I got an email from the Child and Adolescent Bipolar Foundation recently letting me know that the committee that is looking at revamping the DSM criteria for the next edition is looking at adding a diagnostic category called “Temper Dysregulation Disorder with Dysphoria (TDD). The purpose of the email was to dispel the rumors that inclusion of this category would eliminate the Pediatric Bipolar Disorder category. By all reports, Pediatric Bipolar Disorder (PBD) will be included in the upcoming revision. Adding the TDD diagnosis is a good step toward clarifying the diagnosis of PBD which, in my experience, has been one of the most difficult areas of my practice for years.
Once upon a time, I was the Director of the inpatient Children’s Unit and Adolescent Unit at one of our esteemed local hospitals. It used to drive me CRAZY when I would (accurately) diagnose patient with severe ADHD/ODD and get them stabilized on medication only to have them return, mis-diagnosed as Bipolar Disorder with different meds . . . and out of control. For a while there, it seemed like every kid who got angry was being diagnosed with Bipolar Disorder. The confusion, of course, was that there were no published and accepted criteria for PBD. Lots of ideas about it, but no published and accepted criteria. The problem then becomes to determine what is NOT Pediatric Bipolar, because if you create a too inclusive set of criteria, you lose predictive value of the criteria. And the presentation of these kids with mood disorder issues and anger dysregulation is so common that it would appear that there is a huge swelling of PBD–almost to epidemic proportions. So I wait with anticipation for the criteria to be published.
So what about the concept of a TDD diagnosis? I am intrigued! This could be a ground breaking clarification in the criteria. But to understand how revolutionary this might be, you have to understand Bipolar Disorder characteristics. The greatest area of confusion is the irritability. To qualify for a diagnosis of Bipolar Disorder, you must have a distinct period of “mania” which includes things like a decreased need for sleep with high amounts of energy, racing thoughts, significant distractibility, rapid speech and impulsive and potentially dangerous behaviors. Expansive mood or irritability is also an important feature of the diagnosis and it was thought that, for kids, the irritability was much more common than the expansive mood part of this. Hence the overlap of the diagnosis with all those irritable kids out there. Just to add confusion, the “period” of manic symptoms in kids was thought to be typically much shorter than older adolescents and adults. A “manic period” might only last for a few hours or less. And what about those kids who have these “manic periods” only in response to a frustration of some sort . . . you know . . . the two hour “get off the video game” temper tantrum where the kids is wildly out of control. Is that really a manic episode? It is a very tough call, even when it is a repeated event.
So what about the concept of TDD??? I am REALLY intrigued!!! Kids are notoriously unstable and fickle with their moods at best. Being able to identify the pattern of their symptoms and to diagnose them effectively is one of the great challenges in working with them (but also part of the fun). Here is the criteria as I know them:
A. 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 (eg parents, teachers, peers).
D. Duration: 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 and must be severe in one.
F. At least 6 years of age.
G. Onset before age 10
H. Absence of distinct period of abnormally elevated and/or expansive mood.
Intrigued?
I am. I think that this very effectively identifies a group of kids that were previously thrown into the mix of Bipolar Disorder when they should not have been. Further exploration of these kids is obviously needed but so far they seem to be distinct from those kids who have a very clear history of Bipolar Disorder. TDD kids do not tend to develop classic Bipolar symptoms as they get older . . . they tend to develop a more classic pattern of recurrent Major Depression. They also have different biological markers and different demographic factors.
I think this is a major step forward.
–Dan Hartman, MD
My nephew at age 3-4 had a lot of the symptoms of Bipolar II…especially the tempter tantrums caused by only the slightest irritations…which resulted in our being asked to leave a restaurant because the tantrum was so disruptive. I will be very interested to find out what is decided. His father does have manic depression and his mother probably Bipolar II. I have been diagnosed – correctly, I believe – with BP II. It seems only natural that their child would have some form of the illness. On top of all of this, my mother – who had some form of this illness – had custody of the nephew. She is very abusive to children. I can only imagine what must have gone on behind closed doors…the matching of strong will against strong will. Needless to say, this nephew was removed from her home at age 16 for child abuse.
Do you have any thoughts above my nephew’s behavior?
EM–Given the strong family history of Bipolar Disorder, I would have to presume that there is a high likelihood of your nephew having Bipolar Disorder. Add to that a disrupted family situation and some possible abuse and you have such a high chance of dysfunction in that young man. I would phamacologically approach it as a presumed Bipolar Disorder and get him into intensive therapy.
–DH MD