Disruptive Mood Dysregulation Disorder

Overview

Definition

Disruptive mood dysregulation disorder (DMDD) is a mental disorder in children with an age of onset < 10 years old and characterized by:

•  Persistent irritability or angry mood Angry mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder
•  Frequent temper outbursts disproportionate to the situation

Epidemiology

• Lifetime prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency: approximately 3% among children 9–19 years of age
• Higher prevalence Prevalence The total number of cases of a given disease in a specified population at a designated time. It is differentiated from incidence, which refers to the number of new cases in the population at a given time. Measures of Disease Frequency in boys than girls (3:1)

Etiology

• Poorly understood 
• May include biological as well as psychosocial factors
• Structural brain Brain The part of central nervous system that is contained within the skull (cranium). Arising from the neural tube, the embryonic brain is comprised of three major parts including prosencephalon (the forebrain); mesencephalon (the midbrain); and rhombencephalon (the hindbrain). The developed brain consists of cerebrum; cerebellum; and other structures in the brain stem. Nervous System: Anatomy, Structure, and Classification changes:
  • Lower activity of the amygdala Amygdala Almond-shaped group of basal nuclei anterior to the inferior horn of the lateral ventricle of the temporal lobe. The amygdala is part of the limbic system. Limbic System: Anatomy → plays a role in the interpretation and expression of emotions
  • Increased activity of the medial frontal Frontal The bone that forms the frontal aspect of the skull. Its flat part forms the forehead, articulating inferiorly with the nasal bone and the cheek bone on each side of the face. Skull: Anatomy gyrus and anterior cingulate cortex → plays a role in evaluating and processing negative emotions

Diagnosis

Clinical diagnostic criteria:

• Severe, recurrent anger outbursts (verbal or behavioral)
• Outbursts are not appropriate for the age of the patient.
• Outbursts occur at least 3x per week in 2 different settings.
• The child is always angry or irritable between outbursts.
• Onset: 6–10 years of age
• Duration: 12 months (asymptomatic periods do not last > 3 months)
• Exclude other mental disorders or substance use.

Management

Psychosocial therapy

Psychosocial therapy should be the main pillar of treatment for DMDD.

• Cognitive behavioral therapy Cognitive behavioral therapy A directive form of psychotherapy based on the interpretation of situations (cognitive structure of experiences) that determine how an individual feels and behaves. It is based on the premise that cognition, the process of acquiring knowledge and forming beliefs, is a primary determinant of mood and behavior. The therapy uses behavioral and verbal techniques to identify and correct negative thinking that is at the root of the aberrant behavior. Psychotherapy (CBT) is a commonly used form of psychotherapy Psychotherapy Psychotherapy is interpersonal treatment based on the understanding of psychological principles and mechanisms of mental disease. The treatment approach is often individualized, depending on the psychiatric condition(s) or circumstance. Psychotherapy to teach coping and anger management Anger management System of psychological and/or therapeutic techniques used to control and or reduce the triggers, degrees, and effects of anger. Oppositional Defiant Disorder skills to patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship.
• Parent training:
  • A method to help parents interact with the child and reduce trigger-causing outbursts 
  • More appropriate for younger patients Patients Individuals participating in the health care system for the purpose of receiving therapeutic, diagnostic, or preventive procedures. Clinician–Patient Relationship

Medication

• Because the diagnosis is relatively new, a 1st-line drug is not yet available.
• Medications are recommended if the disorder is associated with other diseases or symptoms.

Differential Diagnosis

• Bipolar Bipolar Nervous System: Histology disorder: a highly recurrent psychiatric illness characterized by periods of manic/hypomanic features (e.g., distractibility, impulsivity Impulsivity Attention Deficit Hyperactivity Disorder, increased activity, decreased sleep Sleep A readily reversible suspension of sensorimotor interaction with the environment, usually associated with recumbency and immobility. Physiology of Sleep, talkativeness, grandiosity, flight of ideas) with or without depressive symptoms. Some clinicians theorize the chronic and persistent nature of disturbed mood and irritability in DMDD may be an early presentation of bipolar Bipolar Nervous System: Histology disorder. Disruptive mood dysregulation disorder can be distinguished from bipolar Bipolar Nervous System: Histology disorder: unlike bipolar Bipolar Nervous System: Histology disorder, the irritability in DMDD is persistent and does not occur in episodes.
• Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder (ODD): a continuous pattern of angry/ irritable mood Irritable mood Abnormal or excessive excitability with easily triggered anger, annoyance, or impatience. Oppositional Defiant Disorder, argumentative/ defiant behavior Defiant behavior Oppositional Defiant Disorder, or vindictiveness Vindictiveness Oppositional Defiant Disorder for at least 6 months. Oppositional defiant disorder Oppositional Defiant Disorder Oppositional defiant disorder is a pediatric psychiatric disorder characterized by a continuous pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness directed at adults or other authority figures. Symptoms must be present for at least 6 months to make a diagnosis of ODD. Oppositional Defiant Disorder includes symptoms of defiance and annoyance not present in DMDD. The diagnosis of DMDD is based on irritable outbursts manifesting in multiple settings, which is not a requirement for the diagnosis of ODD. 
• Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder ( IED IED Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder): an impulse-control disorder characterized by abrupt episodes of recurrent, severe, and angry outbursts with a normal mood maintained between episodes. Intermittent explosive disorder Intermittent Explosive Disorder Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder lasts > 3 months. As opposed to persistent irritability in DMDD, the presence of a period with a normal mood in IED IED Intermittent explosive disorder (IED) is an impulse-control disorder characterized by abrupt episodes of recurrent, severe, angry outbursts with normal mood maintained between the outbursts. Intermittent Explosive Disorder differentiates the conditions.
• Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder: a mental disorder in the pediatric population. Conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder includes recurrent behavior of exhibiting noncompliance Noncompliance Clinician–Patient Relationship for the basic rights of others or societal norms > 1 year. Examples of behaviors include violation, destruction, theft, lying, and severe defiance of rules. Compared to conduct disorder Conduct Disorder Conduct disorder (CD) is a pediatric mental disorder characterized by a recurrent behavior in which patients do not comply with social norms and rules or the basic rights of others. Examples include violence, destruction, theft, lying, and serious breaking of rules present over ≥ 1 year. Conduct Disorder, the presentation of DMDD is less severe in nature and does not involve aggressive behavior toward people/ animals Animals Unicellular or multicellular, heterotrophic organisms, that have sensation and the power of voluntary movement. Under the older five kingdom paradigm, animalia was one of the kingdoms. Under the modern three domain model, animalia represents one of the many groups in the domain eukaryota. Cell Types: Eukaryotic versus Prokaryotic, destruction of property, theft, etc ETC The electron transport chain (ETC) sends electrons through a series of proteins, which generate an electrochemical proton gradient that produces energy in the form of adenosine triphosphate (ATP). Electron Transport Chain (ETC).