Would a Diagnostic Label Improve Your Rx For These Children?
Would a Diagnostic Label Improve Your Rx For These Children?
Editor's Note: After you read the case below, weigh in with your comments. The author will offer a wrap-up of key teaching points based on your input. For further reading, see Dr Axelson's December 2010 article, "Adding the Diagnosis of Temper Dysregulation Disorder to DSM-5," on which this case is based.
Albert, Henry, and Bill separately present for assessment at a child psychiatric outpatient clinic for concerns about severe anger outbursts. Each boy has outbursts, which are described as “rages” or “meltdowns,” in which he screams, throws things, turns over chairs, breaks things, and threatens others. At times, he will punch or kick a sibling or caregiver in the midst of the outbursts and will smash things against the door if he is forced to stay in his room. The outbursts can last anywhere from 15 minutes up to 2 hours and occur several times a week. All 3 boys were described by their parents as being moody since their toddler years, but each has become much more irritable over the past year. All 3 seem angry or miserable nearly every day.
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Yes, the most likely diagnoses here are ADHD/ODD, Separation anxiety, and Bipolar d/o. I don't think adding a new definition to temper tantrums is beneficial. It only gives a clinician a label and buys time to tease out what may be the actual underlying source of the rage. They are unlikely to respond to the exact same treatments (ie, stimulant for the first child would worsen the second child).
i agree with Salvatore.
The diagnostic label DMDD will not change the treatment and prognosis much, but it may help to a degree in convincing everone involved that these children's problems cannot be explained away by a label of ADHD and prescription of stimulants (as many psychiatrists and others do now) and that these children's problems are more related to a mood disorder ( Mood disorder NOs / Bipolar Disorder in today's terminology). It will help prescription of Meds more attuned to treatment of Mood disorders, specifically bipolar disorder. Parents may accept a diagnosis of DMDD more readily as they may think it is not as bad as bipolar disorder.
it will not change the prognosis much as most such chldren end up as menatlly ill adults with the problems continuing and they more likely than not will end up being identified/ treated as adults with bipolar / schizoaffective/ borderline personality disorder problems. In the worst case they will be identified and dealt with / neglected as just bad personalities and abused in the criminal justice system and denied SSD benefits. Suicide risk, violent behavior, and substance abuse are frequent risks.
I believe all three siblings suffere from the same or very closely related clinical syndrome and as no two scizophrenic or bipolar siblings have excatly same symptoms and same treatment response, these siblings will also differ in some details and intensity of problems and response to treatment.
I believe their illnesses are more related to bipolar disorder than anything else. We can change names, but remeber: "A rose by any other name is still a rose."
George Isaac, MD
ADHD
Anxiety
Mood/Bipolar