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Chapter 31: Child Psychiatry
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cal phenotypes as precursors of major mood disorders.
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randomized trial of risperidone versus divalproex in pediatric bipolar disorder:
fMRI outcomes.
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2011;193:28–37.
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T, Janicak PG, Sweeney JA. Double-blind randomized trial of risperidone
versus divalproex in pediatric bipolar disorder.
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2010;
12:593–605.
Stringaris A, Baroni A, Haimm C, Brotman M, Lowe CH, Myers F, Rustgi E,
Wheeler W, Kayser R, Towbin K, Leibenluft E. Pediatric bipolar disorder versus
severe mood dysregulation: Risk for manic episodes on follow-up.
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Child Adolesc Psychiatry.
2010;49:397–405.
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lips ML. Altered development of white matter in youth at high familial risk for
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Psychiatry.
2010;49:1249–1259.
31.12c Disruptive Mood
Dysregulation Disorder
Disruptive mood dysregulation disorder, a new inclusion in the
American Psychiatric Association’s
Diagnostic and Statistical
Manual of Mental Disorders, Fifth Edition
(DSM-5), is charac-
terized by severe, developmentally inappropriate, and recurrent
temper outbursts at least three times per week, along with a per-
sistently irritable or angry mood between temper outbursts. In
order to meet diagnostic criteria, the symptoms must be present
for at least a year, and the onset of symptoms must be present by
the age of 10 years old. Children with these symptoms have typ-
ically been diagnosed with bipolar disorder, or a combination of
oppositional defiant disorder, ADHD and intermittent explosive
disorder. Recent longitudinal data suggest, however, that these
children do not typically develop classic bipolar disorder in late
adolescence or early adulthood. Instead, studies suggest that
youth with chronic irritability and severe mood dysregulation
are at higher risk for future unipolar depressive disorders and
anxiety disorders. Although the initial studies of children and
adolescents with severe mood dysregulation included several
symptoms of hyperarousal (such as distractibility, physical rest-
lessness, insomnia, racing thoughts, flight of ideas, pressured
speech, or intrusiveness), the current DSM-5 diagnostic criteria
for disruptive mood dysregulation do not include any hyper-
arousal criteria. Youths diagnosed with mood dysregulation dis-
order who also exhibit multiple symptoms of hyperarousal may
be comorbid for ADHD.
Epidemiology
Most of the epidemiological data applied to disruptive mood
dysregulation disorder was gathered from children and ado-
lescents with severe mood dysregulation, which includes
hyperarousal symptoms. Because disruptive mood dysregula-
tion disorder differs from severe mood dysregulation disorder
only in the absence of hyperarousal symptoms, the epide-
miological data from the severe mood dysregulation disorder
studies can be viewed as a useful proxy for disruptive mood
dysregulation disorder. Severe mood dysregulation has a life-
time prevalence of 3 percent in children age 9 to 19 years.
Within that percentage, males (78 percent) are more preva-
lent than females (22 percent). The mean age of onset is 5 to
11 years of age.
Comorbidity
Disruptive mood dysregulation disorder often co-occurs with
other psychiatric disorders. The most common comorbidities are
ADHD (94 percent), oppositional defiant disorder (84 percent),
anxiety disorders (47 percent), and major depressive disorder
(20 percent). The relationship of severe mood dysregulation and
disruptive mood dysregulation disorder to bipolar disorder has
been a topic of clinical investigation. Youth with severe mood
dysregulation and hyperarousal symptoms have been concep-
tualized as a “broad phenotype” of pediatric bipolar disorder,
however, the term “severe mood dysregulation” was utilized by
researchers for these youth because it remains unclear whether
these youth go on to meet criteria for a bipolar disorder. Disrup-
tive mood dysregulation disorder is conceptualized as a disorder
that is not episodic, and may coexist with ADHD. However, cur-
rent evidence does not support its continuity with an emerging
bipolar disorder.
Diagnosis and Clinical Features
The DSM-5 diagnostic criteria for disruptive mood dys-
regulation disorder (Table. 31.12c-1) requires outbursts that
are grossly out of proportion to the situation. These temper
outbursts present with verbal rages and/or physical aggres-
sion toward people or property, and are inappropriate for
the child’s developmental level. Temper outbursts occur, on
average, three or more times per week, with variations in
mood between outbursts. Symptoms must exhibit before age
10 years, be present for at least 12 months, and be present
within at least two settings (i.e., home and school). The diag-
nosis is not made for the first time in youth younger than 6
years or older than 18 years. In between temper outbursts, the
child’s mood is persistently irritable and angry, and this mood
is observable by others such as parents, teachers, or peers.
There has never been period lasting more than one day in
which full criteria for a manic or hypomanic episode (except
for duration) are fulfilled. The above behaviors do not occur
exclusively in the context of an episode of major depression
and are not better accounted for by another psychiatric disor-
der. The DSM-5 diagnostic criteria for disruptive mood dys-
regulation disorder are found in Table 31.12c-1.
Daniel, a 12-year-old 7
th
grade boy was brought to his pedia-
trician by his mother, who was exasperated with Daniel’s rages
and inappropriate tantrums. Daniel was on the floor in the waiting
room, pounding his hands on the floor, yelling at his mother “get
me out of here!” and crying. His mother had bruises on both legs
from Dylan’s kicks, and she appeared distressed. Daniel’s mother
walked into the office, leaving Daniel on the floor in the waiting
