Review article
Disruptive Mood Dysregulation Disorder (DMDD): An RDoC perspective

https://doi.org/10.1016/j.jad.2016.08.007Get rights and content

Highlights

  • Disruptive mood dysregulation disorder requires further careful examination.

  • Reward-related RDoC constructs may be altered in children with chronic irritability.

  • RDoC Cognitive domain constructs may explain deficits in emotion regulation in DMDD.

  • Further research is needed to improve diagnostic clarity and inform interventions.

Abstract

In recent years, there has been much debate regarding the most appropriate diagnostic classification of children exhibiting emotion dysregulation in the form of irritability and severe temper outbursts. Most recently, this has resulted in the addition of a new diagnosis, Disruptive Mood Dysregulation Disorder (DMDD) in the DSM 5. The impetus for including this new disorder was to reduce the number of diagnoses that these children would typically receive; however, there is concern that it has only complicated matters rather than simplifying them. For example, a recent epidemiologic study shows that DMDD cannot be differentiated from oppositional defiant disorder (ODD) based on symptoms alone. Thus, these children are an ideal population in which to apply RDoC constructs in order to obtain greater clarity in terms of underlying processes and ultimately, inform nosology and appropriate interventions. The aim of this article is to provide a foundation for future research by examining extant theoretical and empirical evidence for the role of four key RDoC constructs in DMDD.

Introduction

Researchers have become increasingly interested in finding alternative frameworks for understanding mental disorders. This stems from a growing dissatisfaction with the current diagnostic nosology that reduces complex systems of functioning into discrete symptom clusters. While the Diagnostic and Statistical Manual of Mental Disorders- Fifth Edition (DSM-5; APA, 2013) has made important revisions, it fails to capture the neurobiological, genetic, behavioral, environmental, and experiential interactions that contribute to the development and maintenance of psychopathology. In response to these deficiencies, the National Institute of Mental Health (NIMH) introduced the Research Domain Criteria (RDoC) initiative. The RDoC initiative provides a dimensional approach to understanding mental disorders by integrating multiple scientific disciplines in a translational manner. The RDoC framework is organized by constructs that represent a particular functional aspect of behavior (Insel and Cuthbert, 2010). Using this approach, researchers can address the heterogeneous mechanisms of dysfunction for each construct.

One disorder that would benefit greatly from an RDoC perspective is Disruptive Mood Dysregulation Disorder (DMDD; APA, 2013). DMDD is a controversial diagnosis characterized by a disturbance in mood (i.e. severe and persistent irritability) and disruptive behaviors (recurrent and severe temper outbursts that are out of proportion to the situational stressor; APA, 2013). This new disorder arose from a concern that pathological irritability and anger in children were not being accurately captured, and thus, treated. More specifically, many of these children were being diagnosed with Bipolar Disorder despite the chronic, versus episodic, nature of their symptoms and evidence for distinct pathophysiology (Brotman et al., 2010, Wiggins et al., 2016, Adleman et al., 2011, Thomas et al., 2012, Deveney et al., 2012). The challenge is that these symptoms are observed across multiple mood and disruptive behavior disorders (Barlow, 1991); the establishment of DMDD aimed to address this issue. However, researchers have questioned the validity of DMDD as a distinct diagnosis (Stringaris, 2011, Axelson et al., 2012, Roy et al., 2014, Lochman et al., 2015). For example, a recent population-based epidemiologic study found that DMDD cannot be differentiated from Oppositional Defiant Disorder (ODD) based on symptomatology alone (Mayes et al., 2016). This suggests that differentiation from other disorders such as ODD will require examination of constructs other than psychopathological symptoms such as those presented in the RDoC initiative.

In this paper, we review RDoC constructs that we propose are most relevant to DMDD. First, we suggest that dysfunction of frustrative non-reward (Negative Valence domain) and reward prediction error (Positive Valence domain) processes may drive symptoms of chronic irritability and severe tantrums. Second, we suggest that the persistence of these symptoms reflect poor emotion regulation, and particularly, impairments in two constructs from the Cognitive domain: attention and language. Several challenges arise when completing such a review. First, few studies have directly examined DMDD and thus, we examine these constructs as they relate to the core symptoms of irritability and severe temper outbursts. Specifically, we primarily focus on disorders that directly informed the development of DMDD due to the prominence of chronic irritability within their symptom presentation, namely oppositional defiant disorder (ODD) and severe mood dysregulation (SMD; a phenotype defined by Leibenluft et al., (2003) that served as the precursor to DMDD). Studies of other disorders (i.e., mood and anxiety disorders) were considered only if they included findings specifically related to symptoms of chronic irritability and temper outbursts. We do not include studies that focus exclusively on pediatric BD since the pathophysiology is believed to be distinct from that of DMDD as indicated above (Brotman et al., 2010, Adleman et al., 2011, Thomas et al., 2012, Deveney et al., 2012, Wiggins et al., 2016). Second, behavioral and neuroimaging protocols are typically complex and may involve multiple RDoC constructs. We classified studies according to their stated aims but recognize that there is significant overlap. Overall, the aim of this review is to provide guidance for future research on DMDD. Ultimately, future studies leveraging these RDoC constructs will help to empirically parse the significant heterogeneity observed in children with severe temper outbursts and chronic irritability and provide evidence that supports DMDD as a distinct disorder or suggest alternative nosological classification.

Section snippets

Frustration, reward, and non-reward

Irritability has been conceptualized as a “low threshold to experience anger in response to frustration.” (p. S32, Krieger et al., 2013). Relatedly, temper outbursts are the behavioral manifestations of these anger responses. Thus, it is logical to consider these symptoms of DMDD within the RDoC domain of Negative Valence Systems, and specifically, in relation to the construct of frustrative non-reward. Frustrative non-reward was originally developed by Abram Amsel (1958) and is defined as an

Emotion regulation capacity

DMDD is typically considered a condition of emotion dysregulation. While irritability has been defined as a negative affective response, the chronicity of this response, which is a core component of DMDD, suggests limited ability to regulate this emotion. Additionally, severe temper outbursts, which also reflect poor regulation of negative affective responses, are also considered to be a hallmark symptom of DMDD, possibly reflecting a more extreme form of irritability (Stringaris et al., 2009,

Conclusions and future directions

Since its introduction into psychiatric nosology in 2013, DMDD has posed a challenge to researchers and clinicians in terms of the reliability and validity of its symptoms as well as selection of appropriate treatments. Rigorous investigations of DMDD are needed and as we suggest here, several of the NIMH RDoC constructs can provide a solid starting point for this work. First, children with chronic irritability and emotional lability typically exhibit low frustration tolerance, supporting the

Author contributions

Drs. Meyers and Roy developed the concept of the manuscript. Dr. Meyers conducted most of the literature review and wrote the first draft of the manuscript. Ms. DeSerisy completed the review of the language development literature. Dr. Roy provided final review and edits. All authors contributed to and have approved the final manuscript.

Role of the funding source

Drs. Meyers and Roy receive salary support from the National Institute of Mental Health (1R01MH091140-01A1). Ms. DeSerisy receives stipend and tuition support from this grant.

Conflict of Interest

All other authors declare that they have no conflicts of interest.

Acknowledgments

We thank Sheina Godovich who assisted with proofreading this manuscript.

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