Minimal Evidence for Disruptive Mood Dysregulation Disorder in Childhood

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.”

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)