Temper Dysregulation Disorder with Dysphoria

Temper Dysregulation Disorder with Dysphoria

Well, it is a little late, but here is my post about a new, proposed disorder entitled Temper Dysregulation Disorder with Dysphoria, or TDD for short.  I guess that best way to present this disorder will be with a little history, at least as I understand it.  As many of you probably know, the past 10-20 years has seen a HUGE increase in the number of children diagnosed with Bipolar Disorder.  This is somewhat of a big deal for three reasons.

First, there are no specified diagnostic criteria for Bipolar Disorder in children.  The criteria typically used to diagnose kids are the adult criteria delineated in the DSM-IV-TR, the diagnostic “bible” for mental health conditions.

Second, although the adult criteria are used to make the diagnosis of Bipolar Disorder in children, most children do not meet the criteria.  For example, in the DSM-IV-TR, manic episodes (the hallmark feature of Bipolar Disorder Type I) must last for up to a week.  Similarly, hypomanic episodes (symptoms similar to manic episodes only not as impairing and are necessary for a diagnosis of Bipolar Disorder Type II) has to be present for at least four days.  “Manic” episodes in children tend to last a few hours at a time.  Because of this, researchers and clinicians began using words such as “ultra-rapid cycling” to describe bipolar mood swings in children as a way to make the symptoms in children “fit” the adult criteria.

Third, because researchers and clinicians use the diagnosis of Bipolar Disorder for these children, they tend to use medications for Bipolar Disorder.  These include heavy psychotropic drugs designed and tested in adults, and rarely approved by the FDA for use in children.  As a result, we have a growing population of children on antipsychotic and other mood stabilizing medications that may have unknown affects on development.

[Let me add a quick caveat here before I go any further.  As you know, I am not a medical doctor and I do not prescribe medication.  However, I do think that medications are needed in many situations.  I often refer my patients to psychiatrists to explore the need for medication when behavioral approaches are not successful.  I say this to make sure that you are aware that I am not anti-medication.  Rather, I am a proponent of research and safety and feel as though a balance between clinical efficacy and safety must be evaluated in most of the medications used in children.  Now, back to the blog.]

Because of some of our early work, a colleague (Dr. Richard Marshall, a co-administrator on this blog) and I have conducted lectures up and down the east coast of the US on Early Onset Bipolar Disorder for about 7 years.  Since the beginning, we have been adamant that Bipolar Disorder is a label being used to identify children with a particular set of behaviors.  We do not know if it really is Bipolar Disorder.  Rather, Bipolar Disorder is the label given so that clinicians discussing these children have a common frame of reference.  That said, let me describe these children.

Overall, these children can be characterized with one word… Irritable.  These children are irritable from the time they wake up until they go to bed.  Parents use statements such as “walking on egg shells” to describe their household.  Everyone in the home works to prevent the child’s irritability from exploding into a rage that could last up to an hour, if not longer.  While there may be times where the child is pleasant and loving, those time periods usually last as long as they are getting what they want.  As soon as demands are placed upon them, the irritability returns in full force.  These children are often aggressive (physically and verbally)  to people, toys and other objects.  They tend to express violent themes in play and conversation.  They are drawn to aggression and violence in movies and video games.  Another difficult characteristic of these children is that they do not sleep well.  These children take a long time to fall asleep, are restless throughout the night, and wake up in the morning in a very bad mood.  Finally, their behaviors and “attitude” tend to result in poor social skills and the lack of friends and relationships.

Presented in this way, these children do not really sound Bipolar.  There are no clear and persisting “manic” behaviors.  Rather, most of these children have persistent irritability that affects their ability to regulate their emotions.  They “fly off the handle” with very little (and sometimes no) provocation.  All that is required for these children to “explode” is a “perceived threat.”  Perceived meaning that the child believes it to be the case (even if not real).  Threat meaning that things are not going the way in which the child wants.

As time has passed, researchers and some clinicians have moved away from a diagnosis of Bipolar Disorder and are moving towards the more descriptive label of “Emotional Dysregulation.”   This label seems to more accurately describe the child’s presenting behaviors and is somewhat less stigmatizing than Bipolar Disorder.

In the upcoming revision of the DSM (in 2013, the DSM-V will be published) the committee is proposing to include a diagnosis that formally identifies children with the behaviors described above.  To do so, they are recognizing that Bipolar Disorder is a poor label for the condition and moving in a direction that may lead to alternative treatment ideas.  Currently, the proposed diagnosis is TDD, though there are some that would prefer to replace “Temper” with “Emotional”.  Some information about this condition, including diagnostic criteria, can already be found on the DSM-V website (www.dsm5.org).

In my next blog, I will continue to talk about TDD, but plan to focus on treatment ideas.  I will touch on medications used as well as other methods for working with these children at home and at school.

Dr. B.