Wednesday, February 10, 2010

Say Hello to Temper Dysregulation Disorder with Dysphoria

The buzz around the new version of the DSM is already starting. The draft version is now online and it features a new condition with the ungainly moniker of "Temper Dysregulation Disorder with Dysphoria." That's a friggin' mouthful, so let's try T-Triple D for short. WTF is this disorder? Well, according to my first look, it closely resembles the bad-behavin' kids who have been labeled as bipolar for the last few years. The symptoms are below, and can also be found on the official DSM-V website:

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.

I've not given this a lot of thought yet. The committee that examined the topic has some discussion of T-Triple D/bipolar here and here. The committee takes a couple of digs at the the child bipolar diagnosis. So if this new disorder is adopted, we're going to have yet another name for children who behave badly. Fortunately, the criteria appear to require much worse behavior than what has been passing for "bipolar" according to some child psychiatrists. The diagnostic threshold is higher and should theoretically lead to fewer kids being unnecessarily diagnosed. But even if the current criteria are adopted without any changes - look for a movement to diagnose "subthreshold" cases of T-DDD, as untreated subthreshold T-DDD will be found to cause untold psychological and physical damages across the world. Damages that can only be mitigated through aggressive treatment using [insert name of latest patented tranquilizer here]. So whatever antipsychotics or "mood stabilizers" are hot in 2013 when the DSM-V is released... they will be the "cure" for T-DDD or bipolar or whatever the hell we decide to label kids with behavior problems.

That's my first impression. This is definitely going to be a hot-button topic. There is apparently some mechanism to send comments to the DSM-V folks, since this is only a draft version - feel free to comment here or send your ideas to the DSM-V posse.


The Shrink said...

I'm uneasy. Rather than a specific neuropsychiatric or biological disorder, it's a symptom cluster of undesirable behaviours being elevated to an "illness" necessitating "treatment" which inevitably will involve medication.

This is bad medicine, no? It erodes the veracity of biomedical neorupsychiatry whilst also diminishing psychosocial psychiatry (through formulating psychological experiences as psychiatric illness).

Lose, lose, to my mind. Unless you're a drug company . . .

Anonymous said...

Sounds like this author has this disorder with all the cursing and anger going on here. S/he has also probably not lived with a child that "behaves badly", because he would be looking for any help possible to bring sanity to his world by helping this child behave better; whether it be in the form of the latest "tranquilizer" or other treatments.

From one who needs hekp.

CL Psych said...

Anon: Yes, I definitely have this disorder - thank you for pointing this out. Your witty remarks have really put me in my place.

JC said...

I would be more than excited if they simply and explicitly removed the word disorder for the obvious reasons, but as a "victim" of Biederman's academic/clinical tyranny in the Boston area and confirmational proof of all the longitudinal data, I am still very pleased. Here's why.

1. This group of children will be diagnosed with something explicitly not Bipolar Disorder. Say goodbye to pharmacological-only treatment.

2. Secondly, intellectually, they did an honest job of calling a spade a spade, and so whether for treatment purposes or diagnosis purposes this will allow for more intellectually honest research to be done in these areas.

3. I do not like labeling either, and wish they would simply remove the word Disorder because it tends to impart this unjustified validity to the diagnosis and as such its a lot stickier than it should ever be, but, this change will still save tens of thousands of kids from the grips of a BP diagnosis and massive overmedication, and basically (hopefully) every hairbrained idea that has ever come out of Mass General Child Psychiatry. Furthermore, hopefully, researchers will be able to discern what it is about this presentation of symptoms that imparts a high risk of depressive disorders later on ( i can think of a million ) and then do something about it.

Either way I see this as a resounding rebuke, slap in the face even, to those awful, greedy, dishonest, intellectually disabled zealots that will better the lives of thousands of young kids in situations that need to be changed, and will spare them the agony of having their body and self-concept assaulted by this diagnosis and treatment all through their developing years, while the cause of their problems remains unchanged and ignored by the psychiatric community.

Let's face it. Rebecca Riley lived in an abusive home, where she had no help in learning how to regulate herself, and was obviously not cherished by either abusive parent. That such a grave an unambiguous predicament for the girl could be so epically ignored by her Child Psychiatrist, incompetent, lazy to look into things, whatever, is a disgusting testament to the putrid ideas emanating from MGH.

Again, slap in the face to Biederman, Wozniak, Wilens, Prince, et al, I'm happy. I really wish this happened 10 years ago because I'm sure Rebecca and I would be doing a lot better than the present state of affairs.

