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Disruptive Mood Dysregulation Disorder: A Critical Perspective

The first condition listed in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5), “Depressive Disorders” chapter is disruptive mood dysregulation disorder (DMDD) and thus precedes the presumably more substantive condition of major depressive disorder. The diagnostic criteria for DMDD (which is restricted to children up to 12 years of age) include 4 symptoms, with each making reference to a sentinel feature of “temper outbursts” (characterized as severe, inconsistent with developmental level, occurring 3 or more times per week, and with the interepisode mood being irritability or anger for most of the day). The DSM-5 text states that it was added as a new diagnosis to “address concerns about the potential of the overdiagnosis of treatment for bipolar disorder in children” (p. 155). As no “depressive” symptoms are listed as criteria, the immediate question is why is DMDD listed as a depressive disorder? In this article, 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. In a scene-setting historical article, Leibenluft et al. defined 4 differing juvenile bipolar disorder phenotypes. These, they asserted, reflected reference to “Relevant literature . . . and the input of experts” (p. 430). The 4 classes comprised 1) a “narrow phenotype” respecting full DSMIV diagnostic criteria for hypo/mania, 2) an “intermediate phenotype” for those who failed only to meet DSM-IV duration criteria, 3) another “intermediate phenotype” for those who lacked the hallmark symptom of an elevated mood during hypo/manic states and who instead had “irritable hypo/ mania,” and 4) a “broad phenotype” for those who had a chronic nonepisodic illness marked by severe irritability and hyperarousal. In relation to the last—and certainly the most problematic phenotype—the authors stated that it was marked by the child’s “increased reactivity to negative emotional stimuli in the form of severe rages, as well as chronic hyperarousal (motor hyperactivity, distractibility, etc.),” as well as the symptoms being chronic and, as noted, nonepisodic. Their argument for including such a category was that “none of the DSM-IV diagnoses captures a relatively homogeneous population of patients with mood disturbance, hyperarousal, and decreased frustration tolerance.” Several concerns can be expressed about that argument. First, the mood disturbance component is not included in the phenotypic description. More importantly, do such broad and nonspecific features suggest a “homogeneous” category of necessity, as would be expected of a valid diagnostic entity? The authors themselves earlier suggest that this may not be the case, in stating that such a broad phenotype “may ultimately prove to be a heterogenous group” comprising those with hypo/mania, while others may have dysthymia, major depression, or a form of disruptive behavior disorder. Second, as the primary feature is irritability, and neither depression nor hypo/mania, what was the logic in ever positioning it as a bipolar disorder? Third, why include a nonepisodic component to the definition, as this criterion counters one of the few accepted criteria for the bipolar disorders—that symptoms are intermittent and episodic? While Leibenluft et al. suggest several possible validating strategies, they offer no empirical evidence for the category. Their description of the putative phenotypes would of necessity risk merging bipolar disorder in childhood with a range of nonepisodic personality and conduct conditions