31 - 31.12c Disruptive Mood Dysregulation Disorder

31.12c Disruptive Mood Dysregulation Disorder

patients with bipolar I mania: a comparative analysis of acute, randomized, placebo-controlled trials. Bipolar Disorders. 2010;12:116–141. Correll CU, Kratochvil CJ, March JS. Developments in pediatric psychopharmacology: Focus on stimulants, antidepressants and antipsychotics. J Clin Psychiatry. 2011;72:655–670. Findling RL, Landersdorfer CB, Kafantaris V, Pavulari M, McNamara NK, McClellan J, Frazier JA, Sikich L, Kowatch R, Lingler J, Faber J, Taylor-Zapata, Jusko WJ. First-dose pharmacokinetics of lithium carbonate in children and adolescents. J Clin Psychopharmacol. 2010;30:404–410. Larsky T, Krieger A, Elixhauser A, Vitiello B. Children’s hospitalizations with a mood disorder diagnosis in general hospitals in the United States 2000-2006. Child Adolesc Psychiatry Mental Health. 2011;5:27–34. Mathieu F, Dizier M-H, Etain B, Jamain S, Rietschel M, Maier W, Albus M, McKeon P, Roche S, Blackwood D, Muir W, Henry C, Malafosse A, Preisig M, Ferrero F, Cichon S, Schumacher J, Ohlraun S, Propping P, Jamra RA, Schulze TG, Zelenica D, Charon C, Marusic A, Dernovsek MC, Gurling H, Nothen M, Lathrop M, Leboyer M, Bellivier F. European collaborative study of early-onset bipolar disorder: Evidence for heterogeneity on 2q14 according to age at onset. Am J Med Genet Part B. 2010;153B:1425–1433. McNamara RK, Nandagopal JJ, Strakowski SM, DelBello M. Preventive strategies for early-onset bipolar disorder. Toward a clinical staging model. CNS Drugs. 2010; 24:983-996. Miklowitz DJ, Chang KD, Taylor DO, George EL, Singh MK, Schneck CD, Dickinson LM, Howe ME, Garber J. Early psychosocial intervention for youth at risk for bipolar I or II disorder: A one-year treatment development trial. Bipolar Disorders. 2011;13:67–75. Moreno C, Laje G, Blancvo C, Jiang H, Schmidtg AB, Olfson M. National trends in the outpatient diagnosis and treatment of bipolar disorder in youth. Arch Gen Psychiatry. 2007;64:1032–1039. Nieto RG, Castellanos FX. A meta-analysis of neuropsychological functioning in patients with early onset schizophrenia and pediatric bipolar illness. J Clin Child Adolesc Psychol. 2011;40:266–280. Nurnberger JI, McInnis M, Reich SW, Kastelic E, Wilcox HC, Glowinski A, Mitchell P, Fisher C, Erpe M, Gershon E, Berrettini W, Laite G, Schweitzer R, Rhoadarmer K, Coleman VV, Cai X, Azzouz F, Liu H, Kamali M, Brucksch C, Monahan PO. A high-risk study of bipolar disorder. Childhood clinical phenotypes as precursors of major mood disorders. Arch Gen Psychiatry. 2011;68:1012–1020. Pavulari MN, Passarotti AM, Lu LH, Carbray JA, Sweeney JA. Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder: fMRI outcomes. Psychiatry Res: Neuroimaging. 2011;193:28–37. Pavulari MN, Henry DB, Findling RL, Parnes S, Carbray JA, Mohammed T, Janicak PG, Sweeney JA. Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder. Bipolar Disorders. 2010;12:593–605. Stringaris A, Baroni A, Haimm C, Brotman M, Lowe CH, Myers F, Rustgi E, Wheeler W, Kayser R, Towbin K, Leibenluft E. Pediatric bipolar disorder versus severe mood dysregulation: Risk for manic episodes on follow-up. J Am Acad Child Adolesc Psychiatry. 2010;49:397–405. Versace Am Ladouceur CD, Romero S, Birmaher B, Axelson DA, Kupfer DJ, Phillips ML. Altered development of white matter in youth at high familial risk for bipolar disorder: a diffusion tensor imaging study. J Am Acad Child Adolesc Psychiatry. 2010;49:1249–1259. 31.12c Disruptive Mood Dysregulation Disorder Disruptive mood dysregulation disorder, a new inclusion in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is

