A Child Psychiatrist's Thoughts on DSM-5: Disruptive Mood Dysregulation Disorder

This is part 6 of my series on the DSM-5. Previous posts covered general impressions, PTSD, ADHD, autism, and bipolar.

One of the most controversial additions to DSM-5 has to be disruptive mood dysregulation disorder (DMDD), née temper dysregulation disorder with dysphoria (TDDD). The name was supposedly changed because some objected to the negative connotations of saying a child has a temper disorder. This diagnosis tries to answer the question: "So what do we call children who display chronic irritability and have severe tantrums, but do not really have the classic manic or hypomanic symptoms of bipolar disorder?"

The DMDD diagnosis largely grew out of research by Ellen Leibenluft at the NIMH. Her studies examining "broad phenotype" bipolar disorder (the kind of BD advanced by Wozniak, Biederman, et al, which Leibenluft prefers to call "severe mood dysregulation", or SMD) showed that children with this condition were more likely to be diagnosed with depression as young adults, but did not appear at elevated risk of developing actual manic episodes. JAACAP just published a very good review article in May that summarizes the differences between SMD and bipolar.

The DSM-5 mood disorders work group took SMD and modified it to become DMDD. The two are largely similar, with the main difference being that DMDD does not require hyperarousal symptoms such as insomnia, racing thoughts, or intrusiveness. One can certainly argue that there's less evidence to support SMD/DMDD as a distinct entity than there is for other conditions (such as melancholia) which did not end up in the DSM-5 as a separate disorder. Obviously, the DSM is based on an expert consensus process, which reflects politics and cultural trends, not just science. This is neither good nor bad, but just the way the DSM has always been.

Most online reports about DMDD that I have seen have been wrong or misleading (example 1, example 2) because they tend to focus on the mistaken notion that DMDD is just about temper tantrums. The actual diagnostic criteria include: 1) Severe recurrent temper tantrums, inconsistent with developmental level, that are out of proportion to the situation, occurring 3+ times per week; 2) Mood between tantrums is angry or irritable for most of the day, almost every day; 3) Symptoms have lasted more than a year; 4) Must be present in at least 2 settings (school, home, peers).

The symptoms must have an onset by the age of 10, so that the irritable mood of adolescence does not become a confounding factor, and the diagnosis cannot be made for the first time before age 6 or after age 18. The diagnosis also supersedes oppositional defiant disorder (ODD), and can be viewed as a more severe form of ODD. These are pretty stringent criteria, designed specifically to capture severe impairment. In Dr. Leibenluft's SMD population, around 38% of those children have had at least one psychiatric hospitalization. In the past year, I have seen 2, maybe 3 children who would meet the criteria for DMDD.

At last year's American Academy of Child and Adolescent Psychiatry meeting, Dr. Leibenluft, when asked about the new DSM-5 diagnosis, said "I'm about 65% pro-DMDD." I think that's as good an illustration as any that there's very little certainty in psychiatry, and there are pros and cons to the creation of any new diagnosis.

In this case, I think it's good that there is an alternative to labeling irritable, tantrum-prone children as having bipolar. Currently, like ODD, there are no medications for DMDD, so the focus should be on psychotherapeutic and family interventions. On the other hand, I'm sure many folks will end up ignoring the diagnostic criteria altogether and call any tantrum-prone child "DMDD." Also, I'd be surprised if Abilify does not become FDA-approved for treating DMDD by 2016.

Update (4/15/15): I've written a new post with my current thoughts on DMDD, including a review of recent research. You can read it here.

A Child Psychiatrist's Thoughts on DSM-5: Bipolar Disorder

This is part 5 of my series on the DSM-5. Previous posts covered general impressions, PTSD, ADHD, and autism.

Though I did not want to focus on the whole pediatric bipolar controversy in this post, it would be hard to discuss bipolar disorder in the DSM-5 without some historical context. Briefly, in the 1990's, different groups of researchers started to apply the label of bipolar disorder to children. Janet Wozniak at Massachusetts General Hospital (see this NPR story for a good summary) characterized a population of children with ADHD (and often oppositional defiant disorder) whose severe irritable moods and tantrums seemed extreme to the point of appearing "manic-like."

Another major proponent of childhood bipolar disorder was Barbara Geller at Washington University in St. Louis. Her perspective was that children who had bipolar disorder were not just irritable or had severe tantrums, but displayed classic manic symptoms like grandiosity, euphoria, and increased goal-directed activity. However, her child patients had these symptoms in much briefer episodes than adults did, with ultra-rapid cycling of moods over the course of a day for many months or even years in a row. This eventually led to a study in which the children and teens who participated had "manic episodes" lasting almost 5 years in duration.

