Shanghai Archives of Psychiatry, 2016, Vol. 28, No.

5 • 289 •

•Forum•

The history, diagnosis and treatment of disruptive mood

Jun CHEN1, Zuowei WANG2, Yiru FANG1*

Summary: 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.

Key words: Disruptive mood dysregulation disorder; DSM-5

Ever since 1952 when diagnostic and statistical 1. The history of DMDD
manual of mental disorders (DSM) was published, it The results of The Global Burden of Disease study
has continued in its development for more than 60 which were published in 2013 indicate that the burden
years. When DSM-5 was published in 2013, in order to of disease appears during the childhood period (1-10
relieve the concern of over-diagnosing bipolar disorder years old) in individuals with common mental disorders
(BD) in children and teenagers, disruptive mood (e.g., depression disorder, bipolar disorder, anxiety
dysregulation disorder (DMDD) was included as a new disorder), and it reaches a peak during the juvenile
diagnostic category; and it was put in the depression period and adulthood period (10-29 years old).[3] Hence,
disorder module. Even though it has been published there has been heated debate about the diagnoses
for over 3 years, the knowledge regarding DMDD in the of mental disorders within children and teenagers. In
clinical practice field is still limited. Domestic professor 2011, the results of Leibenluft’s study suggested that
Jinsong Zhang introduced this new diagnostic category the ratio of children and teenagers being diagnosed
of disorder briefly in 2012.[1] Xiaoyan Ke also wrote with BD has increased 500% in America during the past
about it after DSM-5 was officially published; however, 20 years.[4] On the other hand, those who advocate
there were no corresponding studies about DMDD in on behalf of children assert that there is a tendency
China after that.[2] As for the reason underlying this of over-diagnosing children and teenagers with BD.
phenomenon, on one hand, it is probably because this Especially intense within this debate is whether
new diagnostic category has not been comprehended children and teenagers who only show severe irritability
widely in the clinical field yet; on the other hand, it is without other symptoms (such as manic or hypomanic
also possible that the low morbidity of DMDD results symptoms) should be diagnosed with BD.
in it lacking attention in clinical practice. Therefore, the
present article aims to introduce DMDD’s history, key In order to test whether the severe chronic
points in diagnosis, treatment and its impact on clinical irritability that appears in children is and early indicator
practice. of BD, Stringraris and colleagues created a new

1
Division of Mood Disorders, Subsidiary Mental Health Centre of Shanghai Jiao Tong University Medical School, Shanghai, China
2
Mental Health Centre of Hongkou District, Shanghai, China
*correspondence: Professor Yiru Fang. Mailing Address: Division of Mood Disorders, Subsidiary Mental Health Centre of Shanghai Jiao Tong University
Medical School, 600 South Wanping RD, Shanghai, China. Postcode: 200030. E-mail: [email protected]
• 290 • Shanghai Archives of Psychiatry, 2016, Vol. 28, No. 5

