Prior to the inclusion of DMDD in the DSM, the default diagnosis often used was that of Bipolar Disorder– this given the broad range of symptoms that may present in that disorder, but the general consensus is that that practice was inappropriate as many of these children did not comfortably fit within the bipolar spectrum.   Although many were at risk for ongoing psychopathology, few would progress to have adult presentations of Bipolar Disorder with manic, hypomanic and depressive episodes.   Additionally, it was felt that many youth exposed to chronic childhood trauma, disruptive upbringings and experiencing underlying learning and/or subtle neurological impairments and delays would be better served by a diagnosis that more accurately described their symptom profiles.

Children with DMDD typically exhibit severe, recurrent temper outbursts that are grossly out of proportion in intensity or duration to the situation occurring several times per week. The temper outbursts have to be disproportionate and out of sync with the child’s developmental age and can include both verbal and physical aggression. Between these temper outbursts, children with DMDD typically also display a tendency toward having an irritable or angry mood and present with challenges in developing and maintaining healthy relationships with adults including their parents (or foster parents), peers, teachers and others involved in their care.   A DMDD diagnosis does require that symptoms be present most of the day, on most days occurring in multiple environments and with persistence of this profile over the course of many months to years.  Brief periods of irritable or disruptive behavioral symptomatology limited to one or only a limited number of interpersonal situational or relationships would typically not be viewed as meeting criteria.   The persistence of negative reactivity and easily aroused irritability in multiple settings with multiple others is the hallmark of this disorder.  Co-occurring attentional difficulties, impulse control problems and depressive and angry mood states are common in the disorder and co-morbidity with various disorders needs to be considered both in diagnostic efforts and these issues clearly need to be adequately addressed in treatment planning.

DSM criteria note that the onset of symptoms must be before age 10 but not younger than 6. It is thought that DMDD is more likely to occur in boys than girls. The prevalence is not yet known, but is expected to be in the 2-5% range.

Some comparisons of the symptom profiles in other childhood disorders are of note:

ADHD is a neurodevelopmental disorder characterized by impairing hyperactivity, impulsivity and inattention, but persistent irritability and out-of-proportion temper outbursts are not typically seen with uncomplicated ADHD. Children with DMDD can have some challenges with hyperactivity and impulsivity but the underlying irritability and angry mood symptoms are distinguishing features.

Children with ODD exhibit a pattern of anger-driven disobedience and defiant behavior toward authority figures. Clinically it is observed that ODD stems from learned behavior and/or parenting challenges, whereas DMDD seems to have a more complex process associated quite often with more substantial life and developmental disruptions consequent to exposure to toxic stress conditions. While some of the symptoms of ODD may overlap with the criteria for DMDD, the symptom severity threshold for a DMDD diagnosis is higher and it is typically seen as a more severe condition. Most children with DMDD also meet criteria for ODD but only about 15% of children with ODD might be considered to also meet criteria for DMDD.   In this context, it is recommended that children who meet the criteria for both ODD and DMDD should only be diagnosed with DMDD.

Children with full syndrome presentations of bipolar disorder can have symptoms that are similar to those with DMDD. The primary difference is that the mood symptoms seen in bipolar disorder are typically episodic and recurrent, which is not the case in DMDD where the symptoms are more persistent.  Overtly manic episodes with grandiosity and inflated moods that can occur in bipolar conditions are not typically seen in children with DMDD.  Additionally, children with bipolar disorder would most typically have distinct periods of severe depression interspersed with periods of more normative and euthymic mood states, whereas the DMDD affected child is more likely to have chronic dysthymia and irritable reactivity that persists over time.  A diagnosis of pediatric bipolar disorder should be substantiated by overt mood cycling and would often be supported by positive family history.

As noted earlier, it has been shown that children who present with chronic, rather than episodic, irritability, who may have previously been given a diagnosis of bipolar disorder for lack of a better fit, are at greater risk of developing depression and generalized anxiety rather than life-long bipolar disorder.

Treatment of youth presenting with DMDD profiles will typically require multimodal interventions to address the behavioral, emotional, interpersonal and environmental challenges associated with the disorder and not infrequently this will entail referral to higher levels of care and more intensive coordination of services.   Medications, including SSRIs, stimulants, alpha adrenergic agonists and, at times, the antipsychotic medications may be appropriate to help modulate and regulate mood, impulsivity, attention and aggressive symptomatology.  Trauma focused and supportive psychotherapies and organized behavioral modification regimens are often required.   As noted above, it is important to assess for co-morbid disorders, underlying factors and antecedents/triggers to help make an accurate diagnosis and develop an optimal treatment plan.

Reference:  Diagnostic and Statistical Manual of Mental Disorders, 5th Edition; 2013: American Psychiatric Association

Depression is highly co-morbid with other psychiatric disorders, like anxiety disorders, substance abuse disorders and disruptive behavior disorders. If an adolescent is presenting with depressive symptoms, it is important to take a careful history of bipolar symptoms, including current and past manic, hypomanic or psychotic symptoms, family history of bipolar disorders, and history of medication-induced manic or hypomanic symptoms. Twenty percent of young patients with depression go on to develop bipolar disorder as adults. The typical timeline is that adults with bipolar disorder will report they first experienced depressive symptoms starting in childhood or adolescence.

Adolescents will sometimes turn to drugs, like alcohol and marijuana, to self-medicate. If they are using on a regular basis, the use can be contributing to their depressive symptoms, and psychoeducation about that interaction will be important. Ongoing regular drug use can also limit the efficacy of a medication treatment for depression, if that is being considered, and it is important to talk with teens about limiting their drug use if they are interested in a medication intervention.

In terms of general treatment guidelines, consider therapy alone for mild-moderate symptoms and consider combination therapy and medication treatment for moderate-severe symptoms, particularly if there is a significant impairment from their symptoms. Fluoxetine is the medication that has been studied the most for MDD in children and adolescents but the other SSRIs, like citalopram, escitalopram and sertraline, can also be utilized. Other options to consider are bupropion and mirtazapine. The antidepressants to consider avoiding include: paroxetine and venlafaxine (because of their short half-lives, there is a higher risk of side effects and discontinuation symptoms with inconsistent use), and duloxetine (because of limited data in children and adolescents). It is important to consider a slower titration, starting with ½ the usual starting dose, to minimize the risk of side effects including akathisia (internal restlessness), behavioral activation and increased anxiety. So for example if considering fluoxetine, a starting dose of 10mg qday would be appropriate with a plan to increase to 20mg after 1-2 weeks if tolerated and needed. It is important to discuss the length of time it can take for a patient to see a full positive result, so that the teen and family is realistic with their expectations. It is also important to carefully discuss with the teen and family the FDA black box warning about the increase in risk of spontaneous reporting of suicidal thinking and have close monitoring (follow-up in 1-2 weeks either in person or by phone), particularly when medication is started or when the dose is being increased.  With open disclosure and judicious monitoring this relatively infrequent side effect can comfortably managed, typically without having to terminate the medication trial.

It is our hope that this e-Weekly is helpful for primary care providers to develop comfort with assessing and treating adolescents with depression, as it is a fairly common presenting concern in the primary care office.