Essential Features

DMDD is a depressive disorder diagnosis intended for children and adolescents between the ages of 6 and 18 with onset before the age of 10 (APA, 2013a). The disorder is marked by severe, recurrent outbursts of temper, either verbal or behavioral, that are significantly out of proportion in intensity and duration with situational factors and the developmental stage of the individual. The individual’s mood between temper outbursts is persistently irritable or angry. Frequency must average at least three times per week for at least 12 months or more, and the behavior must be observable by others (e.g., parents, teachers, peers). The behaviors must occur in at least two settings (e.g., school and home) and must be severe in at least one of these settings. The individual cannot be free from severe recurrent temper outbursts for longer than 3 months (APA, 2013a). See the Diagnostic Criteria section below for a complete listing of DMDD criteria.

Special Considerations

Counselors diagnosing DMDD need to consider whether symptoms of an abnormally elevated or expansive mood have ever been present most of the day during the course of 1 day or have a duration of longer than 1 day. If so, counselors need to consider the presence of grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with a high potential for painful consequences. If these symptoms are present, a diagnosis of bipolar disorder might be warranted. Special care should also be taken to differentiate abnormally elevated mood from developmentally appropriate mood elevation because the latter could occur in the context of anticipation or participation in a special event.

Note

Although initially proposed, criteria regarding hyperarousal were removed because these symptoms could be accounted for by assigning an additional diagnosis of ADHD.

Differential Diagnosis

DMDD cannot be diagnosed if behavioral concerns are exclusively present during a major depressive episode or are better accounted for by another diagnosis. Additionally, DMDD cannot be diagnosed alongside oppositional defiant disorder (ODD) or bipolar disorder, although it can coexist with ADHD, conduct disorder, and substance use disorder. Only DMDD should be assigned if the client meets the criteria for this disorder as well as ODD. Finally, counselors must ensure that no other explanation, such as a medical or neurological condition, better accounts for the behavior.

Note

If an individual has ever experienced a manic or hypomanic episode, the diagnosis of DMDD should not be assigned.

Coding, Recording, and Specifiers

There is only one diagnostic code for DMDD: 296.99 (F34.8). There are no specifiers for this diagnosis.

Diagnostic Criteria for DMDD 296.99 (F34.8)

1. 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.
   
2. The temper outbursts are inconsistent with developmental level.
   
3. The temper outbursts occur, on average, three or more times per week.
   
4. 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, peers).
   
5. Criteria A–D have been present for 12 or more months. Throughout that time, the individual has not had a period lasting 3 or more consecutive months without all of the symptoms in Criteria A–D.
   
6. Criteria A and D are present in at least two of three settings (e.g., at home, at school, with peers) and are severe in at least one of these.
   
7. The diagnosis should not be made for the first time before age 6 years or after age 18 years.
   
8. By history or observation, the age at onset of Criteria A–E is before 10 years.
   
9. There has never been a distinct period lasting more than 1 day during which the full symptoms criteria, except duration, for a manic or hypomanic episode have been met.
   

   Note: Developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation, should not be considered as a symptom of mania or hypomania.

   
   
10. The behaviors do not occur exclusively during an episode of major depressive disorder and are not better explained by another mental disorder (e.g., autism spectrum disorder, posttraumatic stress disorder, separation anxiety disorder, persistent depressive disorder [dysthymia]).
    

    Note: This diagnosis cannot coexist with oppositional defiant disorder, intermittent explosive disorder, or bipolar disorder, though it can coexist with others, including major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and substance use disorder. Individuals whose symptoms meet criteria for both disruptive mood dysregulation disorder and oppositional defiant disorder should only be given the diagnosis of disruptive mood dysregulation disorder. If an individual has ever experienced a manic or hypomanic episode, the diagnosis of disruptive mood dysregulation disorder should not be assigned.

    
    
11. The symptoms are not attributable to the physiological effects of a substance or to another medical or neurological condition.

From Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, 2013, p. 156. Copyright 2013 by the American Psychiatric Association. All rights reserved. Reprinted with permission.

