Understanding DMDD Treating kids with protracted anger outbursts and irritability
•Download as PPTX, PDF•
1 like•263 views
Learning Objectives: Examine why DMDD was established as a stand-alone diagnosis in DSM-5, review the diagnostic criteria for DMDD, along with the differential diagnosis from other common conditions and explore what we know about treating kids with DMDD
Recommended
More Related Content
What's hot
What's hot (20)
Similar to Understanding DMDD Treating kids with protracted anger outbursts and irritability
Similar to Understanding DMDD Treating kids with protracted anger outbursts and irritability (20)
More from Stephen Grcevich, MD
More from Stephen Grcevich, MD (20)
Recently uploaded
Recently uploaded (20)
Understanding DMDD Treating kids with protracted anger outbursts and irritability
- 1. Understanding DMDD Treating kids with protracted anger outbursts and irritability Stephen Grcevich, MD Associate Professor of Psychiatry – NEOMED Presented for Stark MHAR Board November 10, 2021
- 2. Learning Objectives • Examine why DMDD was established as a stand- alone diagnosis in DSM-5 • Review the diagnostic criteria for DMDD, along with the differential diagnosis from other common conditions • Explore what we know about treating kids with DMDD
- 3. Where did DMDD come from? • NIMH began to explore a broad phenotype of adolescents with chronic, impairing irritability - severe mood dysregulation (SMD) • SMD required recurrent temper outbursts, persistent negative mood, and the presence of at least three “hyperarousal” symptoms…pressured speech, racing thoughts/flight of ideas, intrusiveness, distractibility, insomnia, agitation Leibenluft E. Am J Psychiatry. 2011 February ; 168(2): 129–142
- 4. A large group of kids experience: • Irritability as their predominant mood state • Problems with emotional self-regulation often resulting in aggression • Problems with attention, concentration, academic performance • “At-risk” behaviors…self- injury, substance use, suicidal threats
- 5. The impetus for a new diagnostic category “The introduction of the DMDD diagnosis was designed to address the problematic over-diagnosis of bipolar disorder and the associated rise in antipsychotic and polypharmacy use in youths.” Robert Findling, MD Findling RL et al. J Am Acad Child Adolesc Psychiatry 2021 – in press
- 6. DSM-5 Diagnostic Criteria for DMDD: • A. Characterized by severe recurrent temper outbursts manifested verbally or behaviorally in response to common stressors grossly out of proportion in proportion in intensity or duration to the situation or provocation • B. Outbursts are inconsistent with developmental level • C.Temper outbursts occur, on average, three or more times per week. • D. Mood between temper outbursts is persistently negative (irritable, angry, and/or sad) and observable by others. • A-D criteria present for at least 12 months, with no period of > 3 months in which ALL of the criteria met DSM-5, American Psychiatric Association, 2013
- 7. DSM-5 Diagnostic Criteria for DMDD (Continued): • Present in at least two of three settings (home, school, peers), severe in at least one of the three • Cannot be initially diagnosed prior to age 6 or after age 18 • Age of onset before 10 years • No period of > 1 day when symptoms of mania or hypomania present • Behavior not exclusively present during a major depressive disorder, not better explained by another mental disorder • Not attributable to the physiological effects of substances or another medical/neurologic condition. DSM-5, American Psychiatric Association, 2013
- 8. What do kids with DMDD look like? • Most have ADHD (86.3%) and ODD (84.2%) • 60% at NIMH were diagnosed in community with bipolar disorder • Elevated prevalence of lifetime anxiety disorders (58.2%), major depression (16.4%) • 7X greater risk of depression at age 18 • Chronic irritability in adolescence predicts MDD, GAD, dysthymia at age 33 Leibenluft E. Am J Psychiatry 2011; 168(2):129-42
- 9. DMDD Exclusion Criteria: DMDD CAN coexist with: • Major depression • ADHD • Anxiety disorders • PTSD • Conduct disorder • Substance use disorders DMDD CAN’T coexist with: • Bipolar disorder • Oppositional Defiant Disorder • Intermittent Explosive Disorder
- 10. Distinguishing between Bipolar Disorder and DMDD Bipolar Disorder • Episodic irritability • Distinct change from baseline mood • Mood episodes >7 days (mania) or >4 days (hypomania) • Grandiosity common DMDD: • Chronic irritability • Persistent mood state • Severe outbursts typically last minutes to hours (30 minutes to 4 hours) • Poor self image
- 11. Prevalence of Bipolar Disorder vs. DMDD Findling RL et al. J Am Acad Child Adolesc Psychiatry 2021 – in press
- 12. Distinguishing between DMDD and Oppositional Defiant Disorder (ODD): ODD • Mood symptoms rare • Doesn’t require “severe” impairment in at least one setting • 85% of kids with ODD do not meet criteria for DMDD DMDD • Persistently irritable • “Severe” impairment required in at least one setting • Most kids (84%) with DMDD meet criteria for ODD
- 13. What does the research say about treating DMDD… • NO FDA-approved treatments exist for DMDD. • One open-label study suggested stimulants improved irritability in kids with ADHD + DMDD • 71% irritability improved, 19% irritability worsened • DB/RC trial: citalopram + MPH vs. placebo + MPH • 35% response to citalopram + MPH, 6% to PBO + MPH, but no difference in functional impairment between groups • Open-label aripiprazole + MPH significantly improved irritability, externalizing symptoms, depression, anxiety, attention, social problems Winters DE et al. J Child Adolesc Psychopharmacol. 2018 Jun;28(5):298-305 Towbin K et al. J Am Acad Child Adolesc Psychiatry. 2020 Mar;59(3):350-361 Pan PY et al. J Child Adolesc Psychopharmacol. 2018 Dec;28(10):682-689
- 14. How DMDD is being treated • Greater use of ADHD meds (60.2 vs. 34.4%), antipsychotics (58.9 vs. 51.0%), antidepressants (54.3 vs. 46.0%) in DMDD vs. Bipolar Disorder • Greater use of mood stabilizers (32.6 vs. 27.3%), anxiolytics (19.3 vs. 14.8% in Bipolar Disorder vs. DMDD Findling RL et al. J Am Acad Child Adolesc Psychiatry 2021 – in press
- 15. Is DMDD really trauma under another name? “Unfortunately, the developers of this diagnostic category (severe mood dysregulation and its successor, DMDD) have largely neglected the clear association between trauma exposure and these symptom clusters. DMDD is usually treated in the same way as an errant bipolar disorder diagnosis, namely, with medications presumed to reduce mood instability and aggression. In fact, based on the work of Findling et al., the introduction of the DMDD diagnosis may have exacerbated the overuse of these medications.” Havens JF et al. J Am Acad Child Adolesc Psychiatry, 2021 Aug 4;S0890-8567(21)00485-8.
