In response to the newly proposed Temper Dysregulation Disorder with Dysphoria (TDD), the Child and Adolescent Bipolar Foundation issued a press release commending the APA work group on the proposal, but suggesting that the name was not helpful because of the connotations of the word "temper." They subsequently sent out a response to others’ criticisms of the proposed diagnosis. I am reproducing their mailing below with their kind permission:
We are writing to clarify some inaccurate media reports and email distributions. You may have heard about the proposed diagnostic category for children called Temper Dysregulation Disorder with Dysphoria (TDD). This new diagnosis is intended for children who have some overlapping symptoms of bipolar disorder, but do not have clear episodes of mania. CABF has provided feedback to the DSM V committee of the American Psychiatric Association. You can read our comments, concerns and recommendations in our press release and blog. Some media reports and listservs have provided inaccurate information, claiming that TDD is intended to replace a diagnosis of bipolar disorder in children, and that TDD is not supported by scientific evidence. These claims are untrue. CABF is guided by a Scientific Advisory Council that includes the nation’s leading pediatric psychiatric researchers, and we are committed to providing the most accurate and carefully-vetted information which affects our children.
- TDD is NOT meant to replace a diagnosis of bipolar disorder in children. Instead, it is meant to offer a diagnostic “home” for those children who do not fit the criteria for mania, but have been given this diagnosis because it was the best fit. There is “unambiguous agreement” within the Childhood Disorders Work Group of the DSM V committee that bipolar disorder presents in children. TDD is proposed to address overdiagnosis and misdiagnosis of BD in children.
- Read more
The Juvenile Bipolar Research Foundation has been involved in important and fascinating research on juvenile Bipolar Disorder. If you are not familiar with their research program and findings, you can read the first two parts of their three-part series at http://www.jbrf.org/news/newsflash1.html and http://www.jbrf.org/news/newsflash3.html.
In response to the DSM-V proposal to create a new diagnosis, Temper Dysregulation Disorder with Dysphoria, discussed in previous blog entries on this site, JBRF sent out a newsflash, which they have kindly given me permission to reproduce on this blog:
An important proposal that will affect the diagnosis of juvenile bipolar disorder for the next decade has just been released by the American Psychiatric Association (APA). It is part of the planned revision of the Diagnostic and Statistical Manual for Mental Disorders, commonly referred to as the DSM. The DSM contains the information upon which professionals assign their psychiatric diagnoses. It cannot be overstated how important and influential this manual is in YOUR life. It is the book by which clinicians and doctors are trained, insurance is reimbursed, school accommodations are approved, legislation is passed, justice is executed, and research is guided.
On February 10th, the proposed revisions were made public and covered extensively by the media. You can find the proposed draft on the American Psychiatric Association website:
Why should you be concerned? Because one of the recommended changes includes a new diagnostic classification that may prevent children who need treatment consistent with a bipolar diagnosis from receiving it.
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. Read more
As noted in my first post on this topic, one of the challenges facing the Mood Disorders and Childhood Disorders work groups stems from the fact that although some children do show the same type of clear cyclicity or episodes as adults with Bipolar Disorder, many children do not seem to have clearly defined mood episodes. So is Bipolar Disorder being overdiagnosed in children? Are children being given a Bipolar diagnosis and treatment when what ails them is not really Bipolar Disorder? To address this problem, the work groups proposed:
- refining the diagnostic criteria for mood episodes to clarify that an episode requires the presence of the symptoms "almost all day, every day," and the symptoms represent a change from baseline for the individual; and
- introducing a new diagnosis that may be more consistent with what we see in many children, Temper Dysregulation Disorder with Dysphoria (TDD).
The diagnostic criteria proposed for TDD are provided here for reference and discussion purposes. In this post, I’ll try to summarize some of the research that led up to the proposal. As part of its consideration and work, a new (temporary) diagnosis was proposed and defined, called Severe Mood Dysregulation (SMD). The criteria for SMD included severe but non-episodic irritability with anger outbursts and hyperarousal/ADHD-like symptoms. The name SMD would subsequently be changed to TDD and the hyperarousal criterion dropped. Read more
The following are the tentatively proposed diagnostic criteria for Temper Dysregulation Disorder with Dysphoria, being considered for inclusion in the DSM-V. I am posting them here as a convenient reference to facilitate discussion of the topic in other blog entries. This thread is not open for comments, but comments are permitted in the blog entries that discuss the proposal.
Temper Dysregulation Disorder with Dysphoria
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).