Examining the Proposed Disruptive Mood Dysregulation Disorder Diagnosis in Children in the Longitudinal Assessment of Manic Symptoms Study

ArticleinThe Journal of Clinical Psychiatry 73(10):1342-50 · October 2012with50 Reads
DOI: 10.4088/JCP.12m07674 · Source: PubMed
Abstract
To examine the proposed disruptive mood dysregulation disorder (DMDD) diagnosis in a child psychiatric outpatient population. Evaluation of DMDD included 4 domains: clinical phenomenology, delimitation from other diagnoses, longitudinal stability, and association with parental psychiatric disorders. Data were obtained from 706 children aged 6-12 years who participated in the Longitudinal Assessment of Manic Symptoms (LAMS) study (sample was accrued from November 2005 to November 2008). DSM-IV criteria were used, and assessments, which included diagnostic, symptomatic, and functional measures, were performed at intake and at 12 and 24 months of follow-up. For the current post hoc analyses, a retrospective diagnosis of DMDD was constructed using items from the K-SADS-PL-W, a version of the Schedule for Affective Disorders and Schizophrenia for School-Age Children, which resulted in criteria closely matching the proposed DSM-5 criteria for DMDD. At intake, 26% of participants met the operational DMDD criteria. DMDD+ vs DMDD- participants had higher rates of oppositional defiant disorder (relative risk [RR] = 3.9, P < .0001) and conduct disorder (RR = 4.5, P < .0001). On multivariate analysis, DMDD+ participants had higher rates of and more severe symptoms of oppositional defiant disorder (rate and symptom severity P values < .0001) and conduct disorder (rate, P < .0001; symptom severity, P = .01), but did not differ in the rates of mood, anxiety, or attention-deficit/hyperactivity disorders or in severity of inattentive, hyperactive, manic, depressive, or anxiety symptoms. Most of the participants with oppositional defiant disorder (58%) or conduct disorder (61%) met DMDD criteria, but those who were DMDD+ vs DMDD- did not differ in diagnostic comorbidity, symptom severity, or functional impairment. Over 2-year follow-up, 40% of the LAMS sample met DMDD criteria at least once, but 52% of these participants met criteria at only 1 assessment. DMDD was not associated with new onset of mood or anxiety disorders or with parental psychiatric history. In this clinical sample, DMDD could not be delimited from oppositional defiant disorder and conduct disorder, had limited diagnostic stability, and was not associated with current, future-onset, or parental history of mood or anxiety disorders. These findings raise concerns about the diagnostic utility of DMDD in clinical populations.
    • "The search and review of studies resulted in 12 studies appropriate for inclusion in the meta-analysis for the prediction of psychiatric disorders, 19,30,31,35,43,44,49,57,63-66 and 12 studies predicting continuous outcomes 37,40,42,46,52,53,67-70 or appropriate for descriptive analysis 58,71 (see Figure S1 , available online). In addition, 5 studies among those included in the meta-analysis provided information about future functional outcomes, 19,30,35,49,63 including suicidal behaviors. "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: Research and clinical interest in irritability have been on the rise in recent years. Yet several questions remain about the status of irritability in psychiatry, including whether irritability can be differentiated from other symptoms, whether it forms a distinct disorder, and whether it is a meaningful predictor of clinical outcomes. In this paper we try to answer these questions by reviewing the evidence on how reliably irritability can be measured and its validity. Method: We combine a narrative and systematic review and meta-analysis of studies. For the systematic review and meta-analysis, we searched studies in Pubmed and Web of Science based on preselected criteria (i.e., irritability as a predictor of future psychiatric outcomes). One hundred sixty-three papers were reviewed, and 24 were included. Results: We find that irritability forms a distinct dimension with substantial stability across time and that it is specifically associated with depression and anxiety in longitudinal studies. Evidence from genetic studies reveals that irritability is moderately heritable, and its overlap with depression is explained mainly by genetic factors. Behavioral and neuroimaging studies find that youth with persistent irritability show altered activations in amygdala, striatum, and frontal regions compared with age-matched healthy volunteers. Most knowledge about the treatment of irritability is based on effects of treatment on related conditions or through post hoc analyses of trial data. Conclusion: We identify a number of research priorities including innovative experimental designs and priorities for treatment studies and conclude with recommendations for the assessment of irritability for researchers and clinicians.
