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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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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Disruptive Mood Dysregulation Disorder, DMDD, DSM 5, Health, Kids Health, oppositional defiant disorder, pediatric bipolar disorder | Categories:
Behavior, Health, Must Read, Parenting, Questions