# 31 - 31.12c Disruptive Mood Dysregulation Disorder

# 31.12c Disruptive Mood Dysregulation Disorder

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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.
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