By Nestor Lopez-Duran PhD
Today the American Psychiatric Association released a draft of the major changes that are expected in the new version of the Diagnostic and Statistical Manual of Mental Disorder 5th Edition (DSM-V). While most people in the field will be underwhelmed by the relatively minor changes, there are a few areas where the DSM-V will likely make some drastic changes. Today most of the news coverage was focused on the proposed changes to the Autism diagnosis, which has raised some heated debate in the autism community. However, there is another major change that has received little, if any, attention: the clarification that a syndrome that in recent years has been labeled childhood bipolar disorder is actually NOT bipolar disorder. Instead, a new disorder category was created: Temper Dysregulation Disorder with Dysphoria (TDD).
Let me start by explaining that the creation of TDD does NOT deny the existence of classic bipolar disorder in childhood. That is, although extremely rare, bipolar disorder can occur in children and adolescents, and it looks very much like adult bipolar. Instead, TDD was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. The available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood. This means that thousands of children that have been diagnosed with childhood bipolar disorder may not have bipolar and instead have a completely different syndrome now called Temper Dysregulation Disorder with Dysphoria.
So what is TDD?
Here is the proposed criteria for TDD:
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., 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; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
The syndrome captured by section A-C (frequent and intense temper outbursts, happening several times per week in the context of negative emotionality) is the core of the symptoms that has been incorrectly interpreted as indicative of childhood bipolar disorder. Section H is very interesting. It states that this diagnosis is not appropriate if the person has experienced classic mania (e.g., bnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.
So why did the DSM-V decide that this syndrome is not simply bipolar disorder of childhood?
1. Lack of continuity to bipolar.
If TDD is simply the expression of bipolar disorder during childhood, then children diagnosed with this condition would eventually develop symptoms of classic bipolar disorder as they reach adulthood. The data do not support this hypothesis. That is, children who display the TDD syndrome in childhood (and are often incorrectly diagnosed as bipolar) are not more likely to develop classic bipolar disorder later in life as their peers (see Brotman et al., 2006; Leibenluft et al, 2006; Stringaris et al, 2009). Instead, these children are more likely to develop depression, not bipolar!
2. Different Biological Markets.
Youth who are diagnosed with classic bipolar differ significantly from those who have a TDD-like syndrome (see Brotman et al, 2010; Guyer et al, 2007; Rich et al, 2008). If TDD is simply bipolar, then the biomarkers of TDD should be similar to those of bipolar, but this is not the case.
3. Different Demographic Factors.
If TDD is simply bipolar, then the gender distribution of TDD should be similar to that of bipolar. This does not appear to be the case. Specifically, there is no gender differences in the rate of classic bipolar; male and females are equally likely to develop the condition. However, the TDD-like syndrome is disproportionately observed in boys rather than girls.
4. A need for a new category that would impact treatment and research.
In theory, the presence of TDD will educate clinicians, researchers, and the public that this syndrome is not simply a version of bipolar disorder. This would facilitate research on the causes, features, and treatments for this condition. This has major implications for treatment. For example, the standard treatment for bipolar disorder does NOT seem to work in children that have the TDD syndrome (Dickstein et al, 2009). By explicitly stating that TDD is not bipolar, researchers would be less likely to approach the search for treatments from a bipolar framework, which would potentially facilitate the discovery of more effective interventions.
I am actually glad about this change as it will have a clear impact on clinical practice and research that will most likely benefit the children affected with this condition.
Brotman MA, Schmajuk M, Rich BA, Dickstein DP, Guyer AE, Costello EJ, Egger HL, Angold A, Pine DS, & Leibenluft E (2006). Prevalence, clinical correlates, and longitudinal course of severe mood dysregulation in children. Biological psychiatry, 60 (9), 991-7 PMID: 17056393
Dickstein DP, Towbin KE, Van Der Veen JW, Rich BA, Brotman MA, Knopf L, Onelio L, Pine DS, Leibenluft E (2009): Randomized double-blind placebo-controlled trial of lithium in youth with severe mood dysregulation. J Child Adolesc Psychopharm 19: 61-73
Guyer AE, McClure EB, Adler AD, Brotman MA, Rich BA, Kimes AS, Pine DS, Ernst M, Leibenluft E (2007): Specificity of face emotion labeling deficits in childhood psychopathology. Journal of Child Psychiatry and Psychology, 48:863-71
Leibenluft E, Charney DS, Towbin KE, Bhangoo RK, Pine DS (2003): Defining clinical phenotypes of juvenile mania. Am J Psychiatry 160: 430-437
Rich BA, Grimley ME, Schmajuk M, Blair KS, Blair RJR, Leibenluft E (2008): Face emotion labeling deficits in children with bipolar disorder and severe mood dysregulation. Development and Psychopathology 20: 529-546
Stringaris A, Cohen P, Pine DS, Leibenluft E (2009): Adult outcomes of adolescent irritabilty: A 20-year community follow-up. Am J Psychiatry 166: 1048-54