DSM-5: disruptive mood dysregulation disorder

Neuropsychological mechanisms of social difficulties in disruptive mood dysregulation disorder versus oppositional defiant disorder

Children with Disruptive Mood Dysregulation Disorder (DMDD) or Oppositional Defiant Disorder (ODD) are characterized by irritability and social difficulties. However, the mechanisms underlying these disorders could be different. This study explores differences in social cognition and executive function (EF) across DMDD and ODD and the influence of these factors and their interaction on social problems in both groups. Children with DMDD (n = 53, Mage = 9.3) or ODD (n = 39, Mage = 9.6) completed neuropsychological tasks measuring social cognition (Theory of Mind and Face-Emotion Recognition) and EF (cognitive flexibility, inhibition, and working memory). Parents reported social problems. More than one-third of the children with DMDD and almost two-thirds of those with ODD showed clear difficulties with Theory of Mind. Most children with DMDD (51-64%) or ODD (67-83%) showed difficulties with EF. In children with DMDD, worse EF (β = -.36) was associated with more social problems, whereas in children with ODD, better EF (β = .44) was associated with more social problems. In those with ODD, but not in those with DMDD, the interaction between social cognition and EF contributed to the explained variance of social problems (β = -1.97). Based on the observed interaction pattern, enhanced EF may lead to increased social problems among children with ODD who also exhibit social cognition difficulties. This study suggests the existence of distinct neuropsychological mechanisms underlying the social issues observed in children with DMDD versus those with ODD.

Appetite hormone dysregulation and executive dysfunction among adolescents with bipolar disorder and disruptive mood dysregulation disorder

Appetite hormone dysregulation may play a role in the pathomechanisms of bipolar disorder and chronic irritability. However, its association with executive dysfunction in adolescents with bipolar disorder and those with disruptive mood dysregulation disorder (DMDD) remains unclear. We included 20 adolescents with bipolar disorder, 20 adolescents with DMDD, and 47 healthy controls. Fasting serum levels of appetite hormones, including leptin, ghrelin, insulin, and adiponectin were examined. All participants completed the Wisconsin Card Sorting Test. Generalized linear models with adjustments for age, sex, body mass index, and clinical symptoms revealed that patients with DMDD had elevated fasting log-transformed insulin levels (p = .023) compared to the control group. Adolescents with DMDD performed worse in terms of the number of tries required to complete tasks associated with the first category (p = .035), and adolescents with bipolar disorder performed worse in terms of the number of categories completed (p = .035). A positive correlation was observed between log-transformed insulin levels and the number of tries required for the first category (β = 1.847, p = .032). Adolescents with DMDD, but not those with bipolar disorder, were more likely to exhibit appetite hormone dysregulation compared to healthy controls. Increased insulin levels were also related to executive dysfunction in these patients. Prospective studies should elucidate the temporal association between appetite hormone dysregulation, executive dysfunction, and emotional dysregulation.

A Delphi consensus among experts on assessment and treatment of disruptive mood dysregulation disorder

Objective

The aim of this study was to explore consensus among clinicians and researchers on how to assess and treat Disruptive Mood Dysregulation Disorder (DMDD).

Methods

The Delphi method was used to organize data collected from an initial sample of 23 child psychiatrists and psychologists. Three rounds of closed/open questions were needed to achieve the objective.

Results

Fifteen experts in the field completed the whole study. Finally, 122 proposals were validated and 5 were rejected. Globally, consensus was more easily reached on items regarding assessment than on those regarding treatment. Specifically, experts agreed that intensity, frequency, and impact of DMDD symptoms needed to be measured across settings, including with parents, siblings, peers, and teachers. While a low level of consensus emerged regarding optimal pharmacological treatment, the use of psychoeducation, behavior-focused therapies (e.g., dialectical behavior therapy, chain analysis, exposure, relaxation), and systemic approaches (parent management training, family therapy, parent-child interaction therapy) met with a high degree of consensus.

Conclusion

This study presents recommendations that reached a certain degree of consensus among researchers and clinicians regarding the assessment and treatment of youths with DMDD. These findings may be useful to clinicians working with this population and to researchers since they also highlight non-consensual areas that need to be further investigated.

An expert opinion on the pharmacological interventions for Disruptive Mood Dysregulation Disorder (DMDD)

INTRODUCTION

Disruptive Mood Dysregulation Disorder (DMDD) was officially introduced as a new diagnostic entity in the Diagnostic and Statistical Manual of Mental Disorder, Fifth Edition (DSM-5), under the category of depressive disorders.

