What is a prodrome?

ˈprōˌdrōm/ noun:  an early symptom indicating the onset of a disease or illness

In psychiatry, the word prodrome is often used to describe a period of time during which an individual begins to display symptoms of a mental illness, typically accompanied by some type of disturbance in functioning, but before the disorder fully presents itself.  Classically it has often been used to describe a period of time of social isolation, change in mood or behavior, and change in functioning who go on to develop schizophrenia, but often people who go on to receive a diagnosis of bipolar disorder have a prodrome as well. 

Unfortunately, sometimes the prodrome is best identified in hindsight.  After a teen or adolescent develops a major depressive episode or a manic episode, parents and family look back and say “oh yeah … he WAS moody and irritable, he DID stop hanging out with friends, he DID seem a bit restless and agitated, he WAS very distractable, his grades DID drop significantly”.  Often in the moment, symptoms seem like normal adolescent behavior or “just a phase”, or often can be related to other issues going on, such as peer problems, academic problems, or other life stressors. That is because the symptoms don’t tend to be severe, may not happen all together, and are often non-specific - meaning that they could be seen in a variety of disorders, such as depression, anxiety, attentional disorders, drug and alcohol disorders, etc.

Bipolar disorder often cannot be clearly diagnosed during this period, unless there are symptoms that are specific to the disorder.  However, any changes in an adolescent’s mood or behavior that affects their relationships and their function at school, with peers, and at home, is worth evaluation by a child and adolescent mental health specialist.  This person can help you monitor changes in symptoms and response to treatment so that whatever may be brewing beneath the surface can be caught early and treated appropriately.

-Dr. Buchanan-

Disruptive Mood Dysregulation Disorder (DMDD): What is it, and what does it have to do with Bipolar Disorder?

Most people are aware of the controversy regarding the diagnosis of bipolar disorder in children and young adolescents.  Those on the conservative end think that the criteria for adult bipolar disorder should be strictly adhered to in these young people, whereas others have proposed slight modifications to the criteria. Others who are more liberal have gone as far to suggest that any child with persistent irritability, moodiness, and temper outbursts are budding bipolar patients.   The diagnosis is made even more unclear by the number of other disorders which have symptoms which overlap with or closely resemble symptoms of bipolar disorder, such as depression, attention deficit disorder, and some developmental disorders.  Additionally, the brains of children and adolescents are constantly developing and changing, as does the presentation of their symptoms.

 Given this complexity and variety of opinions, it is no wonder that different clinicians apply the diagnosis in different ways – which results in children and young adolescents WITHOUT bipolar disorder being misdiagnosed as bipolar, and even occasionally, children WITH bipolar disorder NOT being diagnosed when the strict adult criteria is applied.

In an effort to shed some clarity and consistency on this issue, after many years of research and study by various work groups, the American Psychiatric Association has included a new diagnosis, Disruptive Mood Dysregulation Disorder, to the most recent version of their diagnostic manual, the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5). 

What IS Disruptive Mood Dysregulation Disorder (DMDD)?

DMDD is considered a depressive disorder.   It is characterized by severe recurrent temper outbursts that are out of proportion in intensity or duration to what would be expected for the situation. They are inconsistent with the child’s developmental level, and occur, on average more than 3 times per week. The child’s mood in between these episodes is persistently irritable most of the day, nearly every day, and observable by others (parents, teachers, peers, etc.).  This diagnosis is given if these symptoms have lasted for over a year without a symptom free period of more than 3 months.  The age of onset is defined as before 10 years of age. The diagnosis cannot be given if the child is under 6.   Additionally, this diagnosis is not given if the child has met full criteria for a manic episode, or if the symptoms are better explained by another diagnosis, such as a developmental disorder, a major depressive episode, or a substance abuse problem.

Preliminary information available suggests that the majority of children who meet criteria for this diagnosis do not go on to develop bipolar disorder, but are more likely to suffer from depression.  Although this diagnosis will surely better describe some children who may have previously been diagnosed with bipolar disorder, it alone will not solve all of the complexities and intricacies of accurately diagnosing these challenging children.