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The DSM is the classification of mental disorders
in the United States. Clinicians, insurers, legislatures, the FDA and
educators use it. The fifth edition is due to be released next spring,
and it has many ramifications for our children with mood disorders.
One of the most significant proposals for Balanced Mind
families is the proposed inclusion of a new diagnosis for children
called Disruptive Mood Dysregulation Disorder (DMDD). I attended a full
day symposium at the annual meeting of the American Academy of Child
& Adolescent Psychiatry (AACAP) in late October in order to address
our parent’s strong interest in this matter. Many of the members of the
Child Work Group of the DSM-V were on the panel.
Disruptive Mood Dysregulation Disorder (DMDD) is characterized as follows:
A. Severe recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation.
B. The temper outbursts are manifest in the form of verbal
rages or physical aggression towards people or property.
C. The temper outbursts are inconsistent with developmental level.
D. The temper outbursts occur, on average, three or more times per week.
E. Nearly every day, most of the day, the mood between temper outbursts is persistently irritable or angry.
F. The irritable or angry mood is observable by others (e.g., parents, teachers, peers).
G. The diagnosis should not be made for the first time before age 6 or after age 18.
H. The onset of these symptoms is before age 10 years.
I. There has never been a distinct period lasting more than
one day during which abnormally elevated or expansive mood was present
most of the day, and the abnormally elevated or expansive mood was
accompanied by the onset or worsening, of three of the criteria of mania
(such as grandiosity or inflated self-esteem, decreased need for sleep,
pressured speech, flight of idea, distractibility, increase in goal
directed activity, or excessive involvement in activities with a high
potential for painful consequences).
J. The behaviors do not occur exclusively during an episode
of Major Depressive Disorder and are not better accounted for by
another mental disorder. The symptoms are not due to the effects of a
drug or to a general medical or neurological condition.
In summary, DMDD is severe, chronic irritability, lasting
most of the day, every day, for at least a year. It can be contrasted to
bipolar disorder, which is characterized by distinct episodes of mania
and depression.
The field trials for DMDD, where the proposed diagnoses are
tested for reliability and validity, resulted in a rating of “good*.”
Why the asterisk? While two of the smaller study sites produced
“unacceptable” results, those sites had a high proportion of outpatient
children. The larger site where there was a high percentage of children
who were inpatients resulted in a “very good” rating. Since this illness
is characterized by its severity, it was theorized that a population of
inpatient children, whose illnesses are more severe, would yield more
diagnoses for DMDD.
The APA is now in the final stages of deciding whether to
include DMDD in the main section of DSM-5, as opposed to Section III,
which contains “provisional” diagnoses. Stay tuned…we hope to share that
with you by the end of this year.
While speaking with many of the researchers and child
psychiatrists at AACAP, I learned that their opinions are almost as
varied as our parents. Many clinicians think that that DMDD will finally
give many of their young patients a “diagnostic home.” They are
referring to children who are severely ill, but do not meet criteria for
bipolar disorder. Conversely, some researchers worry that the
underlying research for DMDD only took place at one site, and should be
replicated at several sites before it’s included in the DSM-V. While
that research was done at the world-renowned NIMH, and is very highly
regarded, the research was done on a slightly different syndrome called Severe Mood Dysregulation.
I know this can be frustrating for parents. If the experts can’t agree, what does that mean for my child? Remember
that researchers constantly refine and improve our understanding of
these illnesses. That means they will often disagree with one another,
challenge each other’s theories, and try to prove or disprove their own,
or other’s hypotheses. In other words, it’s their job to debate one
another, instead of resting on their laurels. Do not be discouraged!
Look where that debate has taken us since the founding of
The Balanced Mind Foundation in 1999 when only a handful of studies
existed , and a scarce few children received treatment for their severe
mood disorders. We now have hundreds of studies on children and a
proposal to further refine and categorize a large group of children in
two in order to better define their symptom clusters and better inform
treatment. We know a lot more about the safety of treatments for
children, several treatments have received a FDA indication for use in
children, and we have a treatment protocol for children with bipolar disorder.
Is the DSM-V perfect? No, but its an improvement. Science
is by nature evolutionary, and we still have much to learn about the
nature and treatment of our children’s mood disorders. As Helena Chmura
Kraemer, Ph.D., Professor of Psychiatry at University of Pittsburgh and
who heavily influenced the field trial design of the DSM-V stated,
“How does one distinguish between a disorder and a diagnosis? A
disorder is the disruption of normal physical or mental functions; a
disease or abnormal condition. A diagnosis is an opinion that a disorder
exists.”
And so it goes with psychiatric illnesses. Until we have a
biomarker, diagnosis is an opinion based on observation of a cluster of
symptoms. This is one reason why psychiatric illnesses are so highly
controversial; until we have a biomarker, like a blood test or a brain
scan, doctors are making informed opinions based on observations.
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