Temper Dysregulation Disorder in the DSM-5?
David Axelson from Western Psychiatric Institute and Clinic gave a plenary talk on temper dysregulation disorder (TDD) with dysphoria at the 2011 Pediatric Bipolar Disorder Conference, held in Cambridge, Massachusetts in March. Researchers in the field have been discussing whether a diagnosis of TDD or severe mood dysregulation (SMD), a name Ellen Liebenluft of the National Institute of Mental Health has used to describe a similar behavior pattern, is necessary and should be included in the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).
The rationale for including a TDD or SMD diagnosis was the upsurge in the diagnosis of bipolar disorder among children. Researchers like Liebenluft believed that bipolar disorder was being over-diagnosed in children, and that some children could instead be classified as having a disorder that was limited to chronic irritability. Temper dysregulation disorder is what researchers eventually settled on. Post-hoc analysis of longitudinal epidemiological studies suggested that some chronic irritability experienced by children and adolescents developed into depressive and anxiety disorders rather than bipolar disorder.
However, as described in the epidemiological data of Merikangas et al. (which we will post later this week) and others, the frequency of youth diagnoses of bipolar disorder are not out of proportion with the number of diagnoses in adults. Now that it does not seem likely that bipolar disorder is being over-diagnosed among children, there is less rationale for the new diagnosis categories. In addition, it seems that TDD may not even capture a specific set of behaviors or symptoms.
Axelson’s data suggest that TDD does not reflect a specific progression of symptoms and instead overlaps with many different diagnoses. Almost 85% of children meeting this diagnosis have oppositional defiant disorder (ODD) and attention deficit hyperactivity disorder (ADHD). Thus, if the new diagnosis of TDD is adopted in the DSM-5, it may be over-applied where it is unnecessary.
Axelson attempted to use existing data sets to construct a proxy TDD diagnosis and found that those who met TDD diagnoses at intake were highly related to a variety of other diagnoses including bipolar spectrum or subthreshold bipolar disorder (43%), bipolar I (36%), major depressive disorder (42%), ADHD (43%), anxiety disorder (45%), psychotic disorders (47%), and pervasive developmental disorders (22%). He thus concluded that: severe temper outbursts are common in outpatient clinical settings (32-55%); TDD symptoms are common and not distinct from ODD or conduct disorder; youth with a wide range of diagnoses meet criteria for TDD; and TDD did not predict the subsequent onset of depression, anxiety, or bipolar disorder over short-term follow up.
All of these data suggest that TDD should not be considered an independent diagnosis, and Axelson suggested that instead it might be better as a course specifier for a variety of other diagnoses, indicating that the primary diagnosis comes with chronic irritability. Despite these data and this analysis, it is unclear whether the DSM-5 committee will continue to recommend TDD as a separate disorder, and field trials to identify its incidence are proceeding. The observations of Axelson and his colleagues make the case for not having TDD as a separate diagnosis in the DSM-5.
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