    Full-text · Article · May 2016 · Journal of child and adolescent psychopharmacology
    • "Across three large samples, the odds ratio for ODD has ranged from 52 to 103-fold for those with DMDD, with 70% of the children diagnosed with DMDD meeting criteria for oppositional defiant disorder (Copeland et al., 2013). In another large outpatient sample, nearly all (96%) of youth diagnosed with DMDD met criteria for oppositional defiant disorder or conduct disorder (Axelson et al., 2012). One study found that less than half of children persisted with DMDD symptoms at one-year follow-up (Brotman et al., 2006). "
    [Show abstract] [Hide abstract] ABSTRACT: Anger is present as a key criterion in five diagnoses within DSM-5: Intermittent Explosive Disorder, Oppositional Defiant Disorder, Disruptive Mood Dysregulation Disorder, Borderline Personality Disorder and Bipolar Disorder. This review amasses scientific literature demonstrating that within each of these disorders, anger is a central clinical feature that is highly prevalent and predictive of important outcomes. For each disorder, we also discuss the phenomenology and etiology of anger. Although models of anger have been quite distinct across these disorders, few empirical studies have truly tested whether anger stems from different etiological factors across these different conditions. We end with a discussion of transdiagnostic research that draws from cognitive psychology, affective science, and the neuroscience of anger, and that also fits with integrative approaches to treatment.
    Full-text · Article · Apr 2016
    • "As mentioned, youth with SMD have lower rates of parental BD than do youth with BD (Brotman et al. 2007; Leibenluft 2011). In the LAMS study, family history of BD was not associated with DMDD at baseline (Axelson et al. 2012). Contrasting our findings, the Pittsburgh Bipolar Offspring Study (BIOS) found that offspring of parents with BD were significantly more likely to have DMDD than offspring of community controls (Sparks et al. 2014 ). "
    [Show abstract] [Hide abstract] ABSTRACT: Objective: The purpose of this study was to examine the prevalence and correlates of disruptive mood dysregulation disorder phenotype (DMDDP) in a clinical population of adolescents with bipolar disorder (BD). Methods: DMDD criteria were modified and applied to a sample of 116 adolescents with BD-I (n = 30), BD-II (n = 46) or BD-not otherwise specified (NOS) (n = 40) from a tertiary teaching hospital. Diagnoses were determined via the Kiddie Schedule for Affective Disorders and Schizophrenia for School-Aged Children, Present and Lifetime version (KSADS-PL). Diagnostic and Statistical Manual of Mental Disorders (DSM-5) DMDD Criteria A-G were derived from the KSADS oppositional defiant disorder (ODD) screening interview and supplement, as well as narrative summaries. Chi-square analyses or t tests (p < 0.05) were conducted as appropriate, followed by logistic regression. P values were adjusted using the false discovery rate (FDR) approach. Results: DMDDP criteria could not be determined for 8 adolescents because of missing data from the ODD supplement. Twenty-five percent of the remainder (27/108) met criteria for DMDDP. DMDDP was not associated with BD subtype or with family history of BD. In univariate analyses, after controlling for age, sex, and race, DMDDP was associated with lower functioning, increased family conflict, assault history, and attention deficit and/or hyperactivity disorder (ADHD) (FDR adjusted p values: <0.0001, < 0.0001, 0.007, and 0.007, respectively). Lifetime substance use disorder and medication use approached significance (adjusted p = 0.05). In logistic regression, DMDDP was independently associated with greater parent-reported family conflict (odds ratio [OR] 1.17; confidence interval [CI- 1.06-1.30; p = 0.001) and greater functional impairment (OR 0.89; CI 0.82-0.97; p = 0.006). DMDDP was also associated with a threefold increase in ADHD, although ADHD was only marginally significant (OR 3.3; CI 0.98-10.94; p = 0.05). Conclusions: Despite the positioning of DMDD as phenotypically and biologically distinct from BD, these phenotypes commonly overlap in clinical settings. This overlap is not explained by BD-NOS or by nonfamilial BD. The association of ADHD with DMDDP in this sample draws into question whether arousal symptoms should have been retained as originally elaborated in the severe mood dysregulation phenotype. Strategies to mitigate the excessive functional impairment of this comorbidity are warranted.
    Article · Feb 2016
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