Kaplan + Sadock's Synopsis of Psychiatry, 11e

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Chapter 31: Child Psychiatry

dysregulation disorder. Severe mood dysregulation has a life- time prevalence of 3 percent in children age 9 to 19 years. Within that percentage, males (78 percent) are more preva- lent than females (22 percent). The mean age of onset is 5 to 11 years of age. Comorbidity Disruptive mood dysregulation disorder often co-occurs with other psychiatric disorders. The most common comorbidities are ADHD (94 percent), oppositional defiant disorder (84 percent), anxiety disorders (47 percent), and major depressive disorder (20 percent). The relationship of severe mood dysregulation and disruptive mood dysregulation disorder to bipolar disorder has been a topic of clinical investigation. Youth with severe mood dysregulation and hyperarousal symptoms have been concep- tualized as a “broad phenotype” of pediatric bipolar disorder, however, the term “severe mood dysregulation” was utilized by researchers for these youth because it remains unclear whether these youth go on to meet criteria for a bipolar disorder. Disrup- tive mood dysregulation disorder is conceptualized as a disorder that is not episodic, and may coexist with ADHD. However, cur- rent evidence does not support its continuity with an emerging bipolar disorder. Diagnosis and Clinical Features The DSM-5 diagnostic criteria for disruptive mood dys- regulation disorder (Table. 31.12c-1) requires outbursts that are grossly out of proportion to the situation. These temper outbursts present with verbal rages and/or physical aggres- sion toward people or property, and are inappropriate for the child’s developmental level. Temper outbursts occur, on average, three or more times per week, with variations in mood between outbursts. Symptoms must exhibit before age 10 years, be present for at least 12 months, and be present within at least two settings (i.e., home and school). The diag- nosis is not made for the first time in youth younger than 6 years or older than 18 years. In between temper outbursts, the child’s mood is persistently irritable and angry, and this mood is observable by others such as parents, teachers, or peers. There has never been period lasting more than one day in which full criteria for a manic or hypomanic episode (except for duration) are fulfilled. The above behaviors do not occur exclusively in the context of an episode of major depression and are not better accounted for by another psychiatric disor- der. The DSM-5 diagnostic criteria for disruptive mood dys- regulation disorder are found in Table 31.12c-1.

Nurnberger JI, McInnis M, Reich SW, Kastelic E, Wilcox HC, Glowinski A, Mitchell P, Fisher C, Erpe M, Gershon E, Berrettini W, Laite G, Schweitzer R, Rhoadarmer K, Coleman VV, Cai X, Azzouz F, Liu H, Kamali M, Brucksch C, Monahan PO. A high-risk study of bipolar disorder. Childhood clini- cal phenotypes as precursors of major mood disorders. Arch Gen Psychiatry. 2011;68:1012–1020. Pavulari MN, Passarotti AM, Lu LH, Carbray JA, Sweeney JA. Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder: fMRI outcomes. Psychiatry Res: Neuroimaging. 2011;193:28–37. Pavulari MN, Henry DB, Findling RL, Parnes S, Carbray JA, Mohammed T, Janicak PG, Sweeney JA. Double-blind randomized trial of risperidone versus divalproex in pediatric bipolar disorder. Bipolar Disorders. 2010; 12:593–605. Stringaris A, Baroni A, Haimm C, Brotman M, Lowe CH, Myers F, Rustgi E, Wheeler W, Kayser R, Towbin K, Leibenluft E. Pediatric bipolar disorder versus severe mood dysregulation: Risk for manic episodes on follow-up. J Am Acad Child Adolesc Psychiatry. 2010;49:397–405. Versace Am Ladouceur CD, Romero S, Birmaher B, Axelson DA, Kupfer DJ, Phil- lips ML. Altered development of white matter in youth at high familial risk for bipolar disorder: a diffusion tensor imaging study. J Am Acad Child Adolesc Psychiatry. 2010;49:1249–1259.

31.12c Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder, a new inclusion in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), is charac- terized by severe, developmentally inappropriate, and recurrent temper outbursts at least three times per week, along with a per- sistently irritable or angry mood between temper outbursts. In order to meet diagnostic criteria, the symptoms must be present for at least a year, and the onset of symptoms must be present by the age of 10 years old. Children with these symptoms have typ- ically been diagnosed with bipolar disorder, or a combination of oppositional defiant disorder, ADHD and intermittent explosive disorder. Recent longitudinal data suggest, however, that these children do not typically develop classic bipolar disorder in late adolescence or early adulthood. Instead, studies suggest that youth with chronic irritability and severe mood dysregulation are at higher risk for future unipolar depressive disorders and anxiety disorders. Although the initial studies of children and adolescents with severe mood dysregulation included several symptoms of hyperarousal (such as distractibility, physical rest- lessness, insomnia, racing thoughts, flight of ideas, pressured speech, or intrusiveness), the current DSM-5 diagnostic criteria for disruptive mood dysregulation do not include any hyper- arousal criteria. Youths diagnosed with mood dysregulation dis- order who also exhibit multiple symptoms of hyperarousal may be comorbid for ADHD. Epidemiology Most of the epidemiological data applied to disruptive mood dysregulation disorder was gathered from children and ado- lescents with severe mood dysregulation, which includes hyperarousal symptoms. Because disruptive mood dysregula- tion disorder differs from severe mood dysregulation disorder only in the absence of hyperarousal symptoms, the epide- miological data from the severe mood dysregulation disorder studies can be viewed as a useful proxy for disruptive mood

Daniel, a 12-year-old 7 th grade boy was brought to his pedia- trician by his mother, who was exasperated with Daniel’s rages and inappropriate tantrums. Daniel was on the floor in the waiting room, pounding his hands on the floor, yelling at his mother “get me out of here!” and crying. His mother had bruises on both legs from Dylan’s kicks, and she appeared distressed. Daniel’s mother walked into the office, leaving Daniel on the floor in the waiting