How many children with DMDD meet criteria for oppositional defiant disorder?
~80% of children with DMDD will also meet criteria for oppositional defiant disorder, in which case you would only diagnose DMDD
Do not make DMDD diagnosis prior to age ___
: Why was DMDD not included in the same chapter with the disruptive, impulse-control, and conduct disorders?
The original impetus was to give clinicians a mood-related alternative to bipolar I disorder.
However, the prominent feature of persistently depressed (or irritable) behavior throughout the course of illness seems reason enough for placement with other mood disorders.
In aggregate, a number of features seem to set these youngsters well apart from traditional patients with bipolar disorder
(1) Limited follow-up studies find some increase in depression, not mania, in these children as they mature.
(2) Family history studies find no excess of bipolar disorder in relatives of these patients.
(3) The sex ratio is about 2:1 in favor of boys, which is disparate with the 1:1 ratio for bipolar disorder in older patients.
(4) Studies of pathophysiology suggest that brain mechanisms may differentiate the two conditions.
(5) The diagnosis of childhood bipolar disorder has been made far more often in the United States than elsewhere in the world.
(6) Follow-up studies find far more manic or hypomanic episodes in children with bipolar disorder diagnosed according to traditional criteria than in those whose principal issue was with severe mood dysregulation
Essential features of DMDD
For at least a year, several times a week, on slight provocation a child has severe tantrums— screaming or actually attacking someone (or something)—that are inappropriate for the patient’s age and stage of development. Between outbursts, the child seems mostly angry, grumpy, or sad. The attacks and intervening moods occur across multiple settings (home, school, with friends). These patients have no manic episodes
- Duration and demographics (1+ years, and never absent longer than 3 months, starting before age 10; the diagnosis can only be made from age 6 through 17)
- Distress or disability (symptoms are severe in at least one setting— home, school, with other kids—and present in other settings)
- Differential diagnosis (substance use and physical disorders, major depressive disorder, bipolar disorders, oppositional defiant disorder, attention-deficit/hyperactivity disorder, behavioral outbursts consistent with developmental age)
Coding for Bipolar I and MDD
Severity Codes (for manic and depressive episodes)
Mild. Symptoms barely fulfill the criteria and result in little distress or interference with the patient’s ability to work, study, or socialize.
Moderate. Intermediate between mild and severe.
Severe. There are several symptoms more than the minimum for diagnosis, and they markedly interfere with patient’s work, social, or personal functioning.
In partial remission. A patient who formerly met full criteria and now either (1) has fewer than the required number of symptoms or (2) has had no symptoms at all, but for under 2 months.
In full remission. For at least 2 months, the patient has had no important symptoms of the mood episode.
With anxious distress
Patients with bipolar I, bipolar II, cyclothymic, major depressive, or persistent depressive disorder may experience symptoms of high anxiety. These patients may have a greater than average potential for suicide and for chronicity of illness
During a major depressive/manic/hypomanic episode or dysthymia, the patient feels notably edgy or tense, and may be extra restless. Typically, it is hard to focus attention because of worries—“Something terrible could happen,” or “I could lose control and [fill in the awful consequence] . . . ”
- mild (2 symptoms of anxious distress),
- moderate (3 symptoms),
moderate–severe (4–5 symptoms), severe (4–5 symptoms plus physical agitation)
With atypical features
Not all seriously depressed patients have the classic vegetative symptoms typical of melancholia (see below). Patients who have atypical features seem almost the reverse: Instead of sleeping and eating too little, they sleep and eat too much. This pattern is especially common among younger (teenage and college-age) patients. Indeed, it is common enough that it might better be called nonclassic depression.
Two reasons make it important to specify with atypical features. First, because such patients’ symptoms often include anxiety and sensitivity to rejection, they risk being mislabeled as having an anxiety disorder or a personality disorder. Second, they may respond differently to treatment than do patients with melancholic features. Atypical patients may respond to specific antidepressants (monoamine oxidase inhibitors), and may also show a favorable response to bright light therapy for seasonal (winter) depression.
Essential Features of With Atypical Features
A patient experiencing a major depressive episode feels better when something good happens (“mood reactivity,” which obtains whether the patient is depressed or well). The patient also has other atypical symptoms: an increase in appetite or weight (the classic depressed patient reports a decrease), excessive sleeping (as opposed to insomnia), a feeling of being sluggish or paralyzed, and long- existing (not just when depressed) sensitivity to rejection.
The Fine Print: The with atypical features specifier cannot be used if your patient also has melancholia or catatonic features. See Table 3.3 for application.
The catatonia specifier, first mentioned in Chapter 2 in association with the psychotic disorders (p. 100), can be applied to manic and major depressive (but not hypomanic) episodes of mood disorders as well. The definitions of the various terms are given in the sidebar on page 101. When you use it, you have to add a line of extra code after listing and coding the other mental disorder