Anonymous said...

Psychiatry is pathetic and has deteriorated to the state of religion where we must await word from the high priests as to what constitutes a sin/disease or not. How can rational people be taken in by this nonsense? I suppose there is no alternative for psychiatry anymore than there is for Rome.T-DDD. Yet another psychiatric disorder with no basis but for the unmet expectations of failing parents and healthcare providers looking to rationalize their existence. Ugh.

Neuroskeptic said...

Can you have a disorder that doesn't officially exist yet?? Anonymous thinks so... I'm not sure.

Seriously though, this seems like a defeat for the "pediatric bipolar" crowd, but if you define PBD out of existence only by creating a new disorder - which, presumably, will "benefit from" pharmacological treatment in the same way (i.e. giving sedating drugs to kids with this disorder will indeed sedate them more than placebo, which is all most RCTs show) - I'm not sure this is a good thing.

Bob said...

I was a single father raising two kids for over 10 years. Both had AD/HD, OCD, Depression and one has Aspergers.

I have met few MHR Professionals who can even relate to what it is like to be 24/7 with kids like mine. Today, with more patience and focus than most people would ever deliver, the kids are young adults with reasonably good behaviors.

I will be the first person to admit that we have much to learn about the human body especially in the area of brain chemistry et al.

I caution all the MH/MR Professionals to step easy here and not jump to another acronym with light speed.

It has become clear to me that the pharmaceutical firms are very much driving the plane in many cases.

I encourage the MH/MR professionals to truly study before you pop out another diagnosis. Sure, more college studies and clinical trials will drive this stuff.

Ultimately, my kids made it this far becuase I placed them ahead of all else. Another pill is not neccessarily the answer.

The U.S. is one of the sickest countries in the world. We have more doctors, hospitals, ER's and pills than any other country in the world.

I would encourage Western medicine to learn about Eastern practices. I am sorry that this will create a financial hardship on the pill makers but such is life.

Do your research and do it well. We do not always have the need to reinvent something.


DigiMarco said...

Whoops, I'm ten years late for my meds!

Seriously, I'm wondering, "whatever happened to 'the parents are poor, and the child's acting out because he's mad and sad?'" It sounds like a situation that you can work through and learn a lot from.

Can't learn so much with meds, though. If you take away the symptoms forcefully, through meds, then what chance do you have of learning from your negative emotions? I have a friend who acts all hyper ADD without her meds -- and her parents look really neglectful.

Perhaps definitions like these are made to accommodate parents, loved ones, and everyone else, who don't care and want an easy fix-all med solution so they don't deal with bad kids? Sorry, I'm a college student -- that's just my guess. :)

Anonymous said...

You know, I have always been puzzled by DSM criteria for "mental " illness in light of the current wave of biological psychiatric hegemony. How come all of these listed supposed "brain" disorders diagnoses contain the exclusion criteria that the symptoms cannot be due to the direct effects of a medical or neurological condition? WTF? Am I missing something here? I mean, if you are going to claim these are "brain" disorders or "neurobiological illnesses" than aren't all of the symptoms due to a medical/neurological condition? Can some one educate me as to psychiatry's oxymoronic and epistemological status?

A said...

I don't see the huge bandwagon of apologies being passed along to the duped parents of false "bipolar" kids in this newest DDD disease creating revelation.

Just another way to keep the greed ball rolling on pathogizing the broad range of normal developmental behaviors in children with a dangerous disease mongering/drugging modality.

Of course for people like "Anonymous" above that always need an excuse to avoid the focus being placed on "Poor Parenting skills", or on "reflecting their own unresolved control/anger issues upon children", and finally the "quick fix " of a disease to point the finger at as their grand DSM solution to absolve so many questionable parents of their innate personal responsibility.

Heck, once you throw in what a mass market "cash cow" this creates, and you have a perfect storm of destroyed and maimed children for many generations to come.

Nice job DSM committee

doctorz said...

T-DDD sounds like ODD but less descriptive in scope. Of course, this is by design since we have ample literature revealing the limitations of psychotropic medications in effecting a positive outcome for ODD. T-DDD is a step in the right direction away from pediatric Bipolar, but we'd be better off without it, since Big Pharma and academic psychiatry will continue to collude in promoting drug treatment of what is ostensibly an externalizing behavior disorder. Reductionism in psychiatry continues!! What Voltaire said centuries ago, applies more than ever today...Doctors are people who prescribe drugs of which they know little for diseases of which they know less to people of whom they know nothing.

doctorz said...

