and the CBCL-bipolar
phenotype are not useful in diagnosing pediatricbipolar disorder. Journal of Child and Adolescent
Psychopharmacology 19:23-30
Donovan SJ, Stewart JW, Nunes EV et al (2000). Divalproex
treatment for youth with explosive temper and moodlability: a double-blind, placebo-controlled crossoverdesign. American Journal of Psychiatry 157:818–820

Mood dysregulation

E.3

Holtmann M, Buchmann AF, Esser G et al (2011a). The Child
Behavior Checklist-Dysregulation Profile predicts
substance use, suicidality, and functional impairment:a longitudinal analysis. Journal of Child Psychology andPsychiatry 52:139-147
Holtmann M, Poustka L, Zepf FD et al (2013). Severe affective
and behavioral dysregulation in youths is associatedwith a proinflammatory state. Zeitschrift für Kinderund Jugendpsychiatrie und Psychotherapie 41:393-399
Hommer RE, Meyer A, Stoddard J et al (2014). Attention
bias to threat faces in severe mood dysregulation.
Depression and Anxiety 31:559-565
Hudziak JJ, Althoff RR, Derks EM et al (2005). Prevalence andgenetic architecture of Child Behavior Checklistjuvenile bipolar disorder. Biological Psychiatry 58:562568
Jucksch V, Salbach-Andrae H, Lenz K et al (2011). Severe
affective and behavioural dysregulation is associatedwith significant psychosocial adversity andimpairment. Journal of Child Psychology and Psychiatry
52:686-695
James A, Hoang U, Seagroatt V et al (2014). A comparisonof American and English hospital discharge rates forpediatric bipolar disorder. Journal of the American
Academy of Child and Adolescent Psychiatry 53:614-624
Krieger FV, Leibenluft E, Stringaris A et al (2013). Irritability
in children and adolescents: past concepts, current
debates, and future opportunities. Revista Brasileira dePsiquiatria 35 (Sup 1):S32-39

12

IACAPAP Textbook of Child and Adolescent Mental Health

Krieger FV, Pheula GF, Coelho R et al (2011). An open-label
trial of risperidone in children and adolescents withsevere mood dysregulation. Journal of Child andAdolescent Psychopharmacology 21:237-243
Leibenluft E, Charney DS, Towbin KE et al (2003). Defining
clinical phenotypes of juvenile mania. American
Journal of Psychiatry, 160:430– 437
Leibenluft E, Stoddard J (2013). The developmental
psychopathology of irritability. Development andPsychopathology 25:1473-1487
Lochman JE, Evans SC, Burke JD et al (2015). An empirically
based alternative to DSM-5’s disruptive mooddysregulation disorder for ICD-11. World Psychiatry
14:30-33
McGough JJ (2014) Chronic non-episodic irritability inchildhood: Current and future challenges. American
Journal of Psychiatry 171:607–610
Mayes SD, Waxmonsky JD, Calhoun SL et al (2016).
Disruptive mood disregulation disorder symptoms
and association with oppositional defiant disorder andother disorders in a general population child sample.
Journal of Child and Adolescent Psychopharmacology
26:101-106.
Mikita N, Stringaris A (2013). Mood dysregulation. European
Child and Adolescent Psychiatry 22 (sup 1): S11-16
Moreno G, Laje G, Blanco C et al (2007) National trends in theoutpatient diagnosis and treatment of bipolar disorderin youth. Archives of General Psychiatry 64:032-1039
Olfson M, Blanco C, Liu L et al (2006). National trends in theoutpatient treatment of children and adolescents with
antipsychotic drugs. Archives of General Psychiatry
63:679-685
Posner J, Kass E, Hulvershorn L (2014). Using stimulants
to treat ADHD-related emotional lability. Current
Psychiatry Reports 16:478
Roy AK, Lopes V, Klein RG (2014). Disruptive mooddysregulation disorder: A new diagnostic approachfor chronic irritability in youth. American Journal of
Psychiatry 171:918-924
Roy AK, Klein RG, Angelosante A et al (2013). Clinicalfeatures of young children referred for impairing
temper outbursts. Journal of Child and Adolescent
Psychopharmacology 23:588-596
Scott S, O’Connor TG (2012). An experimental test ofdifferential susceptibility to parenting among
emotionally-dysregulated children in a randomized
controlled trial for oppositional behavior. Journal ofChild Psychology and Psychiatry 53:1184-1193

Mood dysregulation

E.3

Stringaris A. (2011). Irritability in children and adolescents: A
challenge for DSM-5. European Child & Adolescent
Psychiatry, 20: 61-66.
Stringaris A, Baroni A, Haimm C et al (2010). Pediatric bipolar
disorder versus severe mood dysregulation: risk formanic episodes on follow-up. Journal of the American
Academy of Child & Adolescent Psychiatry 49:397-405
Stringaris A, Cohen P, Pine DS et al (2009). Adult outcomes ofyouth irritability: a 20-year prospective communitybased study. American Journal of Psychiatry 166:10481054
Stringaris A, Goodman R (2009). Mood lability andpsychopathology in youth. Psychological Medicine
39:1237-1245
Thomas LA, Brotman MA, Bones BL et al (2014). Neuralcircuitry of masked emotional face processing in youth
with bipolar disorder, severe mood dysregulation,and healthy volunteers. Developmental Cognitive
Neuroscience 8:110-120
Thomas LA, Kim P, Bones BL et al (2013). Elevated amygdala
responses to emotional faces in youths with chronic
irritability or bipolar disorder. Neuroimage: Clinical
2:637-645
Tourian L, LeBoeuf A, Breton JJ et al (2015). Treatment
options for the cardinal symptoms of disruptive
mood dysregulation disorder. Journal of the CanadianAcademy of Child and Adolescent Psychiatry 24:41-54
Tufan E, Topal Z, Demir N et al (2016). Sociodemographic
and clinical features of disruptive mood dysregulation
disorder: A chart review. Journal of Child & Adolescent
Psychopharmacology, 26: 94-100
Uran P, Kiliç BG (2015). Comparison of neuropsychological
performance and behavioral patterns of children withattention deficit hyperactivity disorder and severemood dysregulation. European Child and Adolescent
Psychiatry 24:21-30
Volk HE, Todd RD (2007). Does the Child Behavior Checklist
juvenile bipolar disorder phenotype identify bipolar
disorder? Biological Psychiatry 62:15-20
Wakschlag LS, Choi SW, Carter AS, Hullsiek H et al (2012).
Defining the developmental parameters of temper loss
in early childhood: Implications for developmental
psychopathology. Journal of Child Psychology &Psychiatry 53:1009-1108
Zepf FD (2009). Attention deficit-hyperactivity disorder andearly-onset bipolar disorder: two facets of one entity?
Dialogues in Clinical Neuroscience 11:63-72

13