Minimal Evidence for Disruptive Mood Dysregulation Disorder in Childhood

Researchers offer a critical take on the inclusion of the Disruptive Mood Dysregulation Disorder in the DSM-5.

Sadie Cathcart
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What is the difference between age-appropriate negotiation of intense emotion in early childhood and clinically significant fluctuation of emotion consistent with the psychiatric diagnosis known as Disruptive Mood Dysregulation Disorder (DMDD)? According to a new review by the researchers Gordon Parker and Gabriela Tavella, published in The Canadian Journal of Psychiatry, the difference may be less discernable than the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) would lead one to believe.

Parker, the head of Psychiatry at University of New South Wales and the director of the Black Dog Institute (an organization which aims to bring mental health research into practice), and his co-author challenge the validity of DMDD, outlining the lack of lack empirical support for the disorder as a unique diagnostic entity. They argue that even as DMDD was established, in essence, to reduce “overdiagnosis of bipolar disorder in childhood,” the designation of this “disorder” may prevent children from receiving appropriate supports from which they would benefit by distracting from the more likely sources of the challenges they are experiencing.

“In this article,” they write, “we question DSM strategies, both in terms of the logic of positioning DMDD as a depressive disorder as well as the logic in providing the condition as a ‘diversionary’ diagnosis to address concerns about the overdiagnosis of juvenile bipolar disorder.”

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DMDD is the first condition listed in the DSM-5 “Depressive Disorder” domain, and the construct has been controversial and largely unsubstantiated since the publication of the updated manual in 2013. It is characterized by temper outbursts that are “severe, inconsistent with developmental level, occur […] 3 or more times per week, and with the inter-episode mood being irritability or anger for most of the day.” Parker and Tavella stress the peculiarity of the DMDD diagnosis as a “Depressive Disorder” in the absence of “depressive” symptoms. Characterized by “temper outbursts,” the authors suggest that DMDD is a “diversionary” diagnosis designed to reduce the “overdiagnosis” of juvenile bipolar disorder.

DMDD was met with skepticism before the release of the DSM-5. Parker and Tavella’s critical evaluation of the creation and maintenance of the DMDD diagnostic category includes an analysis of publications preceding the release of the DSM-5  that put forth a rationale for the development of the category. Parker and Tavella write that these publications, “offer no empirical evidence for the category.” They go on to argue that the development of DMDD can be characterized by reactive justification rather than proactive validation.

“In addressing the concern that juvenile bipolar disorder was being overdiagnosed, the DSM appears to have assumed that such a process was principally driven by the inclusion of a ‘broad phenotype’ of children with a chronic and non-episodic illness marked by severe irritability and hyperarousal,” they explain. “However, rather than unequivocally reject this phenotype as indicative of a bipolar disorder (as it lacks any empirical support while its features are not compatible with bipolar disorder) and thus excluding it from the DSM-5 manual completely, the DSM-5 went on to fashion a ‘diversionary’ diagnosis.”

In their evaluation of the literature addressing juvenile bipolar disorder and DMDD, Parker and Tavella illustrate methodological flaws in the development of DMDD. Despite the attempt to reduce overdiagnosis of bipolar disorder in children, the invention of DMDD has opened the door to new challenges surrounding misdiagnosis and may contribute to an increase in children struggling with difficult emotions being diagnosed and placed in insufficient services.

 

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Parker, G., & Tavella, G. (2018). Disruptive Mood Dysregulation Disorder: A Critical Perspective. The Canadian Journal of Psychiatry, 070674371878990. (Link)

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Sadie Cathcart
Sadie Cathcart is a doctoral student and researcher within the Counseling and School Psychology program at the University of Massachusetts, Boston. Sadie belongs to the school psychology track, and her research interests include the psychosocial implications of chronic illness in childhood, relationships between health and educational opportunities, and creative approaches to boosting student and family engagement in learning.

12 COMMENTS

  1. Let us be perfectly honest. This supposed diagnosis is pure bull feces, plain and simple. It’s just another attempt by the system and unscrupulous psychiatrists, which includes a great number of them, to profit off of something that is normal in human beings. The DSM 5 is filled with supposed diagnoses that are nothing but attempts to pathologize normal human behaviors. It’s so blatant that I’m surprised that they aren’t totally ashamed of themselves. How do these people get up each and every morning and look themselves in the eye in the mirror? They are lacking in ethics and have little morality. And this kind of snake oil chicanery is supposed to convince us that psychiatry is a valid specialty in medicine?

      • Only about 15% of the U.S. population is directly invested in the Stock Market/Wall St., and another 35% is indirectly invested through 401(k)’s, IRA’s, etc. So about 1/2 the U.S. population is NOT invested. And, companies such as Perdue Pharma, which gave us Oxycontin, and made $Billionaires$ out of the Sackler family, are private companies that you can’t invest in. Truly, PhRMA mostly profits the rich, ruling elites.
        I think MiA should convince the APA to agree to NO “DSM-6”. It’s a catalog of billing codes. Thanks, littleturtle!

    • Yes, DMDD was actually invented to allow doctors to continue to prescribe drugs for what was called “Juvenile Bipolar Disorder” after Biedermann essentially created THAT disorder out of thin air in the late 1990s for the benefit of his buddies at Johnson and Johnson Pharmaceuticals. When it was discovered by research that kids labeled with “Juvenile Bipolar Disorder” did not tend to develop symptoms of “Bipolar Disorder” as adults, and that those who did end up with “Bipolar disorder” diagnoses did not engage in Biedermann’s list of behaviors as kids, they realized they were in a bad spot. So they invented “DMDD” to allow doctors a diagnostic category for the annoying kids that Biedermann had decided were “bipolar” so that they could still bill for drugging kids who were annoying to the adults around them, despite no evidence that these kids actually ever had any medical problem whatsoever. It really is a study in disease invention and shows the complete lack of credibility and ethics in the development of these DSM categories. They seriously do invent them out of whole cloth with the intention of “covering” as wide a range of behavior as possible to increase their market share.

    • The bipolar epidemic was largely caused by most of the doctors neglecting to read and abide by their DSM “bible.” Particularly this statement from the DSM-IV-TR:

      “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

      Although, as Whitaker pointed out in “Anatomy of an Epidemic,” the ADHD drugs, in addition to the antidepressants, also create the bipolar symptoms.

      In other words, the bipolar epidemic was caused by malpractice on a massive societal scale. But what’s good is we, all except the DSM believers, know bipolar is an iatrogenic, not genetic, disease.

      I have to agree, Stephen, the psychiatrists do lack ethics and morals. In their DSM5, they should have added the ADHD drugs to the above mentioned bipolar disclaimer. Instead they completely removed the disclaimer all together. Very unethical indeed.