AREAS COVERED

A comprehensive overview and a critical commentary on the currently investigated psychopharmacological approaches for the treatment of DMDD have been here provided.

EXPERT OPINION

Behavioral and psychosocial interventions should be considered as first-line treatment strategies. When ineffective or partially effective, psychopharmacological strategy is recommended. Overall, pharmacological strategy should be preferred in those individuals with psychiatric comorbidities (e.g. ADHD). Indeed, so far published studies on pharmacological strategies in DMDD are scant and heterogeneous (i.e. age, assessment tools, symptomatology profile, comorbidity, and so forth). Therefore, DMDD psychopharmacological guidelines are needed, particularly to guide clinicians toward the patient's typical symptom profile who could benefit from psychopharmacological strategy.

Constructing childhood depression: a qualitative study with international experts in child psychiatry

After decades of controversy, the concept of childhood depression now seems to be part of standard medical knowledge. Yet the form and content of this nosological entity, like many psychiatric diseases, is continuously shaped by the scientific, clinical, and political communities involved in child psychiatry. In this qualitative study, we explored how the concept of childhood depression is constructed in early twenty-first century child psychiatry. We conducted a series of 18 interviews with practising child psychiatrists, international experts in the field, and interpreted them with thematic analysis informed by discourse analysis. We identified five overarching discourse themes across interviews, relating to the definition of depression, the diagnostic process, the causes of this condition, the therapeutic strategy, and the scientific role of child psychiatry. Most participants agreed that childhood depression was a mental disorder where irritability prevailed, heavily influenced by psychosocial factors, and for which psychotherapy was the ideal treatment. However, subtle points of dissent also surfaced: whether depression is primarily a mood state or psychological suffering, whether categories or dimensions are more suitable to make the diagnosis, and whether there is a genetic predisposition were some of the most controversial topics. Theoretical considerations regarding childhood depression may have significant scientific, moral, and socio-political implications beyond child psychiatry and should be addressed appropriately.

Childhood temperamental, emotional, and behavioral characteristics associated with mood and anxiety disorders in adolescence: A prospective study

BACKGROUND

Mood and anxiety disorders account for a large share of the global burden of disability. Some studies suggest that early signs may emerge already in childhood. However, there is a lack of well-powered, prospective studies investigating how and when childhood mental traits and trajectories relate to adolescent mood and anxiety disorders.

METHODS

We here examine cross-sectional and longitudinal association between maternally reported temperamental traits, emotional and behavioral problems in childhood (0.5-8 years) and clinical diagnosis of mood or anxiety ("emotional") disorders in adolescence (10-18 years), using the prospective Norwegian Mother, Father and Child Cohort Study (MoBa) of 110,367 children.

RESULTS

Logistic regression analyses showed consistent and increasing associations between childhood negative emotionality, behavioral and emotional problems and adolescent diagnosis of emotional disorders, present from 6 months of age (negative emotionality). Latent profile analysis incorporating latent growth models identified five developmental profiles of emotional and behavioral problems. A profile of early increasing behavioral and emotional problems with combined symptoms at 8 years (1.3% of sample) was the profile most strongly associated with emotional disorders in adolescence (OR vs. reference: 5.00, 95% CI: 3.70-6.30).

CONCLUSIONS

We found a consistent and increasing association between negative emotionality, behavioral and emotional problems in early to middle childhood and mood and anxiety disorders in adolescence. A developmental profile coherent with early and increasing disruptive mood dysregulation across childhood was the profile strongest associated with adolescent emotional disorders. Our results highlight the importance of early emotional dysregulation and childhood as a formative period in the development of adolescent mood and anxiety disorders, supporting potential for prevention and early intervention initiatives.

Efficacy of psychosocial interventions for children with ADHD and emotion dysregulation: a systematic review

Attention-Deficit Hyperactivity Disorder (ADHD) is frequently associated with emotion dysregulation (ED) that is characterized by excessive and inappropriate emotional reactions. Children with ADHD and ED present significant social, academic and family functioning impairments. These findings indicate that ED should be regularly monitored in children with ADHD and should be managed with targeted therapeutic interventions. However, few studies have evaluated the efficacy of psychosocial interventions to manage ED in children with ADHD. The aim of this systematic review was to assess the effects of psychosocial interventions for children with ADHD and ED, particularly their benefits and limitations. This review followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) model. A systematic literature search of different databases in February 2018 allowed the identification of five randomized controlled trials, one quasi-experimental study, and four open-label uncontrolled studies. Analysis of the results reported in these studies suggested that psychosocial interventions can improve severe irritability and aggressive behavior in children with ADHD and ED. However, the short trial duration, the lack of follow-up and of control group in several studies, and the heterogeneity of the outcome measures affected the result interpretation. Future studies should use standardized measures of ED and larger samples.

