The Diagnosis of DMDD

The diagnostic criteria and decisional rules for DMDD in the DSM-5 are rather detailed, so only a summary will be provided here. (Readers should consult pages 156–160 in the DSM-5 for more detailed information.) The core diagnostic features for DMDD include recurrent (3 or more times a week) temper outbursts that are developmentally inappropriate, severe, and disproportionate to any identifiable stressor along with the persistence of a chronically irritable or angry mood between these temper outbursts—a disruption in mood that is noticeable by others. These symptoms must have begun before the age of 10, persist for a minimum of a year (with no more than 3 consecutive months of symptom-free periods), and be present in at least two out of three settings (i.e., home, school, peer relationships). According to the DSM-5, this diagnosis should not be made if these symptoms occur exclusively during a major depressive episode or if the symptoms are better explained by another mental disorder, such as autism spectrum disorder. Also, a diagnosis of DMDD cannot be given concurrently with oppositional defiant disorder (ODD), bipolar disorder, or intermittent explosive disorder. If a child meets the diagnostic criteria for both DMDD and ODD, only DMDD should be given. As mentioned previously, DMDD was specifically added to the DSM-5 to prevent clinicians from overdiagnosing bipolar and related disorder in children and adolescents who exhibit non- episodic irritability and temper outbursts. However, at first glance, a youth who meets the diagnostic criteria for DMDD may be suspected of having a bipolar and related disorder. Thus, it is important for counselors to recognize the fundamental differences between the two disorder classifications.

As explained above, in DMDD, a child or adolescent experiences non-episodic irritability that is punctuated by severe and disproportionate temper outbursts. This symptom presentation must occur for at least 365 days, and during the year, have no more than a 3-month period in which the child or adolescent does not experience the core features of the disorder. In contrast, youth who meet the diagnostic criteria for bipolar disorder experience distinctive episodes of mania (at least 7 days), hypomania (at least 4 days), or depression (at least 14 days). Although irritability and temper outbursts can certainly occur in the context of a manic or hypomanic episode, there are additional symptoms that must also be present. Specifically, the irritability or temper outbursts should be episodic, accompanied by an increase in goal-directed activity/energy, and include additional symptoms, such as grandiosity, decreased need for sleep, pressured speech, racing thoughts, or reckless impulsivity. More information on the differential diagnosis of bipolar disorder from DMDD and other conditions can be found in Hatchett and Motley.