About Disruptive Mood Dysregulation Disorder (DMDD): Bipolar is overall controversial, especially with kids, some say the issues are dramatic, it’s definitely stigmatized, and the treatment is usually very complex. DMDD is a childhood condition of extreme irritability, anger, and frequent, intense temper outbursts. These symptoms go beyond being a “moody” child and it requires clinical and immediate attention.
What’s The Problem?
The issue with DMDD is that it’s a relatively new diagnosis, added to the DSM in 2013, and lacks FDA-approved medications. Clinicians often encounter a mix of poor behaviors, with many children diagnosed with DMDD also experiencing hallucinations, delusions, or frequent suicidal thoughts. These additional psychotic symptoms seem critical for distinguishing DMDD from conditions like ODD (Oppositional Defiant Disorder) or IED (Intermittent Explosive Disorder). DMDD cannot be diagnosed alongside bipolar disorder or ODD, as it’s seen as a childhood version of severe mood disturbances. The DSM criteria aim to clarify that DMDD is more than occasional moodiness, though the symptoms can be subjective.
DMDD symptoms typically begin before the age of 10, but the diagnosis is not given to children under 6 or adolescents over 18. A child with DMDD experiences:
- Irritable or angry mood most of the day, nearly every day
- Severe temper outbursts (verbal or behavioral) at an average of three or more times per week that are out of keeping with the situation and the child’s developmental level
- Trouble functioning due to irritability in more than one place (e.g., home, school, with peers)
To be diagnosed with DMDD, a child must have these symptoms steadily for 12 or more months.
Distinguishing DMDD from Other Diagnoses
Considerations for DMDD Treatment
I’ve seen all types of regimens for DMDD but I’ll keep it simple and put my suggestions at the bottom. The above Tables 1&2 was from MDedge and they had some great points in the article:
- Stimulants are considered 1st line: methylphenidate with a dosing recommendation range from 1 to 1.2 mg/kg/d.
- Divalproex sodium is superior to placebo in treating aggression in children and adolescents. However, lithium is the main treatment for mania in bipolar but more research is needed with kids.
- Aripiprazole and risperidone are FDA-approved for treating irritability in autism and use caution related to side-effects.
- Other medications: SSRIs and SNRIs were not found to be helpful but weren’t an outcome of the measure. Alpha-2 agonists (guanfacine, clonidine) and atomoxetine may help irritability.
DMDD from Personal Clinical Experiences:
- For Elevated BMI Children:
– Avoid lithium and divalproex due to potential weight gain.
– Try Topamax or Trileptal as mood stabilizers.
– Target ADHD with stimulants for mood regulation and potential weight loss.
– Lamotrigine should be avoided in younger children due to Stevens-Johnson Syndrome (SJS) risks and the difficulties of communicating a rash/allergic problems, but can be a good option for teens, especially those with weight concerns. - Micro-dose Antipsychotics:
– Use low doses of aripiprazole or risperidone to minimize side effects; both are FDA-approved for kids.
– Consider dosing twice daily if mood issues, impulsivities, or hallucinations persist throughout the day. - Focus on Sleep:
– Address sleep problems, which are common in moody kids. Try to avoid medications like mirtazapine, quetiapine, or olanzapine due to their weight-related side effects.
– Consider clonidine, hydroxyzine, or guanfacine for sleep aid/restlessness and nightmares.
-Promote healthy eating, physical activities, low screen time, and a consistent sleep routine to improve mood and behaviors. - Mood Management:
– Fluoxetine and sertraline are effective for females, especially if PMS is a concern.
– For males, escitalopram and sertraline are useful for anxiety, OCD, and depression.
– Avoid trazodone for its priapism risk, though it works for some children.
– Be cautious when prescribing certain medications, especially at the start of treatment. Anti-depressants e.g. have warnings for SI risks, discussed securing the home/safety plans. - Other Medications:
– Hydroxyzine is effective for anxiety but may cause drowsiness.
– Try to avoid gabapentin and other scheduled/divertible medications.
– Preference for Trileptal over carbamazepine due to better tolerance.
Other Considerations
It’s common for children with DMDD to be on multiple medications, sometimes 3 or more. Genetic testing can help reduce risks and side effects. Once the child is stable, medications can possibly be eliminated or reduce/PRN, starting with medications that have the greatest metabolic effects. Antipsychotics might be used as needed (PRN) to stabilize mood or reduce agitation, and can be decreased or discontinued when appropriate. Teens should undergo drug testing to rule out other potential causes of mood issues… The overall goal includes individualized treatment based on weight, sleep, and mood while minimizing side effects and medication and social risks.
Additional References & Resources
- DMDD information brochure for families/parents by NIMH: FYI government resources and information packets are free (aka your tax paying dollars) so they are great options to give to patients if your job/EMR doesn’t have that option.
- A list of psych diagnoses/DSM-5 criteria that mainly affects children -PMHealthNP