Around the same time, there was certainly a strong trend of adults with chronic irritability (e.g. those with borderline personality disorder, substance dependence, PTSD, etc.) being diagnosed with bipolar disorder because of "mood swings." This is despite the fact that manic or hypomanic episodes have to be episodic (instead of chronic) and present for at least 4 days (for bipolar type II) or 7 days (for bipolar type I) in order to meet the DSM-IV criteria. Clearly, many clinicians just ignore those criteria and go with their gut or with what's diagnostically in vogue. And even though I typically like NOS diagnoses, "bipolar disorder, not otherwise specified" is especially insidious since it allows someone to be diagnosed as "bipolar" even though they've never really had a manic or hypomanic episode.

Using a nonspecific bipolar diagnosis seemed to happen more often with children, since so few have "classic" (or "narrow phenotype") bipolar disorder. It certainly didn't help that many of the manic symptoms seen in adults with bipolar disorder (increased energy, racing thoughts, hypertalkativeness, and distractibility) are also found in kids with ADHD. With the publication of the popular book The Bipolar Child, rates of diagnosis of bipolar disorder in children reached epidemic proportions by the mid-2000's, and many kids were put on antipsychotic medications (see this detailed post at 1 Boring Old Man for a good summary).

With respect to bipolar disorder in the DSM-5, it would appear that the proponents of narrow spectrum bipolar disorder have won the day. Thus, there is no change in the DSM-5 definition of mania or hypomania, and no modifications to loosen the criteria in children. The DSM-5 also places greater emphasis on the fact that bipolar is an episodic disorder. The mood disorders work group tried to clean up bipolar NOS as well, adding a category called "other specified bipolar and related disorder," which includes those who have hypomanic episodes lasting 2-3 days, hypomania without a depressive episode, depressive episodes with some hypomanic symptoms, and short duration cyclothymia. Additionally, "rapid cycling" still refers to 4 or more mood episodes per year, rather than what Dr. Geller and her colleagues described.

So what about those kids who seem like they're constantly "manic?" Stay tuned for my post on disruptive mood dysregulation disorder (DMDD).

Preventing Transition to Schizophrenia: What Doesn't Work, What Might

One of the reasons I decided to become a child psychiatrist was seeing the devastating effects of schizophrenia in adult patients during medical school, and knowing even then how inadequate the treatments were. I thought that by working with children and adolescents, that someday I might be a part of preventing someone from developing schizophrenia in the first place.

However, during residency, I became more jaded about early intervention in treating "prodromal" symptoms, in large part because the institution where I was training emphasized biological treatments above all else. One professor, who had close ties to multiple pharmaceutical companies, exhorted us to use antipsychotic medications not only for teenagers with odd thinking or behaviors, but also for those with paranoid or schizotypal personalities, despite there not being a damn bit of evidence this would help anything.

When the evidence did start coming in for the use of antipsychotics to prevent transition to schizophrenia, it was not encouraging. From the most recent meta-analysis I could find:

One study compared CBT and risperidone with CBT and placebo. Very low quality evidence within the first six months of treatment suggested no difference in transition to psychosis (risk ratio 1.02 (95% confidence interval 0.15 to 6.94)), which remained at 12 months (1.02 (0.39 to 2.67)). Differences in symptoms of psychosis (total, positive, or negative), depression, and quality of life were not significant. Dropout was similar between groups (1.09 (0.62 to 1.92)), although the evidence was also rated as very low quality.

There was very low quality evidence for the benefits and harms associated with olanzapine, from one study comparing olanzapine with placebo. We saw no difference in transition to psychosis after 12 months (risk ratio 0.44 (95% confidence interval 0.17 to 1.08)). Dropout was similar between groups at 12 months (1.59 (0.88 to 2.88)). For participants taking olanzapine, there was a large effect on weight during the first eight weeks (standardised mean difference 0.81 (0.28 to 1.34)), which remained large at 12 months (1.18 (0.62 to 1.73)). Effects on symptoms of psychosis (total, positive, or negative), depression, and mania were not significant. Data at 24 months were not analysed because fewer than 50% of participants remained.

Thus, I was somewhat skeptical when I saw this on the Twitter yesterday:

Early detection and intervention program prevents conversion to psychosis bit.ly/12xVJmI #APAAM13
— Medscape Psychiatry (@MedscapePsych) May 23, 2013

Looking at the article (link is to Google's cached version in case you don't have a Medscape login), it described a comprehensive treatment program, implemented community-wide in Portland, Maine, that has "significantly reduced hospitalization rates for initial psychosis by one third." More encouraging was the fact that this program has successfully been replicated at 5 other locations across the country, and according to lead investigator Dr. William McFarlane, rates of conversion to psychosis were "almost identical" between the prodromal group and a control group. What the program actually entails is interesting, and a very different approach to just using an antipsychotic or doing CBT:

As part of the program, at-risk youth, identified with the Structured Interview for the Prodromal Syndromes (SIPS), are offered a comprehensive package of treatment consisting of family education, assertive community treatment, supported education/employment, and low-dose psychotropic medication.

