Disruptive Mood Dysregulation Disorder: Where Did It Come from and Where Is It Going.

[Author Affiliation]Gabrielle A. Carlson. Division of Child and Adolescent Psychiatry, Stony Brook University School of Medicine, Stony Brook, New York.Address correspondence to: Gabrielle A. Carlson, MD, Professor of Psychiatry and Pediatrics, Stony Brook University School of Medicine, Putnam Hall-South Campus, Stony Brook, NY 11794-8790, E-mail: gabrielle.carlson@stonybrook.eduThe possibility of a specific subtype of childhood mania had been discussed for many years (Carlson and Glovinsky 2009). Biederman et al. most clearly articulated this position when they stated "...the most common mood disturbance in manic children is severe irritability, with 'affective storms' or prolonged and aggressive temper outbursts. The type of irritability observed in manic children is very severe, persistent, and often violent. The outbursts often include threatening or attacking behavior toward family members, other children, adults, and teachers. In between outbursts, these children are described as persistently irritable or angry in mood" (Biederman et al. 2000). This conceptualization of bipolar disorder (BP), where criteria for mania are apparently met, generated a good deal of excitement and hope that a solution had been found for a complex set of childhood behaviors, namely irritability and explosiveness.The counterpoint, nicely articulated by Klein et al. in a point/counterpoint with Biederman et al. (1998), stated "the clinical descriptions of mania have been remarkably consistent over the years, if not centuries, consisting of a distinct episode of elevated mood or irritability, with well established associate features...usually interspersed with episodes of major depression. No diagnostic criteria have ever been proposed for stable, continuous mania."After the NIMH conference on BP in 2000 (NIMH Roundtable 2001), which highlighted these divergent viewpoints, Leibenluft et al. (2003) decided to operationalize the two apparently contrasting descriptions of mania and validate them as similar or different. Note, however, that principal feature of "prepubertal mania" is a "prolonged and aggressive temper outburst," is not a "business as usual" temper tantrum or a frequent snit or loss of temper. It is a volcanic severe outburst. Severe mood dysregulation (SMD) was a condition designed to capture this behavior in the context of severe irritability as the sustained mood in the context of which the explosions occur. Mania in children became controversial, in part, because investigators interpreted and operationalized the criteria differently (see Carlson and Klein 2014 for review). An important question for the future of disruptive mood dysregulation disorder (DMDD), the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-V) (American Psychiatric Association 2013) version of SMD, is how can we prevent this from happening again.The series of 10 articles in this special issue highlights some of the methodological problems of understanding studies that examine DMDD entity using data that had not been gathered with DMDD in mind.The first article is a chart review from three clinics in Turkey. Tufan et al. (this issue) have capitalized on the use of standardized rating scales to screen many charts. They then used chart narratives to further identify children with DMDD, as well as to determine rater agreement. We are provided with an actual case which is helpful. Unlike other conditions in child psychiatry where criteria were derived from an abundance of clinical cases and information, DMDD originated as a set of criteria and clinicians are now looking for the children. The authors found that although consensus was fairly high, there was most disagreement about whether irritable mood existed between episodes.All but one of the articles submitted to this special issue "retrofitted" (to use Dr. Fristad's term) DMDD criteria to existing data sets and samples to help us understand the frequency, phenomenology, and possible treatment of DMDD. …