Prevalence, Comorbidity and Correlates of DSM-5 Proposed Disruptive Mood Dysregulation Disorder
01 Feb 2013-American Journal of Psychiatry (American Psychiatric AssociationArlington, VA)-Vol. 170, Iss: 2, pp 173-179
TL;DR: Disruptive mood dysregulation disorder is relatively uncommon after early childhood, frequently co-occurs with other psychiatric disorders, and meets common standards for psychiatric "caseness."
Abstract: The low prevalence rates in three large community samples of children (0.8% to 3.3%) for the new proposed diagnosis of disruptive mood dysregulation disorder suggest that the diagnosis will not be extensively applied to children with normal behavior. Although the core symptoms are common, the criteria regarding frequency, duration, and context exclude most children. The diagnosis is associated with high levels of social impairment, school suspension, service use, and poverty. It frequently co-occurs with other psychiatric conditions, especially oppositional defiant disorder and depressive disorders, but overlapped only partially with severe mood dysregulation, the research diagnosis on which it was based.
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TL;DR: It is found that irritability forms a distinct dimension with substantial stability across time, and that it is specifically associated with depression and anxiety in longitudinal studies.
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 article, 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. A total of 163 articles were reviewed, and 24 were included. Results We found 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 show that youth with persistent irritability exhibit altered activations in the 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 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.
291 citations
Cites background from "Prevalence, Comorbidity and Correla..."
...However, these rates decreased to 1% in 2 samples of older youth.(32)...
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...3%) in a sample of preschool children.(32) However, these rates decreased to 1% in 2 samples of older youth....
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TL;DR: Sleep problems both predict and are predicted by a diagnostic cluster that includes ODD, GAD, and depression which could offer promising opportunities for reducing the burden of mental illness during the early life course.
Abstract: Objective We tested whether sleep problems co-occur with, precede, and/or follow common psychiatric disorders during childhood and adolescence We also clarified the role of comorbidity and tested for specificity of associations among sleep problems and psychiatric disorders Method Data came from the Great Smoky Mountains Study, a representative population sample of 1,420 children, assessed 4 to 7 times per person between ages 9 and 16 years for major Diagnostic and Statistical Manual-Fourth Edition ( DSM-IV ) disorders and sleep problems Sleep-related symptoms were removed from diagnostic criteria when applicable Results Sleep problems during childhood and adolescence were common, with restless sleep and difficulty falling asleep being the most common symptoms Cross-sectional analyses showed that sleep problems co-occurred with many psychiatric disorders Longitudinal analyses revealed that sleep problems predicted increases in the prevalence of later generalized anxiety disorder (GAD) and high GAD/depression symptoms, and oppositional defiant disorder (ODD) In turn, GAD and/or depression and ODD predicted increases in sleep problems over time Conclusions Sleep problems both predict and are predicted by a diagnostic cluster that includes ODD, GAD, and depression Screening children for sleep problems could offer promising opportunities for reducing the burden of mental illness during the early life course
224 citations
TL;DR: A mechanistic model of irritability is presented that suggests that, relative to healthy children, irritable children have deficient reward learning and elevated sensitivity to reward receipt and omission and is associated with dysfunction in the prefrontal cortex, striatum, and amygdala.
Abstract: Although irritability is among the most common reasons that children and adolescents are brought for psychiatric care, there are few effective treatments. Developmentally sensitive pathophysiological models are needed to guide treatment development. In this review, the authors present a mechanistic model of irritability that integrates clinical and translational neuroscience research. Two complementary conceptualizations of pathological irritability are proposed: 1) aberrant emotional and behavioral responding to frustrative nonreward, mediated by reward-system dysfunction; and 2) aberrant approach responding to threat, mediated by threat-system dysfunction. The authors review the pathophysiological literature, including animal studies, as well as experimental psychology and clinical studies. Data suggest that, relative to healthy children, irritable children have deficient reward learning and elevated sensitivity to reward receipt and omission. These deficits are associated with dysfunction in the prefro...
206 citations
Cites background from "Prevalence, Comorbidity and Correla..."