- 16. My experience in treating kids with DMDD • They have difficulty with transitions…”cognitive rigidity” • They tend to “ruminate”…indecisive, perseverate • They may experience significant improvement in school from ADHD medication, but often become more irritable, have more meltdowns at home on medication • They do better when they’re busy…inactivity increases irritability • They’re prone to behavioral activation on SSRIs that is often mistaken for mania, hypomania
- 17. How I’m treating DMDD in the presence of insufficient data… • Conservative use of ADHD medication… • Coverage limited to school day in many/most instances • Lots of CBT! • Kids need strategies to help manage perseverative thinking • Meltdowns related to perseveration on frustrations may respond to SSRIs, clomipramine • SSRI-related behavioral activation appears dose-dependent • Titrate weekly in VERY small increments • Aggressively dosing accommodations, school-based interventions • SGAs last resort for severe aggression (aripiprazole, risperidone)
- 18. Contact information • drgrcevich@fcbtf.com • sgrcevich@neomed.edu • Twitter: @drgrcevich • LinkedIn:https://www.linkedin.com/in/st ephen-grcevich-md/
Editor's Notes
- Differences between “SMD” as studied by the NIMH and DMDD in the DSM-5: SMD required recurrent temper outbursts, persistent negative mood, and the presence of at least three “hyperarousal” symptoms…pressured speech, racing thoughts/flight of ideas, intrusiveness, distractibility, insomnia, agitation. Age of onset was prior to age 12, maximum symptom-free period = 2 months
- We’re not sure what these kids have! SMD? Most have ADHD in late adolescence, depression in young adulthood
- What are differences with SMD? The name SMD would subsequently be changed to TDD and the hyperarousal criterion dropped. So what did we learn from research on SMD? We learned that children with SMD are as severely impaired as those who suffer from classical (episodic) Bipolar Disorder. But there are important differences between those who met criteria for SMD and those who met criteria for Bipolar Disorder (BD). The groups differed in their outcome, gender ratio, and possibly family history. Let me focus on just a few of the most significant findings here: Children with SMD/chronic irritability were at risk for later anxiety and unipolar depressive disorders — they did not turn out to be risk of developing BD. That finding, which was replicated by several studies, suggests that diagnosing children with non-episodic chronic irritability as having Bipolar Disorder may not only be inaccurate as opposed to premature, it may lead to offering these children ineffective or possibly harmful treatments. In children and adults with classic (episodic) BD, the gender ratio is approximately even. That means that males and females are equally likely to have the disorder. In children with SMD, however, boys outnumbered girls by a ratio of about 3:1.SMD is a serious mood disorder and is as impairing as BD in the short-term and long-term.85% of children and teens diagnosed with SMD also met diagnostic criteria for ADHD and Oppositional Defiant Disorder (ODD). That is not surprising when you think about chronically irritable children look like and how disruptive their behavior can be. But SMD is more than just ADHD+ODD, as it involves mood. Furthermore, children with severe irritability frequently meet diagnostic criteria for an anxiety disorder and have a family history of depression.
- What are differences with SMD? The name SMD would subsequently be changed to TDD and the hyperarousal criterion dropped. So what did we learn from research on SMD? We learned that children with SMD are as severely impaired as those who suffer from classical (episodic) Bipolar Disorder. But there are important differences between those who met criteria for SMD and those who met criteria for Bipolar Disorder (BD). The groups differed in their outcome, gender ratio, and possibly family history. Let me focus on just a few of the most significant findings here: Children with SMD/chronic irritability were at risk for later anxiety and unipolar depressive disorders — they did not turn out to be risk of developing BD. That finding, which was replicated by several studies, suggests that diagnosing children with non-episodic chronic irritability as having Bipolar Disorder may not only be inaccurate as opposed to premature, it may lead to offering these children ineffective or possibly harmful treatments. In children and adults with classic (episodic) BD, the gender ratio is approximately even. That means that males and females are equally likely to have the disorder. In children with SMD, however, boys outnumbered girls by a ratio of about 3:1.SMD is a serious mood disorder and is as impairing as BD in the short-term and long-term.85% of children and teens diagnosed with SMD also met diagnostic criteria for ADHD and Oppositional Defiant Disorder (ODD). That is not surprising when you think about chronically irritable children look like and how disruptive their behavior can be. But SMD is more than just ADHD+ODD, as it involves mood. Furthermore, children with severe irritability frequently meet diagnostic criteria for an anxiety disorder and have a family history of depression.
- J Child Adolesc Psychopharmacol. 2016 Mar;26(2):154-63. J Am Acad Child Adolesc Psychiatry. 2016 Mar;55(3):196-207