Posts Tagged ‘ Disruptive Mood Dysregulation Disorder ’

2013 and … Pediatric Bipolar Disorder

Thursday, December 19th, 2013

The biggest news in 2013 on Pediatric Bipolar Disorder (PBD) centered on a new diagnosis in the DSM-5 – Disruptive Mood Dysregulation Disorder (DMDD) – introduced in part to prevent the overdiagnosis of bipolar disorder in youth. The idea was to provide a separate diagnostic category for kids who have explosive emotional outbursts and severe disruptive behavior without other signals of PBD.

This situation represents another lightning rod in the debates on how we diagnosis psychiatric disorders in youth. Some applaud the attempt to reduce misdiagnosis of PBD. Some argue that while this is a good thing, it’s a bad thing to introduce yet another diagnosis that can lead to medicating kids who may not “have” a disorder.

The fact is that research has validated the use of a PBD diagnosis in youth via clinical and longitudinal studies – but it is very difficult to diagnose at any one moment in time in youth. There is no substitute for evaluation performed by a team that includes substantial experience in assessing PBD – I have personally seen clinicians with little experience with PBD applying the diagnosis inappropriately. What is disconcerting is that the DMDD category was introduced in DSM-5 without the typical platform of studies examining the reliability and (especially) predictive validity of the diagnosis.

Let’s anticipate that the discussions about PBD and DMDD will spur intensive studies focused on differential diagnosis and clinical utility of each diagnostic category.

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“Saving Normal”: Has DSM-5 Gone Too Far?

Thursday, May 30th, 2013

While DSM-5 should be reflecting consensus, it has certainly spurred many reactions – from inside the ranks. 

Consider that the National Institute of Mental Health – the primary funding agency for mental health research in the US – will essentially ignore the DSM-5 in favor of its own research-based criteria. In other words – the DSM-5 is not especially informative for those who do research on mental health.

Consider the serious critique of the process offered by Allen Frances, M.D., in his book Saving Normal: An Insider’s Revolt Against Out-Of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life. Dr. Frances was chair of the DSM-IV Task Force, and as such has an insider’s viewpoint on the whole process. The bottom line for him is that the DSM-5 not only does not improve on what we had before, it makes matters worse, primarily by introducing new disorders and making decisions about diagnostic criteria without sufficient evidence or grounding. The bigger point is that the diagnostic approach is losing the ability to discriminate behaviors that are part of the normal spectrum (and reflective of normative variation) and those that are truly problematic for individuals and deserving of diagnosis as a way of guiding treatment.

So what do we make of all this? I have two reactions.

I’m not all that concerned about the NIMH part of this. The reality is that researchers frequently look at “psychiatric disorders” in a number of ways – and not by following whatever clinical system is in place. That’s the point of research – to come up with something better. The problem, though, is that while there has been a lot of research that impacts our understanding of the various disorders, it has not yielded a radically different way of defining them clinically. It’s the goal, but it’s far from the reality.

That’s where “Saving Normal” comes into play. It’s hard to see that substantial progress was made at the research end to justify a whole new system. The choices made in DSM-5 are bringing more uncertainty to an already uncertain process. Let’s look at kids briefly. What’s especially troubling is that some kids who need treatment may no longer meet criteria for a disorder (like the estimated 10% reduction rate in diagnosing Autism Spectrum Disorder) – whereas others who exhibit potentially age-appropriate typical behaviors (like tantrum tantrums) may be diagnosed with the rather shaky Disruptive Mood Dysregulation Disorder.

So where are we at? Diagnoses need to be made. Kids (and adults of course) need treatment. A diagnostic system for psychiatric disorders is going to be very fuzzy at best. Wouldn’t the best approach be to introduce changes for a given disorder when the evidence suggests it is the time to do so – rather than arbitrarily replace one system with another at a designated time in the future? In this day and age, wouldn’t that be feasible?

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Should Disruptive Mood Dysregulation Disorder Be In DSM-5?

Wednesday, May 29th, 2013

The biggest controversies that arise in diagnostic systems – like DSM-5 – come about when a previous diagnosis category is eliminated (as is the case with Asperger’s Disorder) or a new one is introduced. Such is the case with the new disorder Disruptive Mood Dysregulation Disorder (DMDD). Part of the rationale for including it was to prevent inappropriate use of a diagnosis of pediatric bipolar disorder. But that’s not a strong enough rationale to introduce a whole new diagnosis. So … should it be in the DSM-5? 

The answer is no. Here’s why.