Looking elsewhere, I found more details about the 8 components of the family-aided community treatment (FACT) program in this dissertation. I've truncated each of the bullet points to save space:

• Community education and outreach: Early Assessment and Support Team/Alliance representatives go into the community to increase awareness about psychosis and to encourage early referrals. These education efforts are offered to a wide range of audiences...
• Targeted outreach to those in need: Psychosis is often frightening, and even the thought of being diagnosed with such a serious mental health condition may cause a young person to refuse to seek help. Team members meet the youth and family at their level of readiness to form a relationship built on trust. Services are strengths focused and oriented toward issues young people find relevant...
• Consistent services in the transition from adolescence to adulthood: Services are provided to teens and young adults by the same team...there is no discontinuity of care or caregiver teams just because a person ages out of childhood services.
• Supported employment/education specialist: This specialist works closely with each program participant...the majority of young people involved with [this program] do not pursue federal disability funding.
• Psychopharmacology treatment options: When it comes to medications, [the program] emphasizes education and choice. Medications are used cautiously, and close attention is paid to the side effects experienced by the individual.
• Occupational therapists: These specialists are available to help assess and provide treatment for underlying sensory, cognitive, and functional issues.
• Family inclusion: Families are viewed as essential partners in the decision making process. Most families participate in evidence-based multifamily psychoeducation treatment focused on increasing knowledge, reducing conflict, and problem solving.
• Commitment from systems leaders: State and regional leaders work together to develop and realign funding streams, regulations, and workplace policies to best serve individuals in a flexible way, without barriers such as insurance restrictions and gaps between child and adult systems.

Since I was not at the APA, I have no idea how many of the participants in this program were on antipsychotic medications, or whether they could estimate how much the medications actually contributed to the overall outcome. However, I would be willing to bet that the program would work quite well even without the medication component.

Notably, this research is supported not by the NIMH, but by the Robert Wood Johnson Foundation, "the nation's largest philanthropy devoted solely to the public's health." This public health approach is what we need more of in mental health: It takes a village, not just a pill.

A Most Influential Professor

On the first day of Abnormal Psychology class, The Professor sat on stage, just him with his cane, no notes or Powerpoint. His jowls hung low, giving him a bulldog look. Instead of appearing mean, however, he seemed almost bored, in a wizened sort of way. The Professor began by asking the class to come up with all of the different names that exist in our culture for someone who is "crazy." Students got into it, enthusiastically shouting out dozens of nouns, ranging from the clinical (psychotic, delusional) to the pejorative (nutso, wacko). A graduate assistant wrote all of the words down on a chalkboard while The Professor continued to sit, expressionless. There were almost 50 words on the board by the time people started running out of ideas. "What is the purpose of all these words," The Professor asked us, before answering himself that they are labels, used by those who were "well" or "normal," to define those who were "not normal."

He proceeded to launch into an explanation of his background. "I am an insight-oriented object-relations psychodynamic psychotherapist," he began, and while I had no idea what that actually meant, I was impressed by his certainty. Mental illnesses, he explained, are nothing like physical illnesses. Psychiatric labels are cultural inventions, a "word game" that cannot be separated from the time and the place in which those words originated. "I do not believe in biological reductionism or determinism," he continued, speaking in composed paragraphs to students who were used to hearing bullet points. He lamented how biological treatments have taken over much of mental health, and he told us that we would spend little class time covering conditions like depression, anxiety, or schizophrenia. Instead, he focused on conditions for which there were no medications (at least at the time): Conversion and other somatoform disorders, dissociation, addictions, eating disorders, and of course, personality disorders.

Over the course of the semester, The Professor repeatedly emphasized to us that human traits are on a continuum, even though the DSM tried to fit everything into discrete categories. He used his own dimensional scale to rate each patient on various traits such as impulsivity, neuroticism, and even adaptive regression in the service of the ego. He staged live demonstrations in front of the class in which he interviewed actors trained to portray patients with various psychopathologies; the auditorium was so crowded on those days that I'm convinced he could have sold tickets.

