About Disruptive Mood Dysregulation Disorder (DMDD): Bipolar is overall controversial, especially with kids, some say it’s overdiagnosed, 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 attention and usually multiple medications.
What’s The Problem?
DMDD is also a relatively new diagnosis (appearing in DSM in 2013) and there are no FDA-approved medications. Many times you see a concoction of various poor behaviors. Plus, most of the kids I inherit dx with DMDD have some form of hallucination or delusion, +/- frequent suicidal ideation. I almost feel like these psych symptoms need to be put in the criteria because it’s honestly how you can distinguish between ODD, IED, or other aggressive mood conditions. The graphs below are somewhat helpful.
DMDD cannot be dually diagnosed with bipolar or ODD, it’s simply the kid’s version of difficult moods (bipolar can be dx at any age). The DSM criteria is somewhat vague but it’s trying to make sure it’s more than just a bad rainy day.
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 r/t 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 Experience:
- Is The Child Big? If the child is coming to you with an elevated BMI, try to use lithium and divalproex as the last resort and trial Topamax or Trileptal as the mood stabilizer. Target ADHD since stimulants can help with weight loss and difficult moods. I avoid lamotrigine with young kids due to the SJS risks and possibly not being able to communicate if there’s a (rash) problem but it’s a great option with teens struggling with weight.
- Use Micodosing with Antipsychotics: we are trying to avoid extra side effects and aripiprazole and risperidone are the best options plus FDA approved in kids. Dose BID if the mood is bad all day or if there are hallucinations involved.
- Target Sleep: Kids who are moody usually have poor sleep and ask about nightmares… Again treatment can also be based on weight so avoid mirtazapine, quetiapine, olanzapine, and consider using clonidine, hydroxyzine, or guanfacine. This area also includes healthy eating and increase physical activities (mainly to try to tire/calm the kid down) while working on a good sleep schedule. You don’t always want the meeting to be about how the kid is always irritable and irritating.
- Keep Tackling the Mood: fluoxetine and sertraline are great for females because it also targets PMS. With guys, escitalopram and sertraline help in particular with anxiety, OCD, depression. I usually avoid trazodone because of the priapism risks but have a few kids that are doing well with it. I don’t mind continuing what was prescribed prior but I got certain medications I try to avoid especially starting off…
- Additional Medications: hydroxyzine is great for anxiety and can be frequently dosed, caution with drowsiness or trial it QHS. Some providers will use gabapentin but I try to avoid things that are scheduled or can be easily diverted. I also never used carbamazepine, Trileptal is more tolerated.
Other Considerations
So it’s easy to see how a kid with DMDD can easily be on 4-5+ medications. Use genetic testing to avoid more risks and side effects. Once the child is stable, try to take something away (usually an extra dose or med). Sometimes I’ll tell the parents to use the antipsychotics like a PRN until the mood is stable or to decrease agitation, then we can take it down or away if needed. All kids need to be Rx tested and r/o other reasons for difficult mood behaviors. Younger kids are using cocaine more, parents are selling or taking the meds, or taking stuff that’s not prescribed so yup keep protecting your license!
Additional Information
- 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