...Although the DSM-5 criteria for DMDD require both clinical presentations, the existing data as to whether they are dissociable are limited and equivocal (14, 148)....
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...Indeed, more recent evidence indicates that the pathophysiological correlates of the trait of irritability itself differs between bipolar disorder and DMDD (40)....
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...Indeed, amongchildrenwithoppositionaldefiantdisorder, only those whose irritability severity is within the top 15% would meet criteria for DMDD (17)....
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...Youths with DMDD exhibit severe and recurrent temper outbursts that are more easily elicited, longer lasting, and contextually atypical relative to those of See related features: Clinical Guidance (Table of Contents), CME course (p. 605), and AJP Audio (online) 520 ajp.psychiatryonline.org Am J Psychiatry 174:6, June 2017 REVIEWS AND OVERVIEWS This article addresses the Core Competency of Medical Knowledge their peers (16, 18–20)....
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...The normative threshold, frequency, and behavioral manifestations of anger change over the course of development (23–27); for this reason, the criteria forDMDDstipulate that temper outbursts have to be inconsistent with developmental level (14, 16, 18, 23)....
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TL;DR: A review of relevant published literature was conducted, including published meta-analyses and national guidelines, and searches for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews were conducted.
Abstract: Mental health problems in children and adolescents include several types of emotional and behavioural disorders, including disruptive, depression, anxiety and pervasive developmental (autism) disorders, characterized as either internalizing or externalizing problems. Disruptive behavioural problems such as temper tantrums, attention deficit hyperactivity disorder, oppositional, defiant or conduct disorders are the commonest behavioural problems in preschool and school age children. The routine Paediatric clinic or Family Medicine/General Practitioner surgery presents with several desirable characteristics that make them ideal for providing effective mental health services to children and adolescents. DSM-5 and ICD-10 are the universally accepted standard criteria for the classification of mental and behaviour disorders in childhood and adults. The age and gender prevalence estimation of various childhood behavioural disorders are variable and difficult to compare worldwide. A review of relevant published literature was conducted, including published meta-analyses and national guidelines. We searched for articles indexed by Ovid, PubMed, PubMed Medical Central, CINAHL, EMBASE, Database of Abstracts and Reviews, and the Cochrane Database of Systematic reviews and other online sources. The searches were conducted using a combination of search expressions including "childhood", "behaviour", "disorders" or "problems". Childhood behaviour and emotional problems with their related disorders have significant negative impacts on the individual, the family and the society. They are commonly associated with poor academic, occupational, and psychosocial functioning. It is important for all healthcare professionals, especially the Paediatricians to be aware of the range of presentation, prevention and management of the common mental health problems in children and adolescents.
186 citations
TL;DR: Participants with a history of childhood DMDD were more likely to have adverse health outcomes, be impoverished, have reported police contact, and have low educational attainment as adults compared with either psychiatric or noncase comparison subjects.
Abstract: ObjectiveDisruptive mood dysregulation disorder (DMDD) is a new disorder for DSM-5 that is uncommon and frequently co-occurs with other psychiatric disorders. Here, the authors test whether meeting diagnostic criteria for this disorder in childhood predicts adult diagnostic and functional outcomes.MethodIn a prospective, population-based study, individuals were assessed with structured interviews up to six times in childhood and adolescence (ages 10 to 16 years; 5,336 observations of 1,420 youths) for symptoms of DMDD and three times in young adulthood (ages 19, 21, and 24–26 years; 3,215 observations of 1,273 young adults) for psychiatric and functional outcomes (health, risky/illegal behavior, financial/educational functioning, and social functioning).ResultsYoung adults with a history of childhood DMDD had elevated rates of anxiety and depression and were more likely to meet criteria for more than one adult disorder relative to comparison subjects with no history of childhood psychiatric disorders (non...
155 citations
Cites background from "Prevalence, Comorbidity and Correla..."
...One empirically supported critique of this new disorder is that DMDD is merely a new category for children with comorbid depression and oppositional defiant disorder (9)....
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...As such, DMDD is a distinct disorder in terms of its high rates of associated comorbidity (9)....
