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Evidence-based treatments for youths with severely
dysregulated mood: a qualitative systematic review of
trials for SMD and DMDD
Xavier Benarous, Angèle Consoli, Jean-Marc Guilé, Sébastien Garny de La
Rivière, David Cohen, Bertrand Olliac
To cite this version:
Xavier Benarous, Angèle Consoli, Jean-Marc Guilé, Sébastien Garny de La Rivière, David Cohen, et
al.. Evidence-based treatments for youths with severely dysregulated mood: a qualitative systematic
review of trials for SMD and DMDD. European Child and Adolescent Psychiatry, Springer Verlag
(Germany), 2016, pp.1-19. �10.1007/s00787-016-0907-5�. �hal-01379080�
1
Evidence-based treatments for youths with severely dysregulated
mood: a qualitative systematic review of trials for SMD and DMDD
Xavier Benarous
1
xavierbenarous@gmail.com, Angèle Consoli
1,2
angele.consoli@psl.aphp.fr, Jean-Marc Guilé
1,3,4
guile.jean-marc@chu-amiens.fr, Sébastien Garny de La Rivière
3
garnydelariviere.sebastien@chu-amiens.fr,
David Cohen
1,5
david.cohen@psl.aphp.fr, Bertrand Olliac
1,6
bertrand.olliac@gmail.com
1
Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière Hospital, 47-83 boulevard de l’Hôpital, 75013
Paris, France
2
INSERM U-669, PSIGIAM, Paris, France
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Groupe de Recherches sur l'Analyse Multimodale de la Fonction Cérébrale, INSERM U1105, CHU, Université
Picardie Jules Verne, Amiens, France
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Department of Psychiatry, McGill University, Montreal, Canada
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CNRS UMR 7222, Institute for Intelligent Systems and Robotics-ISIR, Paris, France
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Pôle Hospitalo-Universitaire de psychiatrie de l'enfant et de l'adolescent, Centre Hospitalier Esquirol, Limoges,
France
Address of correspondence: Xavier Benarous, Department of Child And Adolescent Psychiatry, Pitié-Salpêtrière
Hospital, 47-83 boulevard de l’Hôpital, 75013 Paris, France
Email: xavierbenarous@gmail.com
Phone: +33(0)603260193
Fax: +33(0)142162331
Category: Review article
Abbreviated title: Treatments for youths with SMD and DMDD
Conflict of interest: On behalf of all authors, the corresponding author states that there is no conflict of interest.
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ABSTRACT
The aim of this literature review was to examine the evidence for psychotherapeutic and
pharmacological treatments in subjects with severely dysregulated mood and to identify
potential areas for improvements in research designs. A literature search was conducted using
several databases for published (PubMed, PsycINFO) and ongoing (clinical trial registries)
studies conducted in youths who met NIMH’s criteria for Severe Mood Dysregulation (SMD)
or the DSM-5 diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). Eight
completed studies were identified: three randomized trials, four open pilot studies and one
case report. Seven ongoing studies were found in trial registries. The available evidence
suggests potential efficacy of psychotherapies which have previously been developed for
internalizing and externalizing disorders. The two main pharmacological strategies tested are,
first, a monotherapy of psychostimulant or atypical antipsychotic such as risperidone, already
used in the treatment of severe irritability in youths with developmental disorders; and
second, the use of a serotonergic antidepressant as an add-on therapy in youths treated with
psychostimulant. Ongoing studies will further clarify the effectiveness of psychotherapeutic
interventions for DMDD individuals and whether they should be given alone or in
conjunction with other treatments. The short duration of the trials for a chronic disorder, the
low number of studies, the lack of placebo or active comparator arm, and restrictive inclusion
criteria in most of the controlled trials dramatically limit the interpretation of the results.
Finally, future research should be conducted across multiple sites, with standardized
procedures to measure DMDD symptoms reduction, and include a run-in period to limit
placebo effect.
KEYWORDS: disruptive mood dysregulation disorder; severe mood dysregulation;
psychotherapy; pharmacotherapy; therapeutics; irritability
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1. INTRODUCTION
1.1.General background
Children with severely dysregulated mood have become diagnostic and therapeutic
challenges over the last two decades within the context of pediatric bipolar controversy [1-4].
In view of facilitating research programs researchers at the U.S. National Institute of Mental
Health (NIMH) operationalized the criteria of “Severe Mood Dysregulation” (SMD), a
syndrome characterized by chronic abnormal levels of anger or sadness, hyperarousal and
heightened verbal or physical reactivity [5]. On the grounds of studies conducted in youths with
SMD and in view of improving mental health care of youths with chronic irritability, the
Disruptive Mood Dysregulation Disorder (DMDD) was introduced as a new diagnosis in the
Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) within the
Depressive Disorders section [6]. Youths with DMDD present chronic irritability combined
with severe and recurrent episodes of temper outburst inconsistent with their developmental
level at least three times per week and occurring in different settings (e.g., in family, school).
These symptoms should persist more than twelve months with no symptom-free period longer
than three months and with an initial onset prior to the age of 10. Prevalence of DMDD is
reported to be around 8.2% in general population [7-9] and around 26-31% in clinical settings
[10,11]. There is much evidence supporting that DMDD symptoms severely affect a youth’s
level of social functioning [7,8] and that such negative effects could persist into adulthood [9].
Copeland et al. showed that as adults youths with DMDD present a much higher level of
functional impairments (i.e., adverse health outcomes, financial problems, police contact, and
low educational attainment) than those with any other psychiatric disorders (e.g., depressive
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disorders, anxiety disorders, attention deficit hyperactivity disorder ADHD, disruptive disorder,
or substance disorders) [9].
1.2.Phenomenology of youths with severely dysregulated mood
Mood dysregulation (i.e., severe irritability and high level of anger) is seen as a
transdiagnostic symptom, with a dimensional continuum from its typical expression in normal
development of children and adolescences to severely impairing forms in psychiatric disorders
[12]. In this vein, the development of studies based on specific cognitive and emotional domains
rather than DSM-5 categories of disorders has been encouraged, in particular research aligned
with the framework of the Research Domain Criteria articulated by the NIMH. This strategy
has led to significant improvements in our knowledge of the mechanisms underlying varying
aspects of mood dysregulation in youths. Such progress may ultimately lead to discovering new
markers of the disorder and targets for specific interventions. The study published by Stoddard
et al. [13] provides a good example of how these different levels of analysis can be integrated
in research based on a dimensional view of psychopathology; with the articulation between
impaired neural substrates (i.e., orbitofrontal cortex and amygdala activation), a clinical or
psychological marker (i.e., the result at a face-emotion labelling task), and a therapeutic (i.e.,
computer-based) intervention targeting interpretation bias.
A different approach has been used in the present review as we specifically focused on
studies where the clinical categories of SMD or DMDD were applied to define the population
of interest. The SMD (i.e., the research syndrome) and then DMDD (i.e., the DMS-5 diagnosis)
criteria were originally developed in view of facilitating the identification of youths with severe,
persistent and functionally impairing forms of irritability, who were likely to fulfil criteria for
different disorders at different times (“diagnostically homeless”) [14]. The development of a
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