Assessment of irritability in school-aged children by pediatric, family practice, and psychiatric providers

BACKGROUND

Irritability, a common behavioral problem for school-aged children, is often first assessed by primary care providers, who manage about a third of mental health conditions in children. Until recent changes in the Diagnostic and Statistical Manual of Mental Disorders (DSM), irritability was often associated with mood disorders, which may have led to increases in bipolar disorder diagnosis and prescription of mood stabilizing medication.

OBJECTIVE

Our aim was to explore differences between the approaches psychiatric and primary care providers use to assess irritability.

METHODS

A single trained interviewer conducted detailed interviews and collected demographic data from a homogeneous group of physicians that saturated with a sample size of 17 pediatric, family medicine, and psychiatric providers who evaluate and treat school-aged children. Qualitative and quantitative data were collected and analyzed.

RESULTS

In general, primary care providers chose to refer children with irritability to mental health specialists when medication management became complex, while the psychiatric providers chose behavior modification and parent education strategies rather than medications. The psychiatric group had a significantly higher caseload mix, prior experience with irritability, and more confidence in their assessment capabilities. There was lack of continuing medical education about irritability in all groups.

CONCLUSION

This preliminary study highlights the importance of collaboration between primary care and subspecialties to promote accurate assessment and subsequent treatment of school-aged children with irritability, who can represent a safety concern for self and others. More research is needed to establish an efficient method of assessing and managing irritability in primary care and better utilization of specialists.

Trends in diagnosis of bipolar and disruptive mood dysregulation disorders in children and youth

OBJECTIVE

Rates of pediatric bipolar disorders have increased and some are concerned about diagnostic accuracy. Disruptive mood dysregulation disorder (DMDD) was added to the DSM-5 in 2013. The purpose of this study was to assess diagnostic trends of bipolar disorders and DMDD and to identify predictors of receiving the DMDD diagnosis since implementation of DSM-5.

METHOD

Kentucky Medicaid claims from 2012-2017 for children under 18 years (N = 814,919; 2012 n = 473,389; 2013 n = 470,918; 2014 n = 499,094; 2015 n = 517,199; 2016 n = 529,048; 2017 n = 535,814) were used. Logistic regression was used to identify predictors of a diagnosis of DMDD in 2015-2017 for a sub-sample (n = 5,071).

RESULTS

The use of DMDD rose after 2013 and mood disorder NOS decreased steadily through 2017. This decrease was seen when there was a diagnosis of bipolar and oppositional defiant disorder (ODD) combined with mood disorder NOS. A diagnosis of only mood disorder NOS in 2012 did not predict DMDD in 2015-2017, but the same diagnosis in 2013 was predictive (OR 2.14, p = 0.049). The reverse is true for a diagnosis of only ADHD in 2013, which did not predict DMDD in later years, but its presence in 2012 was predictive (OR 1.36, p = 0.010).

CONCLUSIONS

DMDD increased after 2013, and this was associated with a diagnosis of mood disorder NOS, ADHD, as well as with bipolar disorders comorbid with ODD. Given the complexity of comorbid diagnoses, DMDD may be more accurate in classifying some children. Administrative claims data have limitations, which are discussed; and the data represent only children living in Kentucky.

