DMDD: The Wrong Diagnosis in the Wrong Place

The second section of DSM-5 is the heart of the system; it contains 23 categories of psychiatric illness and their diagnostic criteria. For example, these categories include Depressive Disorders, Bipolar and Related Disorders, and Neurodevelopmental Disorders. Within each category of psychiatric illness, specific diagnoses and their diagnostic criteria are described. The category under which an illness is listed creates an expectation that the illness is related to the category. For example, in DSM-IV, obsessive-compulsive disorder was grouped under the Anxiety Disorders category, which reflected the understanding of the time that obsessive-compulsive disorder was an anxiety disorder. In DSM-5 it is not listed under the category of Anxiety Disorders but is instead now in its own category. It is no longer considered an anxiety disorder.

The category in which an illness is placed can have great influence on clinicians’ efforts to understand and treat a disorder. The warranted assumption is that the listed illness has some possible relationship to the category that it is in as well as to other illnesses listed in the same category. There are at least some shared symptoms between disorders in the same category and the etiology and the treatment of the disorders might be similar.

DMDD should not be listed as a depressive disorder

Examining the DSM-5 category of Depressive Disorders, the first illness discussed is Disruptive Mood Dysregulation Disorder (DMDD) (1). As will be demonstrated, DMDD is not a depressive disorder, and listing it as one is a consequential mistake.

Although there are many hedges and exceptions to making the diagnosis of DMDD in DSM-5, the essential criteria are three temper tantrums per week at a minimum and a persistent irritable mood between tantrums. The tantrums and irritable mood must have lasted for at least one year, and the diagnosis must be apparent by age 10 years. The diagnosis can’t be made before age six years and after age 18 years. The diagnosis can’t be made in children with bipolar disorder.

According to the text in DSM-5, the DMDD diagnosis was created to prevent the erroneous diagnosis of bipolar disorder in children with chronic irritability but no symptoms of mania. In children with both DMDD and oppositional defiant disorder (ODD), the DMDD diagnosis is to be given, but ODD is not. In DMDD, irritability between tantrums is present and is more severe than in ODD. Patients with ADHD and patients with depression can be given a diagnosis of DMDD. According to DSM-5, patients whose irritability is only present when the patients are depressed should be given a diagnosis of depression rather than DMDD.

Irritability is not a symptom of depression in adults. Although in children and adolescents it is a permitted depression symptom, it is non-specific and found in most psychiatric disorders. The DSM-5 text explains classifying DMDD as a depressive disorder because of the irritable state between temper tantrums and because irritable children have been reported to grow into depressed adults. Irritability between temper tantrums does not lend any weight to a diagnosis of depression, and irritability in adults is not a permitted depression symptom. Irritability between temper tantrums seems to be a measure of the severity of the patient’s oppositionality rather than a symptom of a new depressive disorder.

This point is underscored in the DSM-5 text in a separate discussion of the diagnosis of major depression in which it is noted that irritability in patients with ADHD should not be counted toward the depression diagnosis unless the irritability only occurs at those times when the child exhibits the usual symptoms of depression (2).

Diagnosing a disorder solely on the basis of speculation about its longitudinal outcome is unprecedented in DSM. Rather, diagnoses in DSM are based on the presence of current, observable, well-defined symptoms.

There are unwelcome clinical consequences of erroneously classifying DMDD as a depressive disorder. First, the diagnosis may lead the clinician to treat the disorder as if it were major depression, with SSRI medications. There is no evidence that these medications are effective for DMDD. Second, the diagnosis may move the focus of treatment away from the patient’s symptoms: irritability and temper tantrums. Based on my clinical experience and having treated many hundreds of children who would meet DMDD criteria, what these children really have is oppositional defiant disorder and, almost always, ADHD. Oppositional defiant disorder and ADHD respond well and safely to behavior modification and stimulant medication.

Placing DMDD in the Depressive Disorders rather than in a Disruptive Behavior category is a disservice to these children and the field.

Copyright Stuart L. Kaplan, MD, 2013