Why DMDD in Children Is Often Misdiagnosed as Bipolar Disorder

Why DMDD Is Often Misdiagnosed as Bipolar Disorder in Children

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Disruptive Mood Dysregulation Disorder is a childhood mental disorder marked by extreme irritability, anger, and frequent, intense temper tantrums. Unfortunately, it is becoming increasingly more common to see DMDD in children and adolescents.

Because it is not well-known, parents frequently mistake it for bipolar disorder. They witness the mood swings and the instability and figure it can’t be anything else.   

But bipolar disorder in people under the age of 18 is rare. According to the NIMH, it affects less than 3% of adolescents in the United States. And while the exact prevalence of DMDD is unknown, research suggests it could affect twice as many children as bipolar disorder.

Here’s a discussion of each diagnosis and what symptoms differentiate the two. 

Why DMDD in Children Is Often Misdiagnosed as Bipolar Disorder
Why DMDD in Children Is Often Misdiagnosed as Bipolar Disorder

What is bipolar disorder? 

Bipolar disorder is a serious mental illness that causes extreme shifts in mood, energy, activity levels, and concentration..

There are three types of bipolar disorder. All three types involve obvious changes in mood, energy, and activity levels. These moods range from periods of extreme energy (i.e., mania) to periods of hopelessness and despair (i.e., dysthymia). Manic periods that are less intense are known as hypomania.

Bipolar disorder has been called many things over the years.

The ancient Greeks called it “Melancholy”. Back then, the term was used to describe mood shifts, depression, and related mental disorders.

In the 19th century, the French called it “La Folie Circulaire,” which translates to “circular insanity.” In the 20th century, we called it “Manic-Depressive Disorder.” Over years the term morphed into “bipolar disorder” Types 1 and 2, along with “Cyclothymia,” which is its long-term, low-grade cousin. 

According to the DSM5 and American Psychiatric Association symptoms of the “manic” phase of bipolar disorder include: 

  • A distinct period of abnormally and persistently elevated, expansive, or irritable mood that lasts at least 1 week and is present most of the day. 
  • Abnormally and persistently increased goal-directed activity or energy 
  • Inflated self-esteem and grandiosity
  • Decreased need for sleep
  • More talkative than usual
  • Flight of ideas or racing thoughts
  • Distractibility
  • Increase in goal-directed activity
  • Excessive involvement in risky activities (e.g. overspending, sexual activity)

The depressive aspect of bipolar disorder is characterized by a major depressive episode, where a person demonstrates five or more of the following symptoms in two weeks:

  • Depressed mood most of the day nearly every day 
  • Loss of interest or pleasure in all, or almost all, activities 
  • Significant weight loss or decrease or increase in appetite
  • Engaging in purposeless movements, such as pacing the room
  • Fatigue or loss of energy
  • Feelings of worthlessness or guilt
  • Diminished ability to think or concentrate, or indecisiveness
  • Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt
  • The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Can children have bipolar disorder? 

The short answer is yes, but it’s fairly uncommon. 

Children don’t have as firm a grasp on their emotions as do their adult counterparts, and that’s one of several reasons why so many children present as emotionally unstable.

Consider a typical two-year-old. They are giggling one minute, sobbing hysterically the next. But the mood swings you see in a two-year-old are usually normal and perhaps even necessary for proper development.

But what if they’re still struggling with these issues when they are 7? Or 10? Or 12? Is that the same thing?

It’s not a good idea to diagnose anyone, especially children — this is the job of a trained clinician. But bipolar disorder is far more likely to develop in adulthood, and there’s way more to it than mood swings and foul tempers.

This doesn’t mean that kids don’t present with behaviors associated with bipolar disorder. However, it does mean that clinicians should use a diagnosis more appropriate for kids.

What is Disruptive Mood Dysregulation Disorder (DMDD)?

Designated in 2013, DMDD in children is basically equivalent to adult bipolar disorder. 

According to the American Psychiatric Association, symptoms of Disruptive Mood Dysregulation Disorder include:

  • Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression)
  • Outbursts are grossly out of proportion in intensity or duration to the situation or provocation
  • The temper outbursts are inconsistent with developmental level (e.g., the child is older than you would expect to be having a temper tantrum).
  • The temper outbursts occur, on average, three or more times per week.
  • The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, friends).
  • The above criteria have been present for 1 year or more, without a relief period of longer than 3 months. 
  • The above criteria must also be present in two or more settings (e.g., at home and school), and are severe in at least one of these settings.