characterized by severe, developmentally inappropriate, and recurrent temper outbursts at least three times per week, along with a persistently irritable or angry mood between temper outbursts. In order to meet diagnostic criteria, the symptoms must be present for at least a year, and the onset of symptoms must be present by the age of 10 years old. Children with these symptoms have typically been diagnosed with bipolar disorder, or a combination of oppositional defiant disorder, ADHD and intermittent explosive disorder. Recent longitudinal data suggest, however, that these children do not typically develop classic bipolar disorder in late adolescence or early adulthood. Instead, studies suggest that youth with chronic irritability and severe mood dysregulation are at higher risk for future unipolar depressive disorders and anxiety disorders. Although the initial studies of children and adolescents with severe mood dysregulation included several symptoms of hyperarousal (such as distractibility, physical restlessness, insomnia, racing thoughts, flight of ideas, pressured speech, or intrusiveness), the current DSM-5 diagnostic criteria for disruptive mood dysregulation do not include any hyperarousal criteria. Youths diagnosed with mood dysregulation disorder who also exhibit multiple symptoms of hyperarousal may be comorbid for ADHD. EPIDEMIOLOGY Most of the epidemiological data applied to disruptive mood dysregulation disorder was gathered from children and adolescents with severe mood dysregulation, which includes hyperarousal symptoms. Because disruptive mood dysregulation disorder differs from severe mood dysregulation disorder only in the absence of hyperarousal symptoms, the epidemiological data from the severe mood dysregulation disorder studies can be viewed as a useful proxy for disruptive mood dysregulation disorder. Severe mood dysregulation has a lifetime prevalence of 3 percent in children age 9 to 19 years. Within that percentage, males (78 percent) are more prevalent than females (22 percent). The mean age of onset is 5 to 11 years of age. COMORBIDITY Disruptive mood dysregulation disorder often co-occurs with other psychiatric disorders. The most common comorbidities are ADHD (94 percent), oppositional defiant disorder (84 percent), anxiety disorders (47 percent), and major depressive disorder (20 percent). The relationship of severe mood dysregulation and disruptive mood dysregulation disorder to bipolar disorder has been a topic of clinical investigation. Youth with severe mood dysregulation and hyperarousal symptoms have been conceptualized as a “broad phenotype” of pediatric bipolar disorder, however, the term “severe mood dysregulation” was utilized by researchers for these youth because it remains unclear whether these youth go on to meet criteria for a bipolar disorder. Disruptive mood dysregulation disorder is conceptualized as a disorder that is not episodic, and may coexist with ADHD. However, current evidence does not support its continuity with an emerging bipolar disorder.

DIAGNOSIS AND CLINICAL FEATURES The DSM-5 diagnostic criteria for disruptive mood dysregulation disorder (Table. 31.12c1) requires outbursts that are grossly out of proportion to the situation. These temper outbursts present with verbal rages and/or physical aggression toward people or property, and are inappropriate for the child’s developmental level. Temper outbursts occur, on average, three or more times per week, with variations in mood between outbursts. Symptoms must exhibit before age 10 years, be present for at least 12 months, and be present within at least two settings (i.e., home and school). The diagnosis is not made for the first time in youth younger than 6 years or older than 18 years. In between temper outbursts, the child’s mood is persistently irritable and angry, and this mood is observable by others such as parents, teachers, or peers. There has never been period lasting more than one day in which full criteria for a manic or hypomanic episode (except for duration) are fulfilled. The above behaviors do not occur exclusively in the context of an episode of major depression and are not better accounted for by another psychiatric disorder. The DSM-5 diagnostic criteria for disruptive mood dysregulation disorder are found in Table 31.12c-1. Table 31.12c-1 DSM-5 Diagnostic Criteria for Disruptive Mood Dysregulation Disorder

Daniel, a 12-year-old 7th grade boy was brought to his pediatrician by his mother, who was exasperated with Daniel’s rages and inappropriate tantrums. Daniel was on the floor in the waiting room, pounding his hands on the floor, yelling at his mother “get me out of here!” and crying. His mother had bruises on both legs from Dylan’s kicks, and she appeared distressed. Daniel’s mother walked into the office, leaving Daniel on the floor in the waiting room and burst into tears. “I can’t deal with him anymore.” She recounted the problems that Daniel had been having for the last 2 years: Severe recurrent tantrums four to five times/week. “He tantrums like a 6-yearold, and even when he is not having a tantrum, he is perpetually angry and irritable.”