diagnostic category – severe mood dysregulation (SMD). studies on the treatment for children’s aggressivity or
According to the diagnostic criteria of SMD, the patients’ chronic irritability symptoms indicate that the range
age should be between 7 and 17, the first episode of choosing DMDD’s pharmacological treatment is
should occur before the age of 12, and the characteristics very wide. A systemic review by Leon Tourian and
are chronic negative emotions with irritability and colleagues has shown that pharmacological treatment
frequent emotional outbursts.[4] Following this research, for the aggression and chronic irritability in individuals
multiple clinical studies on children have shown that with DMDD includes anti-depressants (SSRIs, SNRIs),
the development of chronic paroxysmal irritability has a mood stabilizers (lithium salts, valproate, lamotrigine,
clear pattern in which paroxysmal symptoms are closely carbamazepine), psychostimulants (methylphenidate),
linked with manic episodes, while chronic symptoms typical antipsychotics (haloperidol), atypical
are closely related to depressive or anxiety disorders.[5] antipsychotics (quetiapine, aripiprazole, risperidone),
The chance of children with paroxysmal elation going on and other drugs (α-2 agonist, β blocker, trazodone).[11]
to develop BD is 50 times higher than that of children However, due to the differences between researchers,
with chronic irritability.[6] Based on the relevant series sample size,ethical factors and other reasons, there are
of studies on SMD, the DSM-5 task force created a new still few randomized and double blind DMDD research
diagnostic category – DMDD; and it was classified under studies with large sample sizes and placebo control
depression disorder instead of BD when DSM-5 was groups. Besides this, the long-term effects and safety
published in 2013.[7] of pharmacological treatment also requires further
validation.
Besides pharmacological treatment, other
2. Key points of DMDD diagnosis psychological therapies and rehabilitation therapies
The core characteristic of DMDD is chronic, severe and can also be included in the combined treatment of
persistent irritability. DMDD. Scott and colleagues has shown that parents’
The definition of DMDD is combined with the intervention (based on Wesbter-Stratton technique) can
features of SMD, but it is also different from SMD. help children with emotional irritability; however, its
DMDD inherited some features of SMD, such as real effect and whether it can be used to treat DMDD
the severe and paroxysmal emotional outbursts specifically still need further validation.[12] Additionally,
which overlies the persistent irritability or anger. some research has indicated that behavioral therapies
However, DMDD does not include the criteria for over are effective for patients with DMDD, especially in
activation as seen in SMD (e.g., insomnia, radicalness, improving their cognitive functioning.[13-14]
distractibility, thought acceleration, increase in speech
and invasiveness), [4] because these over activation 4. Conclusions
symptoms are more likely to be seen in manic episodes
or attention deficit hyperactivity disorder (ADHD).[8-9] Even though DMDD was included in the DSM-5 as a
new diagnostic category with clear diagnostic criteria
According to the diagnostic criteria in DSM-5, and exclusion criteria, what true improvements will this
DMDD has two main symptom criteria: (1) severe change have on clinical practice?
and frequent emotional outbursts; (2)chronic and
persistent irritability or anger that exists between First of all, DMDD is still considered as a mental
temper tantrums. Besides these two criteria, there are disorder with a relatively low morbidity. Three
also specific descriptions about other limiting factors community studies with large sample sizes have been
in the diagnostic criteria, including frequency (at least analyzed by William and colleagues, and the results
3 episodes every week), duration (irritability or anger indicate that the three-month prevalence ratios of
occurs almost everyday for most of the day), course DMDD diagnosed by psychiatric structured interviews
of disease (at least more than 12 months, and the are only 0.8% to 3.3% (preschool children have the
period when the criteria are not met never exceeds 3 highest morbidity). More importantly, the ratios of
months), age (at least more than 6 years old), the age DMDD’s comorbidity are very high, which are 62%
of first onset (before the age of 10), and the settings (it to 92%; and the most common comorbid mental
happens in multiple settings).[10] disorders are depressive disorder (odds ratios: 9.9-23.5)
and oppositional defiant disorder (odds ratios: 52.9-
103.0), which is due to the very low morbidity of “pure”
3. The treatment for DMDD DMDD.[14]
Even though the DMDD diagnostic category was Secondly, the high comorbidity ratio and severe
introduced in DSM-5, as of now, there has not been any functional impairment of patients with DMDD has
summarization of the treatment for DMDD. not caused enough attention in the clinical field. Pinar
Clinically, it is a common belief that unlike BD Uran and colleagues have done a comparison study on
which is treated with mood stabilizers or atypical children with DMDD, children with ADHD and healthy
antipsychotics as first choices, DMDD should be treated controls, and found that the comorbidity of DMDD and
with SSRIs as the first choice. However, many clinical other mental disorders is a lot higher than that of ADHD.
Shanghai Archives of Psychiatry, 2016, Vol. 28, No. 5 • 291 •