The idea of the DSM is to represent not just current clinical thinking but sufficient evidence to support a diagnostic category. This process is already murky because DSM-5 operates by defining a disorder as a collection of symptoms. While this is necessary when known causes – and gold standard methods for identifying a disorder – are not available, we typically rely on a number of carefully designed studies that support diagnostic criteria. Simply put, that is what is lacking right now with respect to DMDD.

We are just starting see research studies that evaluate the utility of the diagnosis of DMDD. At best, they highlight the complexities involved in sorting through whether or not DMDD offers unique insight into the developmental profile of a specific subset of children who could profit from intervention.

And that’s the point. This research is important and will continue. But until it yields more clear guidelines – which will take some time – it’s just not time to include it in DSM-5. There is concern that kids with extreme temperamental traits – like those who are prone to tantrums – will get inappropriately labeled. It may be that many kids who will get the DMDD diagnosis can be better captured by other disorders with similar symptom profiles (like oppositional defiant disorder). Until we have better trials to evaluate these issues DMDD should not be in the manual. That’s how clinical science is supposed to work.

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DSM-5: Why (and What) Parents Should Know About It

Tuesday, May 21st, 2013

As a parent, you may be wondering why such a fuss is being made about the release of the DSM-5 (the 5th edition of the Diagnostic and Statistical Manual of the American Psychiatric Association). Here is a brief overview of why it may be (0r become) relevant to you – and why it’s important to learn about the issues that are being debated.

Many Kids Will Experience A Mental Disorder

The primary reason parents need to know about DSM-5 is that many psychiatric disorders that originate in childhood are not uncommon. Consider some rough numbers:

  • Around 1 in 50 kids are being diagnosed with Autism Spectrum Disorder
  • Around 1 in 10 kids are being diagnosed with Attention Deficit Hyperactivity Disorder
  • Around 1 in 10 kids are being diagnosed with Conduct Disorder
  • Around 1 in 10 kids are being diagnosed  with an Anxiety Disorder
  • Around 1 in 10 kids are being diagnosed with a Mood Disorder
  • Around 1 in 2 teens have reported meeting diagnostic criteria for at least 1 disorder in their lifetime

Having a good look at these numbers means that lots of parents will be faced at some point in time with the possibility of having their child evaluated for a disorder – and will need to consider treatment options. That’s where the DSM-5 comes in.

DSM-5 Is The Primary Guide For Clinical Diagnosis

The DSM-5 is the handbook used by a broad range of health care professionals who evaluate individuals (youth and adults) for potential psychiatric disorders. It’s an authoritative guide that reflects a consensus statement on the best way to categorize disorders along with the specific symptoms and rules to be used to make a diagnosis. The intention is to make it reflect current clinical thinking that is supported by research. It is not perfect, it reflects a particular point of view by those charged with generating the guidelines, and there is much debate (and criticism) of the diagnostic approach taken by the DSM-5.

All that said, the fact remains that the DSM-5 will be used if you bring your child to a health care professional for evaluation. The clinician will consider lots of information during this process – the DSM-5 does not dictate what information they use and how they get it. It’s intended to serve as a guide to the endpoint of making (or not making) a diagnosis. And it serves as the template for a health care provider to request reimbursement from insurance companies to support treatment.

Why All The Controversy Now?

The DSM-5 is a revision of the prior version which was released in 2000. As such, it includes a number of changes – some of which are minor, some of which are major. Beyond the more general discussions about what’s “normal” and what isn’t, the key things that parents need to know are the practical implications of the changes. As a parent, you should be aware of the changes to disorders that are especially relevant for youth. Here’s a brief overview:

Autism Spectrum Disorder: Major changes have occurred. In the prior version, a spectrum of disorders were available to clinicians, reflecting important variations in symptom profile. Four disorders were listed: Autistic Disorder, Asperger’s Disorder, Childhood Disintegration Disorder, and Pervasive Developmental Disorder Not Otherwise Specified. The key change is that there is now just one diagnosis made of Autism Spectrum Disorder (ASD) – and the other diagnostic categories will no longer be used. Proponents of this change suggest that it is more accurate by defining the core features of ASD that were common to all of the disorders in the spectrum and allowing for differences in severity level under one diagnostic umbrella. Critics suggest that a number of youth who require diagnosis and treatment will not be diagnosed – and that the reliance on severity levels may make it harder for kids with more mild symptoms to receive treatments they need. There’s no answer to these issues yet – they will unfold over time as data are collected. But if your child is evaluated for ASD, it’s in your best interests to be up on the debates and have informed discussions with your clinician in order to make sure you are advocating for the best care for your child.

