Disruptive Mood Dysregulation Disorder versus Bipolar Disorder

By Candida Fink, Joe Kraynak

DSM-5 introduced a new diagnosis that grew out of research on children with chronic mood dysregulation — irritability and emotional/behavioral outbursts. The concept of chronic mood dysregulation has overlapped with the diagnosis of bipolar disorder, but they’re not the same. This diagnosis helps to capture children with baseline irritability and outbursts who don’t exhibit the cycles or episodes needed to diagnose mania and therefore bipolar disorder.

Disruptive mood dysregulation disorder (DMDD) is listed under Depressive Disorders in the DSM-5, and its diagnostic criteria are as follows:

  • Severe recurrent temper outbursts manifested verbally (for example, verbal rages) and/or behaviorally (for example, physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

  • The temper outbursts are inconsistent with developmental level (they look like more typical reactions in a younger child, for example).

  • The temper outbursts occur, on average, three or more times per week.

  • The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (for example, parents, teachers, and peers).

  • Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting three or more consecutive months without all the symptoms in Criteria A–D.

  • Criteria A and D are present in at least two of three settings (at home, at school, with peers) and are severe in at least one of these.

  • The diagnosis should not be made for the first time before age 6 years or after age 18 years.

  • By history or observation, the age at onset of Criteria A–E is before age 10 years.

  • There has never been a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode have been met.

  • The behaviors do not occur exclusively during an episode of major depression and are not better explained by another mental disorder (for example, autism spectrum disorder, post-traumatic stress disorder, separation anxiety disorder, persistent depressive disorder).

  • The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

Importantly, this diagnosis can’t coexist with bipolar disorder or oppositional defiant disorder. If mania or hypomania is present, bipolar is the diagnosis. If symptoms of ODD present, then the DMDD diagnosis is used instead. DMDD can coexist with depression, ADHD, substance use, and other disorders.

Currently no specific treatment recommendations are available for DMDD. Because it’s considered a subset of depression, treatment for depression is often the first place to start. If coexisting conditions, such as ADHD or anxiety, are present, those are targeted. Multiple resources are typically needed for effective treatment in these children, including psychotherapy, parenting support, educational accommodations, as well as possible medications.

The diagnosis of DMDD can be helpful to families who are trying to understand these difficult behaviors in their children. Realize that these responses aren’t just children being difficult or willful, but rather are due to problems in their nervous system circuits that help to regulate mood and behavior. Understanding this difference in cause changes the treatment and parenting approaches considerably.

An important consideration with this diagnosis is that if your child is diagnosed with bipolar disorder, certain medications, such as antidepressants and stimulants, may be avoided. The DMDD diagnosis doesn’t carry these restrictions beyond baseline caution in using these medications in children. This is extremely helpful, because the overuse of the bipolar disorder diagnosis can lead to restricting the use of medications that may be helpful for diagnoses such as depression, ADHD, and anxiety disorders.