Also, Harvard psychiatrist Jordan Smoller's hilarious satire on the subject of overdiagnosing children seems apropos at this juncture...

Nicole said...

Bad kids and poor parenting? Really? How does that explain a family with multiple kids in which all but one display typical "good behavior" with age appropriate emotions and behavior? How does that explain a child who is clearly upset and embarrassed after tantrums and outbursts, who cries and asks for help to stop acting the way he does?
I'm not sure what the answer is, and I'm frustrated to no end with psychologists that just want to slap a diagnosis on my child (BP at 4yo-which we did not allow) medicate him (which we also did not allow) and send us on our way. But labeling us as bad parents and our son, now 6, as a bad kid is simplistic, narrow minded and highly offensive.

LivePsychiatry said...

Great post!

I find it sad that so many people are ignorant of the reality of things.

Bipolar disorder is a serious problem amongst todays children.

Mark p.s.2 said...

You can read-see visual aids of this disorder on called "fffffuuuuuu".

Anonymous said...

Wow, sounds like my girlfriend!!! Lol, not sure how this differs from a basic borderline personality, but I guess we all need to keep busy somehow..

Anonymous said...

I'm so glad that you people are so cavalierly disregarding the families torn apart by pediatric mood and behavioral issues by blaming the parents for these behaviors. What happens when parenting is not enough?
I want you to come over to my house for the next six months and show me how to avoid physically restraining my daughter when she flies into uncontrollable rages 2-3 times a day! Then let me know if my Magic 1-2-3, Developing Capable People, or any other parenting skills are being so poorly applied that I am neglecting the growth and development of my child.
It is obvious to me that NONE of you have any idea what families like mine are going through. We are not harkening to the drug companies, but when I can see my daughter emerge from this hell and begin living her life in an engaged way with her parents, family and friends by taking medication, I will continue to seek out any help and support from the mental health community that they can offer; pharmaceutical or otherwise. To NOT seek help would be the travesty in this situation.
This proposed diagnosis is the closest thing to an explanation that I've seen in the past six years. Since no pharmaceutical companies label their drugs for pediatric use (don't believe me? Ask them yourselves!), this is not an attempt to corner the market so to speak. I for one hope this is a turning point to truly identify and differentiate pediatric behaviors that need additional attention.

Parent said...

Anyone who thinks this is ridiculous, obviously does not have a child that slips in between all of the diagnoses of ADHD, ODD, Bipolar... When your child has so much to offer, beautiful, smart, talented...however...cannot control their behavior and does not respond well to ADHD meds even though they can't focus for more than 5 minutes in class. A child who cannot catch a break in school because everyone has decided that they are just a kid with behavior issues and they are marked for good... Then you can rattle off all of your opinions about the world of over-diagnosing. And yes, many parents are grateful that they see an description of their child's behavior so they know they are not going crazy themselves or the worst parent ever, despite your 110% effort of doing the right thing for your child. Be careful what you are quick to judge because one day someone very special to you may need just what you are being so negative about. Deal with one of these issues and then make judgment about excuses for poor parenting. These people are professionals and sound completely ignorant...that is what is ridiculous...Not the diagnoses

Anonymous said...

Whether its Early Onset Bipolar or some other label, this set of descriptors mirrors exactly what my own child is dealing with. I feel no compulsion to explain myself or defend his challenges from bloggers with big words. But I do find the newest label helpful and I am hopeful that research will continue to reveal how the biology and psychology overlap. The drugs help my son be more himself...the delightful and brilliant self, not the angry and violent self. None-the-less, he hasn't had a "good day," for a full day, in years. No wonder this leads to depression as an adult.

All of that being said, I do think that psychology is filled with know-it-alls without a clue. It took 2 years working with snobby psychologist, and hundreds of dollars, before a smart psychiatrist (who spent hours with us as a family, not minutes between sips of coffee) nailed what my child's specific challenge was and offered help.

holmegm said...

Yet another parent here ... four children, one of which is (currently) diagnosed with Mood Disorder NOS.

The other three respond to normal parenting. She doesn't. "Simple" as that.

Smug dismissals - "wow, a diagnosis for temper tantrums?" - are just kicking people who are down. Blaming parents ... well, that's practically sadism, or would be, if those doing it knew what they were doing.

This condition - and it is a condition, no matter what you call it - is so far beyond normal ... it's indescribable. If you try to describe it, people try to fit what you are saying into what they know. But it's so far beyond what they know, they don't or won't hear it.