If DSM-5 is officially published (it's due in 2013), kids will be deemed DMDD if they show
severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.At least three times a week. Would giving that label be helpful?
Pittsburg psychiatrists David Axelson and colleagues have just shown that the DMDD concept is deeply flawed. They took a large sample of kids assessed for emotional or behavior problems, and compared those who would meet the new DMDD criteria, to those who wouldn't.
"DMDD" turned out not to be correlated with anxiety or mood symptoms in either the child or their parents - rather unusual for a so-called 'Mood Dysregulation Disorder' which is found in the 'Depressive Disorder' section of the DSM-5.
However, DMDD was correlated with - and in fact "could not be delimited from" - two existing disorders, "Conduct Disorder" and "Oppositional Defiant Disorder". It wasn't even a more severe form of those disorders, it was pretty much the same thing.
So, DMDD seems to be nothing to do with mood, but instead covers a pattern of misbehavior which is already covered by not one but two labels already. Why add a misleadingly-named third?
Well, the back-story is that in the past ten years, many American kids and even toddlers have got diagnosed with 'child bipolar disorder' - a disease considered extremely rare everywhere else. To stop this, the DSM-5 committee want to introduce DMDD as a replacement. This is the officially stated reason for introducing it. On the evidence of this paper and others it wouldn't even achieve this dubious goal.
The possibility of just going to back to the days when psychiatrists didn't diagnose prepubescent children with bipolar (except in very rare cases) seems to not be on the table.
Axelson D, et al (2012). Examining the proposed disruptive mood dysregulation disorder diagnosis in children in the Longitudinal Assessment of Manic Symptoms study. The Journal of Clinical Psychiatry, 73 (10), 1342-50 PMID: 23140653
18 comments:
Looking at this with a research hat on, I think Persons in 1986 really had the right approach to psychopathology by thinking about it in terms of phenomena rather than in terms of diagnoses. This further shows the weaknesses of categorical diagnoses, as if we were thinking about psychopathology in terms of symptoms, we wouldn't be so focused about hitting these checklists of criteria.
Fair point. But it seems that DMDD is an even worse categorical diagnosis than the usual.
@Neuroskeptic: We're in agreement. I just also think the flawed structure of the DSM is what allows for big misses like DMDD.
If you allow me a slight exaggeration:
There is historical precedent to argue that DSM classification is a waste of time, and possibly dangerous: the tedious work done in demonology and studies of possession (or multiple possessions) during centuries led to a dead-end. It is not a given that the DSM is very different qualitatively (since after all demonology also identified meaningful syndromes like pride, avarice, gluttony, envy, lust, vanity, anger,..).
RDoC or dimensional representations of symptoms, traits, personality or characters might be much more promising than the DSM.
In the mean time, the use of the DSM is likely one of the biggest impediment in behavioral genetics, neuroscience, psychology and clinical practice. Damage control centering on denouncing the worst DSM categories sounds depressing.
Several points:
1. DMDD is not just about tantrums. The child also have to have persistent irritability in between the tantrums. I think that's why it's thought of as a mood disorder.
2. The study you described here is from a clinical sample of children who were considered "manic" and followed for their "manic" symptoms over time, and had the DMDD diagnosis retrospectively applied to them. They are nowhere near representative of the general population.
3. I was at the recent American Academy of Child and Adolescent Psychiatry conference in San Francisco, and a group from Duke led by Helen Egger presented a study (not yet published) looking at applying the DMDD diagnosis retrospectively to several population-based samples, and here were some of their main findings from my notes:
a. About 25% of children w/ ODD meet criteria for DMDD, but 70% of those w/ DMDD have ODD. Thus, in DSM-5, DMDD supersedes ODD and may be considered a more severe form of ODD.
b. DMDD is comorbid about 70% of time, with the highest association with depression (OR 9.9-23.5) and ODD (OR 53-103!)
c. Long-term, childhood DMDD is associated with adult depression and anxiety disorders, but *not* with adult alcohol/cannabis abuse or dependence, or with antisocial personality disorder. This, I think, is another reason why it is categorized as a mood disorder.
Anonymous: Hmm, thanks for the comment, that's interesting, but those results don't match with these. And yes the children were assessed for 'mania' but surely those are the kids who'll be first in line to be assessed for DMDD. In the general population the question wouldn't arise.
I assume all parents of the 'irritable children' have had their educational skills and psychological makeup screened as well?
No?
Ah, thought as much.
1 : If you don't display "severe recurrent temper outbursts" quite often, you're not a child.
2 : If people diagnosed with "DMDD" are banned from airplanes, I may stand with DSM-V.
3 : Which firm sells the treatment for DMDD ? I'd like to buy some stocks.
221 saguresI too am not enthused about the concept of DMDD, but it might turn out to have some advantages over the current system, although there are probably better ways to do this. DMDD is derived from Severe Emotional Dysregulation, a construct that tried to identify a group of kids with emotional dysregulation and irritability, but who appeared not to have bipolar disorder. SED kids do appear to develop depression and anxiety later on, but not bipolar disorder.