Construct validity and parent-child agreement of the six new or modified disorders included in the Spanish version of the Kiddie Schedule for Affective Disorders and Schizophrenia present and Lifetime Version DSM-5 (K-SADS-PL-5)

Changes to the Diagnostic and Statistical Manual of Mental Disorders fifth edition (DSM-5) incorporate the inclusion or modification of six disorders: Autism Spectrum Disorder, Social Anxiety Disorder, Intermittent Explosive Disorder, Disruptive Mood Dysregulation Disorder, Avoidant/Restrictive Food Intake Disorder and Binge Eating Disorder. The objectives of this study were to assess the construct validity and parent-child agreement of these six disorders in the Spanish language Schedule for Affective Disorders and Schizophrenia for School Age Children Present and Lifetime Version (K-SADS-PL-5) in a clinical population of children and adolescents from Latin America. The Spanish version of the K-SADS-PL was modified to integrate changes made to the DSM-5. Clinicians received training in the K-SADS-PL-5 and 90% agreement between raters was obtained. A total of 80 patients were recruited in four different countries in Latin America. All items from each of the six disorders were included in a factor analysis. Parent-child agreement was calculated for every item of the six disorders, including the effect of sex and age. The factor analysis revealed 6 factors separately grouping the items defining each of the new or modified disorders, with Eigenvalues greater than 2. Very good parent-child agreements (r>0.8) were found for the large majority of the items (93%), even when considering the sex or age of the patient. This independent grouping of disorders suggests that the manner in which the disorders were included into the K-SADS-PL-5 reflects robustly the DSM-5 constructs and displayed a significant inter-informant reliability. These findings support the use of K-SADS-PL-5 as a clinical and research tool to evaluate these new or modified diagnoses.

Prevalence Rate and Course of Symptoms of Disruptive Mood Dysregulation Disorder (DMDD)

Abstract. Objective: According to DSM-5, Disruptive Mood Dysregulation Disorder (DMDD) is characterized by chronic temper outbursts and irritable moods. So far, little is known about its prevalence rate, course and influence on individual well-being. We assessed the prevalence rates of DMDD symptoms during adulthood and primary school age – the latter retrospectively – and studied their relationship with psychiatric disorders and socioeconomic variables. Methods: A total of 2,413 subjects, aged 18–94 years, participated in this population-based, representative study based on self-reports. Results: 12 (0.50 %) subjects reported elevated DMDD symptoms during adulthood, and 19 (0.79 %) reported elevated DMDD symptoms during primary school age. DMDD symptoms were associated with higher rates of depression and anxiety symptoms. Those reporting elevated DMDD symptoms during adulthood were more often single or divorced, and those reporting elevated DMDD symptoms during primary school age were more often childless and unemployed during adulthood compared to subjects without DMDD symptoms. Conclusions: DMDD symptoms seem to show a chronic course and go hand in hand with elevated psychiatric symptoms and impaired socioeconomic and demographic status.

The History, Diagnosis and Treatment of Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder was newly included as a diagnostic category in Diagnostic and statistical manual of mental disorders fifth edition (DSM-5), but the knowledge about it in the clinical practice field is still limited. Therefore, the aim of the present article is to introduce this diagnostic category's history, key points of diagnosis, treatment and its impact on clinical practice for clinical reference.

Irritability in Pediatric Patients: Normal or Not?

The goal of this article is to describe the concept of irritability in children and youth, which has been revisited in the DSM-5. Traditionally, this behavior has been more commonly associated with mood disorders, which may account for the rising incidence of bipolar disorder diagnosis and overuse of mood-stabilizing medications in pediatric patients. While not predictive of mania, persistent nonepisodic irritability, if undetected, may escalate to violent behavior with potentially serious outcomes. It is therefore important to educate clinicians about how to accurately assess irritability in pediatric patients.

Differential risk for late adolescent conduct problems and mood dysregulation among children with early externalizing behavior problems

To investigate the differential emergence of antisocial behaviors and mood dysregulation among children with externalizing problems, the present study prospectively followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19). Latent class analysis conducted on their conduct and mood symptoms in late adolescence revealed three distinct patterns of symptoms, characterized by: 1) criminal offenses, conduct disorder symptoms, and elevated anger ("conduct problems"), 2) elevated anger, dysphoric mood, and suicidal ideation ("mood dysregulation"), and 3) low levels of severe conduct and mood symptoms. A diathesis-stress model predicting the first two outcomes was tested. Elevated overt aggression at school entry uniquely predicted conduct problems in late adolescence, whereas elevated emotion dysregulation at school entry uniquely predicted mood dysregulation in late adolescence. Experiences of low parental warmth and peer rejection in middle childhood moderated the link between early emotion dysregulation and later mood dysregulation but did not moderate the link between early overt aggression and later conduct problems. Thus, among children with early externalizing behavior problems, increased risk for later antisocial behavior or mood dysfunction may be identifiable in early childhood based on levels of overt aggression and emotion dysregulation. For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality--possibly indicative of disruptive mood dysregulation disorder--emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.