Attention Deficit Hyperactivity Disorder (ADHD): Minor changes have occurred. In the past, there had to be evidence that a child showed symptoms of ADHD before age 7. That has been extended to age 12 in the DSM-5. There is also more attention to making diagnoses in adults more manageable. All of these changes mean that if you have an older child who has never been diagnosed with ADHD, they might now be evaluated differently. It’s also important to know what isn’t in the DSM-5 – a lower limit on age. That is, there are no guidelines in terms of how young a child may be when making a diagnosis. This is relevant as there have been (controversial) suggestions that kids as young as 4 years of age could be diagnosed (and many in fact have). Know that DSM-5 does not offer guidance here and you will need to make up your own mind if this makes sense for your child –  hopefully with the appropriate guidance of a well-trained clinician. Overall, the worry here is that kids of all ages may be overdiagnosed.

Conduct Disorder (CD): Minor changes have occurred. Conduct disorder represents a persistent pattern of rule breaking behavior and behavior that violates the rights of others. It can be diagnosed in young children as well as teens. The primary change has been to incorporate symptoms indicating a callous and unemotional interpersonal style. The thinking here is kids with this profile may be especially prone to experience problems in the future – and require more intensive management and treatment. Be aware that these symptoms will receive more attention now in the diagnostic process.

Disruptive Mood Dysregulation Disorder (DMDD): This diagnosis reflects a major change – it is a new diagnostic category. The idea was to provide a diagnostic option for kids who show persistent irritability and extreme emotional and behavioral outbursts. The rationale for developing the DMDD criteria was to make sure kids who show these symptoms do not get mislabeled as having pediatric bipolar disorder – but still may qualify for treatment. The controversy is that many feel that there is not sufficient evidence to support this new diagnosis – and in the worst case scenario kids who do not have psychiatric problems will be diagnosed with a disorder and get treatment that they don’t need.

Over the next few days, I will publish blog posts that consider each of these four disorders in greater detail, and provide some guidance for parents to help sort through these complex issues. There are no straightforward answers to be found – rather parents need to know about DSM-5 so they can be prepared to navigate the best decisions for their child.




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When A Child Is Misdiagnosed

Saturday, October 29th, 2011

Now and then, I come across a blog post that knocks me out because it says so much – especially when it focuses on issues that I’ve been wrestling with and have struggled to articulate. Such is the case with Ellen Seidman’s post Can Kids Be Wrongly Diagnosed With Cerebral Palsy? Yes, It Turns Out. If you haven’t read it yet, please do – it focuses on 2 kids who were misdiagnosed with Cerebral Palsy (CP) and eventually re-diagnosed (after years of effort by their parents) with a condition that was treatable with medication.

I’ve read this post 10 times since it was published. Why? Because there are so many important points covered. The ones that hit me over the head are as follows:

  • Biological conditions in kids can be misdiagnosed. Even conditions as impairing as CP. I’ve known this, yet there is something about a concrete example that clarifies issues for me. In this case, I’ve been writing about slippery diagnoses for behavioral and emotional conditions, including ADHD and a newly proposed disorder called Disruptive Mood Dysregulation Disorder or DMDD. I’ve talked about over- and under-diagnosis. But I haven’t said clearly that a big issue can be misdiagnosis, particularly when we don’t have biomarkers or other tests that can assist not just diagnosis but differential diagnosis (deciding between diagnoses).
  • Misdiagnosis can lead to an ineffective treatment plan. Okay, this sounds obvious, but the thing is we need to be conservative about offering medication as a treatment plan when it’s not at all clear that a child has one condition versus another condition (or even that they have a condition). This can be the case when we are trying to apply the diagnostic crieria of ADHD to toddlers, or when kids may receive a diagnosis of DDMD in part because they don’t meet criteria for other disorders.
  • I sympathize with parents of kids who seek out treatment and evaluation because the fact is that we don’t just want to help kids – we want to believe that we can make a condition go away. So the idea of diagnosis and biological treatment is seductive. As Ellen says:

While I do not mourn my son’s CP and adore every inch of who he is, if it were possible to make it all go away with a pill, of course I would.

Unfortunately, the reality is that in many cases medication doesn’t cure behavioral and emotional conditions – more typically the goal is to try to reduce the frequency and intensity of the most impairing symptoms.

The point of all this is that diagnosis and treatment is not a perfect science. Practitioners do not have an easy task when kids present with emotional and behavioral symptoms. And I’m not opposed in principle to pharmaceutical interventions with kids – many parents of kids with ADHD would be able to report that they do improve their child’s functioning. My concern is that we are seeing more and more investment in the “diagnosis -> medication” model for complex behavioral and emotional syndromes in younger and younger kids, and less emphasis on non-biological intervention plans that try to encourage behavioral change without reaching too hard for diagnoses that may not always be illuminating – and treatments that might not be justified.

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