They also found that maladaptive behavioral patterns treating it with antidepressants there is the possibility of
and impairments in family functioning were more patients’ irritability symptoms being further aggravated.
significant in those with DMDD than those with ADHD. [15] Furthermore, while more and more clinical studies
Furthermore, the prospective follow-up study with large have shown that mood stabilizers and antipsychotics
sample sizes done by William and colleagues has shown can be used to treat DMDD, there is also evidence
that compared to children with other mental disorders indicating that classifying DMDD within BD might
and healthy controls, children with DMDD are not only be more appropriate. In a survey with 375 children
more prone to develop a depressive or anxiety disorder of patients with BD done by Garrett and colleagues,
in their adulthood, but also to have comorbidity with it was found that compared with healthy controls,
other mental disorders. As well, functional impairments children of patients with BD met DMDD diagnostic
are more common, including poorer physical health criteria significantly more (OR = 8.3, 6.7% v. 0.8%); and
condition, poorer economic conditions, lower education family history of BD increased the risk of suffering from
levels and higher crime rates.[16] DMDD. [19] Ideally the diagnostic classification would
Thirdly, a greater understanding of the effect that depend on a clear biological marker as an objective
DMDD has on decreasing the overdiagnosis of BD indicator, so more basic studies are needed to illuminate
in children and teenagers is needed. In order to test the pathologic mechanism of DMDD in the future.
whether the use of a DMDD diagnosis can actually help
clinicians lower the rate of over-diagnosing children with
BD, Margulies and colleagues evaluated admission and Funding
hospital follow-up for 56 children with manic symptoms
reported by parents; the results showed that based Preparation of this manuscript was funded by the
on the medical histories provided by parents, 45.7% of Youth Science Fund Project of the National Natural
the children met DMDD’s diagnostic criteria, but only Science Fund (81201056, 91232719); Major Research
17.4% of the children could be identified with follow- Program in National Science Fund (91232719); Excellent
up observations in hospital.[17]. In addition, during the Talents Training Project in Shanghai Health System
discussion surrounding the drafting of ICD-11, some (XYQ2011014); Medical Guidance Project in Shanghai
experts asserted that even though the emergence Science Committee (traditional Chinese medical
of DMDD changed how this disorder was addressed, science) (12401906200); Shanghai clinical mental
it did not solve the problem completely in terms of health center (2014); National Key Clinical Disciplines
diagnosis and treatment. There is still a lack of evidence – Shanghai Mental Health Center (The Department of
to differentiate DMDD from BD and other mental Health Administration 2011 – 873); Ministry of Science
disorders.[18] Therefore, there is evidence supporting and Technology’s “ten two five” National Science and
DMDD diagnosis reducing the over-diagnosis of BD, but Technology Support Project (2012BAI01B04).
the impact of this still requires further validation with
cohort follow up studies that have larger sample sizes.
Finally, placing DMDD under the depression Conflict of interest
disorder category still requires further discussion. Even The authors declare no conflict of interest related to this
though the over-activation characteristic of SMD was manuscript.
excluded from the onset of DMDD, in terms of severe
and frequent emotional outbreaks with at least three
episodes a week and irritability or anger occurring most Author contributions
time of almost every day, these symptoms indicate that Jun Chen – article writing
DMDD and BD are related closely and hard to distinguish Zuowei Wang – literature review
from each other. It also should be considered that by
putting DMDD in the depression disorder category and Yiru Fang – guidance and revision

破坏性心境失调障碍的诊断与治疗的思考
陈俊，汪作为，方贻儒
概述 : 美国精神障碍诊断与统计分册第 5 版新增一个 供临床参考。
诊断类别为破坏性心境失调障碍，但是临床实践中对
此认识仍然较为有限。因此，本文就该诊断类别的由 关键词 : 破坏性心境失调障碍，美国精神障碍诊断与
来、诊断要点、治疗以及对临床实践的启示作一介绍， 统计分册第 5 版
• 292 • Shanghai Archives of Psychiatry, 2016, Vol. 28, No. 5

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Dr. Jun Chen graduated from Shanghai Second Medical University (SSMU) with a bachelor’s degree
in Medicine in July 2001. He then received a Ph.D. degree in Psychiatry from Shanghai Jiaotong
University in April 2009. He has been working at the Shanghai Mental Health Center since 2001. He
is currently the director of the office of National Key Clinical Disciplines, associate chief physician
and a supervisor for masters students. He is also the Vice Chairman of the Youth Committee of
the Chinese Society of Psychiatry, secretary of the Chinese Society of Psychiatry and a committee
member of the Chinese Psychiatrist Association. His current research interests are bipolar disorders
and treatment-resistant depression.