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Temper Dysregulation Disorder: Bad Temper, or Mental Illness?

Temper Tantrums Pushed as a New Disorder Called “Temper Dysregulation Disorder”

Severe outbursts grossly out of proportion to the situation, in the form of verbal rages or physical aggression, several times a week -- to moms and dads, these would seem the most common elements of childhood temper tantrums. They are also the proposed criteria for a new childhood mental disorder called Temper Dysregulation Disorder (TDD) with Dysphoria.

TDD is being recommended for inclusion in the next edition of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, a massive catalogue of brain dysfunction now undergoing its first major revision in 16 years. It is considered the psychiatrists' bible of mental disorders. If accepted, TDD could soon become as entrenched in our vernacular as ADD.

TDD is being proposed as an alternative to the runaway diagnosis of childhood bipolar disorder. The number of kids being diagnosed with -- and medicated for -- bipolar disorder has shot up dramatically in the past decade, despite concerns that many don't meet the official criteria, but are getting the lifelong label nonetheless because of their explosive temper outbursts. The idea behind TDD is to create a less-severe diagnostic "home" for these kids.

The fear is that TDD could open the door to the diagnosis of any youngster with a bad temper, that it risks pathologizing a normal part of a youngster's development and could lead to wider prescribing of antipsychotics, antidepressants and mood stabilizers to kids, including preschoolers barely out of training pants.

It's an extremely significant move, and it's a very alarming. Infants and kids have meltdowns, regularly and routinely. It's a healthy expression of frustration. It's a very serious move to contemplate that as a bona fide mental illness, which is what they're very seriously proposing.

The over-diagnosis of bipolar has been a colossal embarrassment to the field. So they've tried to come up with another diagnosis that will somehow let you diagnose unruly kids. But maybe they're unruly, full stop.... To give them a psychiatric diagnosis and treat them with antipsychotics is insane.

But the research director for the task force writing the new edition of the DSM says the following:

“TDD isn't run-of-the mill temper tantrums. We're not talking about the temper tantrum of a two-year-old or a three-year-old who's not getting his way. We're talking about kids of age six or above who kind of have a hair-trigger, and really quite violent temper tantrums totally out of proportion to any kind of provocation that might have brought them on. Something out of the norm of what you would call a normal temper tantrum. And these are the kids who were receiving a diagnosis of bipolar disorder."

Here are 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). 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., abnormally elevated or expansive mood), as in such a case the diagnosis of bipolar is likely more accurate.

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 peer. 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. 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. 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.

Of course there is no way to predict what practical effects creating the TDD category might have. Even if they are successful at changing the label that clinicians use, it could be that the children all get the same medications as before. But the difference is going to be that they won't have to take the medicine for the rest of their life.

TDD is a new term, but its characteristics are not new to research. In scientific papers, the disorder is referred to as “severe mood dysregulation” (SMD).

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