DSM-V: TDD: American Psychiatric Association statement

March 12, 2010 by  
Filed under Commentary

As I’ve mentioned in previous blog entries, the newly proposed diagnosis of Temper Dysregulation with Dysphoria Disorder (TDD) has generated a lot of controversy.  In this blog entry, I’m reproducing part of a statement from the American Psychiatric Association about the proposed diagnosis.  In subsequent blog entries, I’ll provide statements from the Juvenile Bipolar Research Foundation and the Child and Adolescent Bipolar Foundation.

The American Psychiatric Association’s draft diagnostic criteria for the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM) will include a proposed new diagnostic category, temper dysregulation with dysphoria (TDD), within the Mood Disorders section of the manual. [...] Criteria for the proposed diagnosis of TDD include severe, recurrent outbursts of temper occurring three or more times a week that are grossly out of proportion to the situation or provocation and that interfere significantly with functioning. Criteria also include extreme verbal and physical displays of aggression when faced with a common minor demand or stress. In between these outbursts, the individual’s mood is persistently negative: irritable, angry and/or sad. To be considered TDD, the symptoms must have begun before the age of ten. Only children over the age of six will be assigned the diagnosis, and children with the distinct manic episodes found in bipolar disorder will be excluded. "Many children with these symptoms have received a diagnosis of one of the disruptive behavior disorders, such as oppositional defiant disorder, and in most cases that would be appropriate," said David Shaffer, M.D., chair of the ADHD and Disruptive Behavior Disorders Work Group. "However," Shaffer explained, "one of the most important longitudinal studies of adolescent symptoms and diagnoses has shown that many teens with these severe irritable and aggressive behaviors go on to develop depressive or anxiety disorders in adulthood, strongly linking these TDD symptoms to a mood disorder." There have also been reports that many children and teenagers with these behaviors have been diagnosed with juvenile bipolar disorder. A 20-year follow up study that tracked a large representative group of young teens into their thirties, however, found no evidence that chronic irritability was a predictor of bipolar disorder in adults. TDD now offers a diagnosis that adequately describes the severity and frequency of this irritable behavior and highlights the significant, and often overlooked, mood disorder associated with it. By defining TDD, the Task Force hopes to also improve the accuracy of the diagnosis of bipolar disorder in children and teens. "There has been a marked increase in the number of children diagnosed with bipolar disorder in the past decade," said David Kupfer, M.D., chair of the DSM- 5 Task Force. "The new TDD criteria are based on research that helps us better differentiate children who have symptoms of bipolar disorder from those who do not." Members of the Childhood and Adolescent Disorders Work Group developed the criteria for the proposed diagnosis of TDD based on a decade of research to examine the causes of chronic severe irritability. The original term used by researchers to describe these symptoms was severe mood dysregulation (SMD). The work group modified the criteria slightly and decided that temper dysregulation with dysphoria was a more appropriate, descriptive name for the disorder than SMD. Dr. Shaffer cautioned that TDD is very different in frequency and impact from the irritation, anger and temper tantrums seen in normal development. "These are children whose outbursts may injure siblings, parents and schoolteachers," he said. "They may cause extensive damage to property, and the impact of their symptoms on family life is quite profound. It is not uncommon for such children to require psychiatric hospitalization." The work group members hope that specifying TDD as a specific, new diagnostic category will not only help clinicians more appropriately diagnose children with the disorder, but will encourage new research for appropriate treatments, including non-pharmaceutical interventions. Prior to a final decision to include this new category in DSM-5, the work group will review the results of field trials, and continue to carefully assess all relevant research and issues related to the TDD diagnosis. All proposed changes to DSM are being posted on the Web site www.DSM5.org for public review and comment until April 20. More information on the process for developing DSM-5 is also available on the Web site. Final publication of DSM-5 is planned for May 2013.

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