Consistent with a biopsychosocial model of illness, individuals with chronic pain often report that the pain interferes with their ability to engage in occupational and recreational activities. Their inability to engage in these activities can contribute to increased isolation, feelings of worthlessness and hopelessness, sleep disturbance, and depressed mood. It is estimated that ¼ of patients with chronic pain meet criteria for major depression. In addition, conditions such as anxiety, substance abuse and personality disorders occur at a greater rate in individuals who have a chronic pain condition than individuals who do not.

Depression and pain strongly reinforce each other. Therefore it is important to treat both concurrently in order to have the greatest chance for success.  Both antidepressants and anticonvulsants can be used for treating chronic pain. The types of pain that are most responsive to these medications are neuropathic syndromes, such as diabetic neuropathy, trigeminal neuropathy, and post-herpetic neuralgia.  Chronic headaches, migraines, fibromyalgia, arthritis pain, and chronic low back pain may also be treated successfully with these medications.  Combined use may be appropriate for some patients.

In terms of antidepressant medications, tricyclic antidepressants and serotonin norepinephrine reuptake inhibitors (SNRIs) have been found to be particularly helpful. The SSRIs have not been found to be particularly helpful on their own for pain specifically but definitely are helpful for the co-morbid depression frequently seen in patients with chronic pain. Alternatively, a combination of SSRI and low dose tricyclic medication can be helpful more specifically for the pain symptoms of a chronic pain syndrome which include sleep disturbance as a significant symptom.

In terms of anticonvulsant medications, carbamazepine, depakote, lamotrigine and gabapentin have the most evidence for being helpful for chronic pain syndromes. Lamotrigine and gabapentin have fewer drug interactions and don’t require blood monitoring, making them easier to use in general.

One of the most effective psychological approaches for pain management is based on a cognitive-behavioral therapy (CBT) approach. Its aim is to change maladaptive thoughts and behaviors that serve to maintain and exacerbate the experience of pain, to introduce relaxation training, and to promote increased activity and functioning. Alternative pain treatments like physical therapy and acupuncture/acupressure can also be considered.

In summary, when treating a patient with chronic pain, it is important to assess how the pain is affecting their quality of life and try to concurrently treat their chronic pain, their emotional discomfort and their overall functional capacity whenever possible.

ADHD is a neurodevelopmental disorder characterized by impairing hyperactivity, impulsivity and inattention, and persistent irritability and out of proportion temper outbursts are not typically seen with ADHD alone. Children with DMDD can have some challenges with hyperactivity and impulsivity but with the underlying irritability and angry mood present as well. A child can present with both diagnoses concurrently.

Children with ODD exhibit a pattern of anger-guided 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 organic process. While some of the symptoms of ODD may overlap with the criteria for DMDD, the symptom threshold for DMDD is higher since it is considered to be a more severe condition. Most children with DMDD also meet criteria for ODD and about 15% of children with ODD also meet criteria for DMDD. Therefore it is recommended that children who meet the criteria for both ODD and DMDD should only be diagnosed with DMDD.

Children with 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 episodic, which is not the case in DMDD. If the irritability is episodic and there are also distinct periods of depression, a child is more likely to have bipolar disorder. A diagnosis of pediatric bipolar disorder would rule out DMDD. It has been shown that children who present with chronic, rather than episodic, irritability, who may have 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. This was additional information to support the idea that a different diagnosis was needed to describe children with clinically impairing chronic irritability.

Because DMDD is such a new diagnosis, research is being conducted to determine the is being conducted to determine the best treatment. Medication, including SSRIs and stimulants, psychotherapy and a combination of the two are being used. The differential diagnosis includes: ADHD, ODD, bipolar disorder, major depression, substance abuse and ASD. It is important to assess for co-morbid symptoms, underlying factors and antecedents/triggers to help make an accurate diagnosis.