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...previous research (9) suggests that the concern about...
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...This criterion was not applied, as we have previously demonstrated that it would exclude many cases (9)....
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References
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TL;DR: The risk of having at least 1 psychiatric disorder by age 16 years is much higher than point estimates would suggest and concurrent comorbidity and homotypic and heterotypic continuity are more marked in girls than in boys.
Abstract: Results: Although 3-month prevalence of any disorder averaged 13.3% (95% confidence interval [CI], 11.7%15.0%), during the study period 36.7% of participants (31% of girls and 42% of boys) had at least 1 psychiatric disorder. Some disorders (social anxiety, panic, depression, and substance abuse) increased in prevalence, whereas others, including separation anxiety disorder and attention-deficit/hyperactivity disorder (ADHD), decreased. Lagged analyses showed that children with a history of psychiatric disorder were 3 times more likely than those with no previous disorder to have a diagnosis at any subsequent wave (odds ratio, 3.7; 95% CI, 2.94.9; P.001). Risk from a previous diagnosis was high among both girls and boys, but it was significantly higher among girls. Continuity of the same disorder (homotypic) was significant for all disorders except specific phobias. Continuity from one diagnosis to another (heterotypic) was significant from depression to anxiety and anxiety to depression, from ADHD to oppositional defiant disorder, and from anxiety and conduct disorder to substance abuse. Almost all the heterotypic continuity was seen in girls. Conclusions: The risk of having at least 1 psychiatric disorder by age 16 years is much higher than point estimates would suggest. Concurrent comorbidity and homotypic and heterotypic continuity are more marked in girls than in boys.
3,729 citations
"Prevalence, Comorbidity and Correla..." refers background in this paper
...This is a longitudinal, representative study of 920 children ages 9–17 years from four rural counties in North Carolina (13)....
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...By comparison, 3-month rates were between 2% and 3% for depressive disorders and between 2% and 5% for conduct disorder in the older samples (12, 13)....
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...This is a longitudinal, representative study of children in 11 predominantly rural counties of North Carolina (12)....
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...This is a cross-sectional study of a representative sample of preschoolers (ages 2–5) attending a large primary care pediatric clinic in central North Carolina....
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TL;DR: Evidence now shows quite convincingly that the rates of the common child psychiatric disorders and the patterns of comorbidity among them in preschoolers are similar to those seen in later childhood.
Abstract: We review recent research on the presentation, nosology and epidemiology of behavioral and emotional psychiatric disorders in preschool children (children ages 2 through 5 years old), focusing on the five most common groups of childhood psychiatric disorders: attention deficit hyperactivity disorders, oppositional defiant and conduct disorders, anxiety disorders, and depressive disorders. We review the various approaches to classifying behavioral and emotional dysregulation in preschoolers and determining the boundaries between normative variation and clinically significant presentations. While highlighting the limitations of the current DSM-IV diagnostic criteria for identifying preschool psychopathology and reviewing alternative diagnostic approaches, we also present evidence supporting the reliability and validity of developmentally appropriate criteria for diagnosing psychiatric disorders in children as young as two years old. Despite the relative lack of research on preschool psychopathology compared with studies of the epidemiology of psychiatric disorders in older children, the current evidence now shows quite convincingly that the rates of the common child psychiatric disorders and the patterns of comorbidity among them in preschoolers are similar to those seen in later childhood. We review the implications of these conclusions for research on the etiology, nosology, and development of early onset of psychiatric disorders, and for targeted treatment, early intervention and prevention with young children.
1,365 citations
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...and Angold [21])....
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TL;DR: Stringent tests of homotypic and heterotypic prediction patterns suggest a more developmentally and diagnostically nuanced picture in comparison with the previous literature.