One of the anomalies of the DSM-IV that is apparently not going to be addressed in the DSM-V, is that ODD has a number of symptoms related to mood, including often loses temper, often argues, often deliberately annoys people, is often touchy or easily annoyed (irritable), is often angry and resentful, and is often spiteful or vindictive (sure doesn't sound like carving nature at the joints, does it). Although ODD is often thought of as a precursor to conduct disorder (in the sense that most kids with conduct disorder had oppositional/defiant disorder before even though most kids with ODD don't go on to conduct disorder) there are no mood symptoms, whatever associated with conduct disorder. Conduct disorder has only behaviors that are associated with the failure to respect the norms of society and the rights of others. If conduct disorder had the same sorts of mood symptoms that ODD does, then there would be no reason for DMDD, as conduct disorder would flow naturally from ODD as it would be describing kids on a particular developmental trajectory. I'm sure that the DSM authors had some reason to drop the mood symptoms from conduct disorder, or perhaps it was just a particularly difficult compromise to make.
DMDD has a surprising amount in common with Intermittent Explosive Disorder, and to appear to have considerable overlap. Intermittent Explosive Disorder is now often diagnosed in conjunction with conduct disorder to try to explain the emotionally dis-regulated aspect of conduct disorder (which apparently would sometimes be referred to as agitated conduct disorder, a term now out of use), but it's not clear that IED adds a lot in the way of understanding.
When i was a kid i got a bad case of 'empathy-blind doctor diagnosing me with something requiring a speed prescription for my hyperactivity he knew nothing of in the real world'. Where am I now? I guess where you'd expect anyone who really just had a propensity for schizophrenia/bipolar in later life who took speed since the age of 7 anything. Thanks for bringing to light such issues... the reductionistic fallacies that are cropping up in understanding how to jump to conclusions in order solve the problems of absolutely everyone in western society losing their minds as a recursive loop are perceptible as nothing but abhorrent from a perspective like mine
Smack your bloody kids once in a while, and take responsibility for being a poor parent!
That the child form of BD is characterized by conduct disorder and tantrums is like how attention disorders have been characterized as hyperactive in children. Both lean towards the mostly male expressions of the spectrums.
Allen Frances said: " My advice to child psychiatrists -- tame the fad you have already created and please don't create another fad of a new "disorder" that can so easily be misused. No one denies that irritable children are a problem, but let's not prematurely and blindly invent essentially meaningless, but potentially very dangerous labels for them." http://www.psychiatrictimes.com/blog/couchincrisis/content/article/10168/1970399
Given this study's results, I wonder if DMDD might be (unwittingly) highlighting one of the two temperamental subtypes research has shown to exist within the Dx of Childhood-Onset Conduct Disorder, and as a result could be included as a specifier for this Dx.
The Dx criteria of DMDD sounds awfully similar to those youth who have childhood CD w/o callous-unemotional traits (and emotional dysregulation).
Can't we just go back to the last printing of DSM-II. It's really no more or less useful than anything since
Mmm I am just wondering then if this diagnosis will then mean that quite young children will be medicated with psychotropic medications that are not FDA approved for youngsters? Those children diagnosed in Canada and the USA are often given antipsychotic medication and mood stabilising drugs. These drugs cause all manner of side effects in adult users, including obesity, blood sugar and lipid problems to name only a couple. Such drugs also change the chemistry of the brain. Given that the brain isn't fully developed until aged 25years (I think) is this not worrying?
Children do often go through patches of horribleness. I would hope that family therapy/therapy would be used as a first port of call? The few children I have seen with this label have in fact got significant familial difficulties, though to be fair that is a very minute sample.
I am an adult that has had summer long manic episodes, classic mania since I was 4 or 5 and I would go through it every summer and to this day, I have my maintenance meds and my lower test benzo/seroquel combo on hand for sounds making me freak and haldol,ativan and benadryl in case meditation will not calm anger. I am also hyper and upping the Ritalin will slow my brain down but that rush of mania that possesses you is nothing like this "disorder".
I used to throw tantrums and I was disciplined, the belt, corner. Also, I was sent to a neurologist, did scans up the wazoo because a classic manic episode seemed off in 1986 in a little kid. In that state I scream and yell so rapidly with no sleep that I lose my voice and as a kid, torched curtains. I was obsessed with the Formosa and Bermuda triangles and have a box filled with years of manic physics and calculus theories about those two places and tachyon theory being factual. I have always had mania, never depression, sadness and grief over a family death but after seeing this, up til I was 11, I would have gotten the belt and spent hours for most of this brat BS.
Yeah, these kids for the most parts are probably brats. Except for the episode rapidly ends part, how can most of that be bipolar disorder... and if depression gets its own designation, how come mania has to be part of bipolar disorder. Most adults I meet with this label are just mean people who have no regard for anyone.
Just don't rule out mania in children if it goes from June to December and give those of us who don't get depressed our own disorder... Bipolar I Disorder isn't appropriate.
oh, and again, I am almost finishing grad school for my MS in International Relations and I only take 2 meds for maintenance and have done well for years. Plus, I eat organic, vegan food, work out for hours per day, am in great shape, love judo and I am fluent in German and Farsi, at the advanced level as I am in English and proficient in Spanish, French and Italian as well as creole American Sign... (i.e. I know many signs but I can speed spell out the rest LOL)
I think this choice was more based on the overdiagnosis of this in the late 90's early 2000's and also, I was given the conduct disorder label as an early teen because I used to sneak to Nine Inch Nails and Marilyn Manson concerts and liked smoking pot and never took the crappy combos they gave me. Prozac made me think there were bugs under my body and I took a steak knife to get them out when I was 9 and I tattooed over it but some meds help some people but once I got on lamictal 12 years ago, it was my lithium. Ritalin makes me think straight but I have lowered it from 140 mg per day to a 20 mg tablet and 30 mg patch and within a year of grad school I should learn skills to get what I missed out on. PRN meds are all best used short term. Antidepressants are just as bad as benzos or antipsychotic use long term when discontinued.
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