31.12c Disruptive Mood Dysregulation Disorder
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Table 31.12c-1
DSM-5 Diagnostic Criteria for Disruptive Mood
Dysregulation Disorder
A. Severe recurrent temper outbursts manifested verbally
(e.g., verbal rages) and/or behaviorally (e.g., physical
aggression toward people or property) that are grossly out
of proportion in intensity or duration to the situation or
provocation.
B. The temper outbursts are inconsistent with developmental
level.
C. The temper outbursts occur, on average, three or more
times per week.
D. The mood between temper outbursts is persistently
irritable or angry most of the day, nearly every day, and is
observable by others (e.g., parents, teachers, peers).
E. Criteria A–D have been present for 12 or more months.
Throughout that time, the individual has not had a period
lasting 3 or more consecutive months without all of the
symptoms in Criteria A–D.
F. Criteria A and D are present in at least two of three settings
(i.e., at home, at school, with peers) are severe in at least
one of these.
G. The diagnosis should not be made for the first time before
age 6 years or after age 18 years.
H. By history or observation, the age at onset of Criteria A–E is
before 10 years.
I. There has never been a distinct period lasting more than
1 day during which the full symptom criteria, except
duration, for a manic or hypomanic episode have been
met.
Note:
Developmentally appropriate mood elevation, such
as occurs in the context of a highly positive event or its
anticipation, should not be considered as a symptom of
mania or hypomania.
J. The behaviors do not occur exclusively during an episode
of major depressive disorder and are not better explained
by another mental disorder (e.g., autism spectrum disorder,
posttraumatic stress disorder, separation anxiety disorder,
persistent depressive disorder [dysthymia]).
Note:
This diagnosis cannot coexist with oppositional
defiant disorder, intermittent explosive disorder, or bipolar
disorder, though it can coexist with others, including major
depressive disorder, attention-deficit/hyperactivity disorder,
conduct disorder, and substance use disorder. Individuals
whose symptoms meet criteria for both disruptive mood
dysregulation disorder and oppositional defiant disorder
should only be given the diagnosis of disruptive mood
dysregulation disorder. If an individual has ever experienced
a manic or hypomanic episode, the diagnosis of disruptive
mood dysregulation disorder should not be assigned.
K. The symptoms are not attributable to the physiological
effects of a substance or to another medical or neurological
condition.
(Reprinted with permission from the
Diagnostic and Statistical Manual of
Mental Disorders, Fifth Edition
(Copyright ©2013). American Psychiatric
Association. All Rights Reserved.)
room and burst into tears. “I can’t deal with him anymore.” She
recounted the problems that Daniel had been having for the last
2 years: Severe recurrent tantrums four to five times/week. “He
tantrums like a 6-year-old, and even when he is not having a tan-
trum, he is perpetually angry and irritable.” She reported that Dan-
iel had lost all of his friends due to his short fuse and frequent
verbal and physical outbursts. He was almost always irritable, even
on his birthday. Daniel’s mother wonders whether there is anything
physical wrong with him, but physical examination and routine
blood tests reveal no abnormalities. Daniel’s tantrums had less-
ened somewhat last summer during the 2-month summer vacation;
however, as soon as school resumed, he was back to consistent
irritability. After an interview with Daniel, his pediatrician deter-
mined that he was not acutely suicidal; however, he required urgent
psychotherapeutic intervention. Daniel was referred to a clinical
psychologist for cognitive-behavioral treatment, and a child and
adolescent psychiatrist for a medication evaluation. Daniel resisted
psychotherapy; however, after several sessions, Daniel’s parents
felt more hopeful than they had in a long time, and learned that
Daniel’s problems were not “all their fault.” Daniel agreed to begin
a trial of fluoxetine, which was titrated up to 30 mg over several
weeks, and after about a month, it became clear that his irritability
had diminished noticeably. Daniel still had many problems with
peers, and he still had one or two tantrums per week; however,
the tantrums were becoming less prolonged and less intense. Dan-
iel seemed genuinely happy when he was invited to a classmate’s
birthday party, and he was able to interact successfully with his
peers during the party without any conflicts. Daniel continues to
benefit from CBT, and he remains on fluoxetine 40 mg a day. Dan-
iel is still described as a “temperamental” boy, but he is doing well
in school, has rekindled several friendships, and is able to partici-
pate in family gatherings without a major tantrum.
Differential Diagnosis
Bipolar Disorder
Disruptive mood dysregulation disorder closely resembles the
“broad phenotype” of bipolar disorder. Although not episodic,
it has been theorized by some clinicians and researchers that
the chronic and persistent symptoms of mood disturbance and
irritability may be an early developmental presentation of bipo-
lar disorder. Disruptive mood dysregulation, however, does not
meet formal diagnostic criteria for mania in bipolar disorder,
because irritability in disruptive mood dysregulation disorder is
chronic and nonepisodic.
Oppositional Defiant Disorder
Disruptive mood dysregulation disorder is similar to opposi-
tional defiant disorder in that they both include irritability, tem-
per outbursts, and anger. Many patients with disruptive mood
dysregulation disorder meet the criteria for oppositional defiant
disorder; however, most patients with oppositional defiant dis-
order do not meet the criteria for disruptive mood dysregulation
disorder. Oppositional defiant disorder includes symptoms of
annoyance and defiance that are not found in disruptive mood
dysregulation disorder. Disruptive mood dysregulation disorder
requires that irritable outbursts be present in at least two set-
tings, whereas oppositional defiant disorder requires that they
be present in only one setting.
Course and Prognosis
Disruptive mood dysregulation disorder is a chronic disorder.
Longitudinal studies thus far have shown that patients with dis-
ruptive mood dysregulation disorder in childhood have a high
