Kaplan + Sadock's Synopsis of Psychiatry, 11e

1243

31.12c  Disruptive Mood Dysregulation Disorder

Table 31.12c-1 DSM-5 Diagnostic Criteria for Disruptive Mood Dysregulation Disorder A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation. B. The temper outbursts are inconsistent with developmental level. C. The temper outbursts occur, on average, three or more times per week. D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, peers). E. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D. F. Criteria A and D are present in at least two of three settings (i.e., at home, at school, with peers) are severe in at least one of these. G. The diagnosis should not be made for the first time before age 6 years or after age 18 years. H. By history or observation, the age at onset of Criteria A–E is before 10 years. I. There has never been a distinct period lasting more than 1 day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met. Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania. J. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]). Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorder. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned. K. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition. (Reprinted with permission from the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (Copyright ©2013). American Psychiatric Association. All Rights Reserved.)

physical wrong with him, but physical examination and routine blood tests reveal no abnormalities. Daniel’s tantrums had less- ened somewhat last summer during the 2-month summer vacation; however, as soon as school resumed, he was back to consistent irritability. After an interview with Daniel, his pediatrician deter- mined that he was not acutely suicidal; however, he required urgent psychotherapeutic intervention. Daniel was referred to a clinical psychologist for cognitive-behavioral treatment, and a child and adolescent psychiatrist for a medication evaluation. Daniel resisted psychotherapy; however, after several sessions, Daniel’s parents felt more hopeful than they had in a long time, and learned that Daniel’s problems were not “all their fault.” Daniel agreed to begin a trial of fluoxetine, which was titrated up to 30 mg over several weeks, and after about a month, it became clear that his irritability had diminished noticeably. Daniel still had many problems with peers, and he still had one or two tantrums per week; however, the tantrums were becoming less prolonged and less intense. Dan- iel seemed genuinely happy when he was invited to a classmate’s birthday party, and he was able to interact successfully with his peers during the party without any conflicts. Daniel continues to benefit from CBT, and he remains on fluoxetine 40 mg a day. Dan- iel is still described as a “temperamental” boy, but he is doing well in school, has rekindled several friendships, and is able to partici- pate in family gatherings without a major tantrum. Disruptive mood dysregulation disorder closely resembles the “broad phenotype” of bipolar disorder. Although not episodic, it has been theorized by some clinicians and researchers that the chronic and persistent symptoms of mood disturbance and irritability may be an early developmental presentation of bipo- lar disorder. Disruptive mood dysregulation, however, does not meet formal diagnostic criteria for mania in bipolar disorder, because irritability in disruptive mood dysregulation disorder is chronic and nonepisodic. Oppositional Defiant Disorder Disruptive mood dysregulation disorder is similar to opposi- tional defiant disorder in that they both include irritability, tem- per outbursts, and anger. Many patients with disruptive mood dysregulation disorder meet the criteria for oppositional defiant disorder; however, most patients with oppositional defiant dis- order do not meet the criteria for disruptive mood dysregulation disorder. Oppositional defiant disorder includes symptoms of annoyance and defiance that are not found in disruptive mood dysregulation disorder. Disruptive mood dysregulation disorder requires that irritable outbursts be present in at least two set- tings, whereas oppositional defiant disorder requires that they be present in only one setting. Course and Prognosis Disruptive mood dysregulation disorder is a chronic disorder. Longitudinal studies thus far have shown that patients with dis- ruptive mood dysregulation disorder in childhood have a high Differential Diagnosis Bipolar Disorder

room and burst into tears. “I can’t deal with him anymore.” She recounted the problems that Daniel had been having for the last 2 years: Severe recurrent tantrums four to five times/week. “He tantrums like a 6-year-old, and even when he is not having a tan- trum, he is perpetually angry and irritable.” She reported that Dan- iel had lost all of his friends due to his short fuse and frequent verbal and physical outbursts. He was almost always irritable, even on his birthday. Daniel’s mother wonders whether there is anything