She reported that Daniel had lost all of his friends due to his short fuse and frequent verbal and physical outbursts. He was almost always irritable, even on his birthday. Daniel’s mother wonders whether there is anything physical wrong with him, but physical examination and routine blood tests reveal no abnormalities. Daniel’s tantrums had lessened somewhat last summer during the 2-month summer vacation; however, as soon as school resumed, he was back to consistent irritability. After an interview with Daniel, his pediatrician determined that he was not acutely suicidal; however, he required urgent psychotherapeutic intervention. Daniel was referred to a clinical psychologist for cognitive-behavioral treatment, and a child and adolescent psychiatrist for a medication evaluation. Daniel resisted psychotherapy; however, after several sessions, Daniel’s parents felt more hopeful than they had in a long time, and learned that Daniel’s problems were not “all their fault.” Daniel agreed to begin a trial of fluoxetine, which was titrated up to 30 mg over several weeks, and after about a month, it became clear that his irritability had diminished noticeably. Daniel still had many problems with peers, and he still had one or two tantrums per week; however, the tantrums were becoming less prolonged and less intense. Daniel seemed genuinely happy when he was invited to a classmate’s birthday party, and he was able to interact successfully with his peers during the party without any conflicts. Daniel continues to benefit from CBT, and he remains on fluoxetine 40 mg a day. Daniel is still described as a “temperamental” boy, but he is doing well in school, has rekindled several friendships, and is able to participate in family gatherings without a major tantrum. DIFFERENTIAL DIAGNOSIS Bipolar Disorder Disruptive mood dysregulation disorder closely resembles the “broad phenotype” of bipolar disorder. Although not episodic, it has been theorized by some clinicians and researchers that the chronic and persistent symptoms of mood disturbance and irritability may be an early developmental presentation of bipolar disorder. Disruptive mood dysregulation, however, does not meet formal diagnostic criteria for mania in bipolar disorder, because irritability in disruptive mood dysregulation disorder is chronic and nonepisodic. Oppositional Defiant Disorder Disruptive mood dysregulation disorder is similar to oppositional defiant disorder in that they both include irritability, temper outbursts, and anger. Many patients with disruptive mood dysregulation disorder meet the criteria for oppositional defiant disorder; however, most patients with oppositional defiant disorder do not meet the criteria for disruptive mood dysregulation disorder. Oppositional defiant disorder includes symptoms of annoyance and defiance that are not found in disruptive mood

dysregulation disorder. Disruptive mood dysregulation disorder requires that irritable outbursts be present in at least two settings, whereas oppositional defiant disorder requires that they be present in only one setting. COURSE AND PROGNOSIS Disruptive mood dysregulation disorder is a chronic disorder. Longitudinal studies thus far have shown that patients with disruptive mood dysregulation disorder in childhood have a high risk of progressing to major depressive disorder, dysthymic disorder, and anxiety disorders over time. TREATMENT The current treatment of disruptive mood dysregulation is based on symptomatic interventions, in view of the fact that its etiology is not well understood at this time. If disruptive mood dysregulation disorder is confirmed to resemble unipolar depression and anxiety disorders in its pathophysiology, and it is often comorbid with ADHD, then SSRIs and stimulants would likely be the pharmacological agents of first choice. However, if the pathophysiology of disruptive mood dysregulation disorder is similar to that of bipolar disorder, then first-line treatments for youth would include atypical antipsychotic agents and mood stabilizers. There are scant treatment studies of disruptive mood dysregulation disorder in the current literature. One controlled trial of youths with symptoms of severe mood dysregulation and ADHD symptoms who did not respond to stimulants, responded to divalproex (Depakote) combined with behavioral psychotherapy compared to placebo and behavioral psychotherapy. There are treatment studies underway of youth who exhibit symptoms of severe mood dysregulation utilizing an SSRI plus a stimulant compared to a stimulant and placebo. Psychosocial interventions such as cognitive-behavioral psychotherapy are likely to be an essential component of treatment for youth with disruptive dysregulation disorder, and psychosocial interventions targeting children diagnosed with bipolar disorder may be beneficial. REFERENCES Blader JC, Schooler NR, Jensen PS, Pliszka SR, Kafantaris V. Adjunctive divalproex versus placebo for children with ADHD and aggression refractory to stimulant monotherapy. Am J Psychiatry. 2009;166:1392–1401. Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, Leibenluft E. Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biol Psychiatry. 2006;60:991–997. Copeland WE, Angold A, Costello J, Egger H. Prevalence, comorbidity, and correlates of DSM-5 proposed disruptive mood dysregulation disorder. Am J Psychiatry. 2013;170:173. Fristad MA, Verducci JS. Walters K, Young ME. Impact of multifamily psychoeducational psychotherapy in treating children aged 8 to 12 years with mood disorder. Arch Gen Psychiatry. 2009;66:1013–1021. Leibenluft E. Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. Am J Psychiatry. 2011;168:129.