The Professor told us many stories, colorful and memorable. He mesmerized us with tales of 18th century mass hysteria. He lectured authoritatively on the superego lacunae present in those with narcissistic and antisocial personalities, and I could not help but visualize Swiss cheese. He recounted many of his own experiences with patients, especially those with histrionic and borderline personalities, whom he described as very "kiss kiss bang bang." Though I missed the James Bond reference (there was no Google back then), that description still strikes me as particularly apt.

Of course, The Professor was far from infallible. Humility and self-doubt were not part of his repertoire. He was prone to broad generalizations, delivered matter-of-factly: Bulemics were histrionic and attention-seeking, while anorexics had more severe super-egos and conflict with their mothers. Women who were sexually abused as children became obese as an unconscious defense against further advances. People who suffered severe enough abuse could develop multiple personalities as a way of coping. The Professor, after the first day of class, never stooped to acknowledge any other perspectives besides those which he knew to be true.

A friend of mine, who took Abnormal Psychology with a different professor, hated the class because his professor treated the DSM diagnoses as if they were naturally-occurring phenomena like planets or animal species. Looking back on my journey through psychiatry, this was often the perspective of the teachers I had from medical school onward. Therefore, I'm especially glad I had The Professor so early on. He was not a big name at the university, as a clinical psychologist in a department filled with researchers and "cognitive neuroscientists." Yet he has influenced me more than anyone else with regard to how I think about psychopathology and psychiatric diagnosis. In particular, the dimensional system just made sense. The DSM-5 even incorporates some dimensional scales to rate symptom severity, though I was disappointed when the APA Trustees voted down efforts to add a dimensional element to personality disorders in DSM-5.

I also learned from The Professor the importance of recognizing the limits of our knowledge and perhaps why psychoanalysis had fallen out of favor, even though those were not lessons he was explicitly trying to teach.

Challenges of Psychiatry Blogging: Why Start? Why a Pseudonym?

This is part 4 of my series on the challenges of psychiatry blogging. Previous posts covered content, audience, and design.

Why Start?

I'm sure everyone who blogs does so for intensely personal reasons; thus, I will not speculate on anyone's motivations but my own here. I've always enjoyed writing but have not done much of it since college. I enjoy reading other psychiatry and neuroscience-related blogs, and I've long wished that there were more blogs focused on the many important issues related to child psychiatry. Eventually, I decided to start a blog myself for that niche. I hope to be critical in the sense of "involving skillful judgment as to truth, merit, etc.; judicial," rather than being "inclined to find fault or to judge with severity, often too readily." Though I've focused a lot on the DSM thus far, it is no accident that my first post was a movie review, and I hope to write about a broad range of topics, including vignettes from my own clinical experiences.

Why Now?

Why did I choose to start the blog last month, instead of at some other time? This question is harder to answer, and so let me examine it as I would any complex human behavior. Could it be that some life change increased the free time I have? Could I have been inspired by reading other blogs and being caught up in the zeitgeist with the DSM-5 about to be released? Is it that I finished writing a self-reflective piece offline, and encouraged by how rewarding it felt, managed to overcome previous inertia? Does it have anything to do with the fact that, after having knee pain for the last few years, I finally found a way to deal with the pain in April, thus allowing me to run again (and I'm getting good ideas while running)? Could it be the increased daylight and seasonal change helped me be more alert and focused? Is it that I've been drinking stronger coffee? I can't give you a simple explanation for why now, except to say it's likely a combination of several of those factors.

The Name Thing

Why am I using a pseudonym instead of my real name? Well, first let me say it's not so that I can vent my frustrations or write mean things. I'm more likely to use profanity in real life than on this blog. I'm fully aware that there is no true anonymity on the Internet, so I write everything as if it were under my actual name. I treat a blog post like I would an essay, refining each one until I am somewhat satisfied with the result.

Neuroskeptic has actually written a paper on the topic of anonymity in science, and how it can "facilitate the free expression of interpretations and ideas, and can help to ensure that suggestions and criticisms are evaluated dispassionately, regardless of their source." I'd like to think that's one of the main reasons why I use a pseudonym. Another reason is simply convenience. It's much easier for someone to Google "psycritic" to look up my blog (as well as my comments on other blogs), than to search for a name that belongs to many people. It helps me compartmentalize; though my patients are unlikely to bring up this obscure blog, I would still prefer to not have to chat about the blog during our sessions, and instead focus on what is going on in their lives.

Lastly, we come to the name itself. Why Psycritic? Well, as I said on Twitter:

Hoping to have a productive time blogging, emulating @neuro_skeptic & @neurocritic, with an emphasis on child & adolescent psychiatry.
— Psycritic (@psycrit) April 28, 2013

What can I say? It's certainly not original, but the domain name was available. Now, we just need a psychskeptic who blogs, and we'll have a complete tetrarchy!