Imagine a typical suburban family with a mother and father and two children, a 7-year-old boy and a 5-year-old girl. Dad is a plumber and Mom is a part-time librarian at the local high school. They are financially secure and have a nice home with a bedroom for each child. There is just one problem that ruins their apparently idyllic life.
The 7-year-old son (we will call him Johnnie) has temper tantrums from hell. With any frustration, however small, he flies into an uncontrollable rage and screams, curses and insults his parents, and sometimes tries to hit his mother. He frightens his younger sister when he does this so she usually runs to her room or clings to a parent. These rages occur 3 or more times a week.
If that wasn't bad enough, Johnnie is always irritable. He rarely seems happy and is called "cranky" by every adult who knows him. His second grade teacher is exasperated with him and has sent him to the Principle at least weekly. The school psychologist is recommending an emotional support program and consideration for special placement. His grades are poor despite seeming to be intelligent enough to do better.
Johnnie's pediatrician does not look forward to his appointments since Johnnie has "gone off" on her more than once. She has diagnosed him with Oppositional Defiant Disorder when he was younger but tells Mom that she has never seen such a severe case and recommends a referral to a Child & Adolescent Psychiatrist.
The psychiatrist determines that Johnnie has never had a manic episode, that there is no family history of Bipolar Disorder, and that Johnnie has both irritability and anxiety on an ongoing basis between episodes of behavioral dyscontrol. A neurological evaluation is normal, and there is no evidence of Autism Spectrum Disorder, PTSD, or Intermittent Explosive Disorder.
The psychiatrist tells the parent that Johnnie has Disruptive Mood Dysregulation Disorder (DMDD), a new diagnosis officially recognized in 2013. It has been distinguished from childhood Bipolar Disorder, which does exist but has been over diagnosed in recent years. DMDD is distinct from Bipolar Disorder but has some overlapping symptoms. In children with Bipolar Disorder they have episodes of mania or hypomania and do not have an irritable mood continuously between angry episodes. In contrast, DMDD is characterized by ongoing irritability.
DMDD is much more common in boys, unlike Bipolar Disorder, which is equally common in boys and girls. It is estimated that 2-5% of children have DMDD. The onset is before the age of 10 and is developmentally inappropriate. So, for example, temper tantrums in 2-year-olds are normal and not predictive of DMDD. It is not unusual for a child with DMDD to be diagnosed with Oppositional Defiant Disorder before manifesting DMDD.
Children with DMDD often have information-processing deficits such as difficulty "reading" emotions on other people's faces or making poor decisions. They also have other psychiatric disorders at the same time such as anxiety or ADHD. Suicidal thoughts are not rare in these children and any expression of such thoughts must be taken seriously since they may act on those thoughts.
Not surprisingly, children with DMDD often cause severe disruption in their families and typically have few friends, if any. They do poorly in school and are often in trouble in that setting. Psychiatric hospitalization is often required at times.
Unfortunately, there is no fully validated treatment for this disorder. Various medications may be tried with limited results as a rule. Behavioral therapies can provide some benefit but don't typically work miracles. Family counseling may help the family to cope better.
Most of these children do eventually have relief from their severe irritability and rage attacks, but they commonly have unipolar depression and/or anxiety disorders when they reach adolescence. Very few of them turn out to have a Bipolar Disorder. Clearly, more research is needed to better understand DMDD and to discover effective treatments.
Peter M. Hartmann, MD
Family Medicine & Psychiatry
