Disruptive Mood Dysregulation Disorder

Disruptive mood dysregulation disorder (DMDD) is chronic severe irritability with frequent temper outbursts (3 or more per week) in children aged 6 to 18, with onset before age 10, for at least 12 months.

• Prevalence 1 to 3%, more in boys; replaces the diagnosis of paediatric bipolar disorder for chronic irritability.
• Predicts later unipolar depression and anxiety rather than bipolar disorder.
• Comorbid ADHD, oppositional defiant disorder, anxiety, learning disorders.
• Risk factors: parental psychopathology, harsh parenting, trauma.

• Outbursts grossly out of proportion to provocation, persistently irritable or angry mood between outbursts in multiple settings (home, school, peers).
• School suspension, family conflict, peer rejection.
• No distinct manic episodes.

• DSM-5 criteria: history from parents and teachers; Affective Reactivity Index.
• Exclude bipolar disorder, ODD, ADHD, autism, PTSD, anxiety, depression, substance misuse, medical causes (thyroid, epilepsy, lead exposure).
• Assess trauma, family functioning, learning, suicide and safety.

• Parent management training and CBT for children (emotion regulation, frustration tolerance) are first line.
• School supports, structured routines.
• Pharmacotherapy for comorbid disorders: stimulants (methylphenidate 0.3 to 1 mg/kg/day) for ADHD can reduce irritability; SSRI (fluoxetine 10 to 40 mg, sertraline 25 to 100 mg) for anxiety or depression; alpha agonists (guanfacine 1 to 4 mg).
• Risperidone 0.25 to 2 mg or aripiprazole 2 to 10 mg for severe aggression with monitoring of weight and metabolic parameters, short term.
• Avoid mood stabilisers as routine; review at regular intervals.