Abstract: Context Most adults with a psychiatric disorder first met diagnostic criteria during childhood and/or adolescence, yet specific homotypic and heterotypic patterns of prediction have not been firmly established. Objective To establish which childhood and adolescent psychiatric disorders predict particular young adult disorders when accounting for comorbidities, disaggregating similar disorders, and examining childhood and adolescent predictors separately. Design Eleven waves of data from the prospective population-based Great Smoky Mountains Study (N = 1420) were used. Setting The Great Smoky Mountains Study is a longitudinal study of the development of psychiatric disorder and need for mental health services in rural and urban youth. A representative sample of children was recruited from 11 counties in western North Carolina. Participants Children in the community aged 9 to 16, 19, and 21 years. Main Outcome Measures Common psychiatric disorders were assessed in childhood (ages 9-12 years) and adolescence (ages 13-16 years) with the Child and Adolescent Psychiatric Assessment and in young adulthood (ages 19 and 21 years) with the Young Adult Psychiatric Assessment. Results Adolescent depression significantly predicted young adult depression in the bivariate analysis, but this effect was entirely accounted for by comorbidity of adolescent depression with adolescent oppositional defiant disorder, anxiety, and substance disorders in adjusted analyses. Generalized anxiety and depression cross-predicted each other, and oppositional defiant disorder (but not conduct disorder) predicted later anxiety disorders and depression. Evidence of homotypic prediction was supported for substance use disorders, antisocial personality disorder (from conduct disorder), and anxiety disorders, although this effect was primarily accounted for by DSM-III-R overanxious disorder. Conclusions Stringent tests of homotypic and heterotypic prediction patterns suggest a more developmentally and diagnostically nuanced picture in comparison with the previous literature. The putative link between adolescent and young adult depression was not supported. Oppositional defiant disorder was singular in being part of the developmental history of a wide range of young adult disorders.
738 citations
"Prevalence, Comorbidity and Correla..." refers background in this paper
...This is exactly the same pattern that has been found for the putative behavioral disorder of oppositional defiant disorder (4, 24, 25), which so commonly co-occurs with disruptive mood dysregulation....
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TL;DR: There is a place in both research and clinical settings for a rigorously operationalized interview (such as the CAPA) that focuses on ensuring that respondents understand what is being asked and on clearly defining levels of symptom severity and functional impairment.
Abstract: Great advances have been made during the last 20 years in the development of structured and semi-structured interviews for use with psychiatric patients. However, in the field of child and adolescent psychiatry there have been weaknesses in the specification and definition of both symptoms and the psychosocial impairments resulting from psychiatric disorder. Furthermore, most of the available interviews for use with children have been tied to a single diagnostic system (DSM-III, DSM-III-R, or ICD-9). This has meant that symptom coverage has been limited and nosological comparisons have been inhibited. The Child and Adolescent Psychiatric Assessment (CAPA) represents an attempt to remedy some of these shortcomings. This paper outlines the principles adopted in the CAPA to improve the standardization, reliability and meaningfulness of symptom and diagnostic ratings. The CAPA is an interviewer-based diagnostic interview with versions for use with children and their parents, focused on symptoms occurring during the preceding 3 month period, adapted for assessments in both clinical and epidemiological research.
707 citations
TL;DR: The presence of distinct episodes and hallmark symptoms can be used to differentiate clinical phenotypes of juvenile mania and the utility and validity of this system can be tested in subsequent research.
Abstract: OBJECTIVE: The authors suggest criteria for a range of narrow to broad phenotypes of bipolar disorder in children, differentiated according to the characteristics of the manic or hypomanic episodes, and present methods for validation of the criteria. METHOD: Relevant literature describing bipolar disorder in both children and adults was reviewed critically, and the input of experts was sought. RESULTS: Areas of controversy include whether the diagnosis of bipolar disorder should require clearly demarcated affective episodes and, if so, of what duration, and whether specific hallmark symptoms of mania should be required for the diagnosis. The authors suggest a phenotypic system of juvenile mania consisting of a narrow phenotype, two intermediate phenotypes, and a broad phenotype. The narrow phenotype is exhibited by patients who meet the full DSM-IV diagnostic criteria for hypomania or mania, including the duration criterion, and also have hallmark symptoms of elevated mood or grandiosity. The intermediate...
635 citations
"Prevalence, Comorbidity and Correla..." refers background in this paper
...(6) by opting for a more descriptive name and eliminating hyperarousal as a criterial symptom....
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