While nobody likes to place labels on kids, the emergence of DMDD as a recognized disorder allows clinicians to provide appropriate treatment for kids who have repeated tantrums, verbal and/or physical aggression, and a persistent, angry or irritable mood.

Symptoms of Bipolar DisorderSymptoms of DMDD in Children
A distinct period of abnormally and persistently elevated, expansive, or irritable mood and abnormally and persistently increased goal-directed activity or energy, lasting at least 1 week and present most of the day, nearly every day (or any duration if hospitalization is necessary).Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression toward people or property) that are grossly out of proportion in intensity or duration to the situation or provocation
During the period of mood disturbance and increased energy or activity, 3 (or more) of the following symptoms (4 if the mood is only irritable) are present to a significant degree and represent a noticeable change from usual behavior:The temper outbursts are inconsistent with developmental level (e.g., the child is older than you would expect to be having a temper tantrum).
Inflated self-esteem and grandiosity; Decreased need for sleep; More talkative than usual; Flight of ideas or racing thoughts; Distractibility; Increase in goal-directed activity; Excessive involvement in risky activities (e.g. overspending, sexual activity)The temper outbursts occur, on average, three or more times per week.
The depressive aspect of bipolar disorder is characterized by a major depressive episode that results in depressed mood or loss of interest or pleasure in life. A person must experience five or more of the following symptoms in two weeks to be diagnosed with a major depressive episode:The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others (e.g., parents, teachers, friends).
Depressed mood most of the day, nearly every day; Loss of interest or pleasure in all, or almost all, activities; Significant weight loss or decrease or increase in appetite; Engaging in purposeless movements, such as pacing the room; Fatigue or loss of energy; Feelings of worthlessness or guilt; Diminished ability to think or concentrate, or indecisiveness; Recurrent thoughts of death, recurrent suicidal ideation without a specific plan, or a suicide attempt The above criteria have been present for 1 year or more, without a relief period of longer than 3 months. The above criteria must also be present in two or more settings (e.g., at home and school), and are severe in at least one of these settings.
The symptoms of depression or the unpredictability caused by frequent alternation between periods of depression and hypomania causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.The diagnosis should not be made for the first time before age 6 years or after age 18. Age of onset of these symptoms must be before 10 years old
*Courtesy, DSM5 and American Psychiatric Association

Bipolar Disorder Versus DMDD in Children 

Tantrums in children are to be expected, but a pattern of severe tantrums is a cause for concern. DMDD at least gives a name to a condition that many parents and clinicians already know exists and it provides a criterion-based framework for proper diagnosis and treatment.

Here are some key features that distinguish DMDD in children from bipolar disorder:

  1. Bipolar can be a lifelong affliction and is episodic in nature. 
  2. DMDD is persistent but does not manifest with severe mania (i.e., incredible energy, sleeplessness).
  3. “Mood swings” are NOT characteristic of bipolar disorder. They are, however, a feature of DMDD in children.
  4. Bipolar often leads to psychosis (delusions, hallucinations); DMDD does not. 
  5. Grandiose thinking and elevated mood are typical with Bipolar; these symptoms are not present with DMDD. 
  6. Severe tantrums are a feature of DMDD; this feature is absent from bipolar disorder in children.
  7. The diagnosis should not be made for the first time before age 6 years or after age 18. The onset of these symptoms must be before 10 years old.

What to do If You Suspect Your Child Has DMDD

Any concerned parent will want to learn more about how to best care for and support their children, especially if they are demonstrating behavioral problems, but they should never attempt to diagnose or treat mental illness alone. 

Because children are always navigating various developmental stages and learning how to regulate their moods and emotions in age-appropriate ways, they need specialized care, especially when it comes to mental health.     

DMDD in children manifests as severe emotional and behavioral challenges. If your child is struggling with this, it’s important to enlist the services of a licensed clinician who specializes in the diagnosis and treatment of children and adolescents.

References

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About The Author
Randy Withers, LCMHC
Randy Withers, LCMHC is a Board-Certified and Licensed Clinical Mental Health Counselor at a private practice in North Carolina where he specializes in co-occurring disorders. He has masters degrees in Clinical Mental Health Counseling from Lenoir-Rhyne University and Education from Florida State University, and is the managing editor of Blunt Therapy. He writes about mental health, therapy, and addictions. In his spare time, you can find him watching reruns of Star Trek: TNG with his dog. Connect with him on LinkedIn. You can also see what he writes about on Medium.
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