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.

Promoting Social Inclusion, Connectedness

This article entitled "Promoting Social Inclusion and Connectedness in the Mentally Ill Patient" was recently published in Clinical Psychiatry News. Written by two residents affiliated with the Family Center for Bipolar, the article describes numerous types of community resources that can help patients broaden their social lives.

Mania/Hypomania and the Creative Process

Mania and hypomania are often referred to as the "up" side of bipolar disorder. Though either a manic or a hypomanic episode can be quite destructive, we as clinicians often hear concerns from patients about treating these kinds of mood episodes. The reality is that after a long struggle with depressive episodes, a manic or hypomanic episode can sometimes feel like a welcome break for our patients. It is during these episodes that patients oftentimes become non-compliant with their medicine and other on-going treatment modes (e.g. therapy) - perhaps because a part of them does not want to let go of the euphoria that mania and hypomania induce.

As clinicians it is our responsibility to negotiate this difficult and delicate dilemma in our patients' mood functioning. On one hand we want our patients to feel good, and on the other we know how precipitous the guise of euphoria can prove to be for the patient, his/her loved ones, and for the course of treatment.

In my own experience working with patients with bipolar illness I often hear people express fear that treating mood symptoms, especially hypomania, will negatively impact their creative process. On one hand I can easily empathize with their concerns, yet as a clinician I worry about the impact that these concerns will have on their treatment and progress. There are no easy answers to this dilemma.

In contemplating about all this I recently came across a very interesting article that poignantly discusses this very real and fairly common predicament.

You can read the article here:

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3181877/pdf/DialoguesClinNeurosci-10-251.pdf

If you have any thoughts or input on this topic - whether from a clinician's or patient's point of view - kindly share it with us. We would love to hear your thoughts.

What To Do When You Don't Want To Do Anything?!

When we’re not feeling well we often don’t feel like doing anything. However, a simple fact is that getting out to actually do something often makes us feel a bit better. Sounds like a catch 22, right? 

How do we get out to do anything if we don’t have the motivation to do it? 

We often hold the common misconception that we need motivation in order to actually do something. The truth is, it is often the opposite. We have to actually do something in order to ignite the motivation. The first step is often the most difficult.

 

Are you at a loss for what to do? Here is a link to a list of 279 Pleasant Activities: 

Let's Get Moving!

Look over the list and pick something new that you feel you can actually do in this moment. Whatever time frame you think you can do it for, scale it back (if you think you can do something for 20 minutes, plan for 15). 

Know that taking that first step is the hardest, but once you start the activity, you may realize your motivation has increased, along with increased positive thoughts, emotions and physical sensations!

Family Involvement and Relapse Prevention in BD

A recent article published in BMC Psychiatry in November 2011 titled Involving relatives in relapse prevention for bipolar disorder: a multi-perspective qualitative study of value and barriers focused on both the benefit and barriers of involving family members in relapse prevention treatment. Some of the benefits include another “pair of eyes” to monitor the patient, relatives' increased understanding of the illness, increased support during a crisis, and earlier intervention during a relapse. The paper also notes that during relapse prevention training it is important that each member clearly understands their role in the therapeutic relationship and does not use their new role in a threatening way.  In addition, some obstacles such as confidentiality and family dynamics must also be addressed in order for the relapse prevention model to be effective.

The research strongly supports the involvement of relatives in relapse prevention, while recognizing barriers to effective treatment and tools to prevent and overcome these barriers.

Dr. Burns

Children's Books

Bipolar Disorder and mental illness affect the entire family. It is especially important to make sure that young children feel loved, validated and supported.  One way to engage and provide age-appropriate psychoeducation to children is to read them thoughtful stories about Bipolar Disorder.  Please visit the links below.

The Bipolar Bear Family: When a Parent Has Bipolar Disorder
Why is Mommy Sad? A Child's Guide to Parental Depression
My Mother's Bipolar, So What Am I?
Sometime My Mommy Gets Angry

Family Support Groups

The following websites might help patients cope with family members who have mental illness:

P The Crooked House

P National Family Caregivers Association

P American Foundation for Suicide Prevention

P Family Connections: Coordinated by the National Education Alliance for Borderline Personality Disorder

P Families for Depression Awareness

P Families Together

P Depression and Bipolar Support Alliance

P Mental Health America

P The Children’s Society’s Include Project

P The National Alliance on Mental Illness Family-to-Family Education Program

P Support and Education Program for Families

P Network of Care

P Children and Adults with Attention Deficit/Hyperactivity Disorder

P Active Minds

P Substance Abuse and Mental Health Services Administration Resources for Military Families

P Compeer

P National PLAN (Planned Lifetime Assistance Network) Alliance

For full article entitled Family Support Groups: An Integral Part of Patient Care, visit the Families in Psychiatry Section of Clinical Psychiatry News.