Case Example

Angelo is a 16-year-old Latino American high school student living with his biological, married parents in a middle-class urban environment. He has no siblings and reports feeling particularly close to his mother. Angelo’s dad has traveled extensively for work for the past 7 years, and Angelo reports not having a close relationship with him. Angelo presents as physically healthy although slightly underweight and generally small in stature. His physical appearance is unkempt, his clothes are soiled, and he appears to have problems with personal hygiene. His mother states that getting Angelo to complete daily living activities is often very difficult; she does not push him unless she feels it is very important. When asked about his personal hygiene, Angelo reports that showering is stupid because he is just going to get dirty again, and he feels he looks fine. Aptitude testing suggests Angelo is of above-average intelligence. However, he is in danger of not passing the 11th grade, mainly because of his refusal to turn in homework and failure to attend class. Angelo states that school is pointless because he will never use the information in real life. He frequently gets into verbal conflicts with his teachers.

Angelo reports that he has had many acquaintances over the years but none who are long-term friends. When asked why, he reports that “they are idiots and don’t do what I tell them to do so I stop hanging out with them.” Angelo admits to wanting to hit people when they make him angry. He has been suspended from school for fighting. Angelo is active in sports and excels in baseball, for which he has a high batting average. However, school reports indicate he is frequently left out of the lineup or removed from the game because of excessive anger and verbal aggression toward other players. His coach states that he could have a future in baseball, but his reputation for poor sportsmanship prohibits him from progressing in the sport. He is not friends with any of his teammates.

Angelo’s mother states that beginning at approximately 9 years of age, Angelo began showing signs of undue irritability and outbursts. These outbursts included yelling, throwing objects, and refusing to engage in social or daily living activities. This behavior occurred both at home and at school. Over the course of the past year, Angelo’s outbursts have occurred at least three times per week, with 3 weeks the longest Angelo has gone without an outburst. He has been required to speak to the school counselor two times over the course of the year because of his outbursts. When asked about his mood, Angelo reports feelings of sadness, helplessness, and hopelessness but denies any thoughts of harm to himself. Angelo has never experienced symptoms of a manic episode. Angelo has no history of previous clinical diagnosis or substance utilization.

Diagnostic Questions

1. Do Angelo’s presenting symptoms meet the criteria for a depressive disorder? If so, which disorder?
   
2. Based on the disorder identified in Question 1, which symptom(s) led you to select that diagnosis?
   
3. What would be the reason(s) a counselor may not diagnose Angelo with ODD?
   
4. Would Angelo be more accurately diagnosed with bipolar disorder? If so, why? If not, why not?
   
5. What rule-outs would you consider for Angelo’s case?
   
6. What other information may be needed to make an accurate clinical diagnosis?

Major Changes From DSM-IV-TR to DSM-5

A major and somewhat controversial change to the DSM-5 is the removal of the bereavement exclusion. In the DSM-IV-TR, the diagnosis of major depression was excluded for individuals who experienced depression for up to 2 months after the death of a loved one. The idea of excluding bereaved individuals from diagnosis began with the DSM-III, which noted that “uncomplicated bereavement” is not the same as major depression (Kendler, Myers, & Zisook, 2008). However, researchers and the DSM-5 Task Force have since made the argument that bereavement-related depression does not differ significantly from other stressor-related depressive episodes such as those related to divorce or job loss (APA, 2013c, 2013d). This change is also consistent with long-standing ICD criteria for depression.

Kendler et al. (2008) studied individuals who experienced depression related to various types of stressful life events. They compared responses of those reporting bereavement-related depressive episodes with those who reported other life events as a trigger. The results did not differ significantly in frequency or duration of symptoms, nor did they differ significantly in the number of Criterion A symptoms identified. Participants with bereavement-related depressive symptoms were more likely to be women and tended to be older at age of symptomatology onset. These participants tended to seek treatment less frequently and expressed more fatigue and loss of interest but less guilt than peers who experienced depression related to another stressful event. Because of these and similar research findings, the bereavement exclusion was not carried over to the DSM-5 (APA, 2013c, 2013d).

In response to criticism that removal of bereavement could pathologize a normal grieving process, APA stated that bereavement does not always lead to a diagnosis of MDD. Whereas a natural grieving process can occur without a diagnosis of MDD, individuals who experience clinically significant and impairing symptoms deserve appropriate care for concerns related to bereavement and depression. In recognition of this difficult balance, the DSM-5 includes language that advises practitioners to carefully differentiate normal grieving from MDD.