Psychiatric Times.

Should Temper Tantrums Be Made Into A DSM-5 Diagnosis?

By Allen Frances, MD | October 13, 2011

A recent front page story by Shari Roan in the Los Angeles Times explores the heated controversy over the DSM-5 proposal to include a Disruptive Mood Dysregulation Disorder (DMDD) in DSM-5. I very much oppose the inclusion of this new "disorder" -- fearing that DMDD would medicalize temper tantrums in children and run the risk of exacerbating the already shameful overuse of antipsychotics.

When it comes to DMDD, everyone agrees on one thing only- that it is based on the thinnest possible research support; studies by one lone group for a mere 6 years. DMDD was largely dreamed up by the DSM-5 Work Group. They are trying to deal with a real problem -- the massive overdiagnosis of childhood bipolar disorder and its attendant stigma and overprescription of potentially dangerous medication. But the proposed solution will create its own set of unintended consequences with the likely increase overprescription of medication for the new and inviting target of temper tantrums. And we are talking about lots of kids-- estimated at 3% now and likely to grow to many more once the diagnosis is official and drug companies get their hands on it.

The right solution to the childhood bipolar fad is so much simpler and safer. DSM-5 should include a warning black box in its definition of Bipolar Disorder alerting clinicians to the dangers of overdiagnosis and overtreatment in children. My advice to child psychiatrists -- tame the fad you have already created and please don't create another fad of a new "disorder" that can so easily be misused. No one denies that irritable children are a problem, but let's not prematurely and blindly invent essentially meaningless, but potentially very dangerous labels for them.

The truly incredible thing about child psychiatrists is their inability to learn from their past experience of fad creation. These are the people who brought us the 3 main fads of the past 15 years -- childhood bipolar, attention deficit disorder, and autism. And now they recklessly suggest a potential fourth in DMDD. DSM-5 clearly needs some adult supervision with this thought in mind -- beware nosologists bearing new and untested child diagnoses.

This brings us to the most dispiriting chapter in this sad story. The DSM-5 "scientific review group" has proven not to be scientific and seems incapable of careful reviewing. Most remarkably, it has approved DMDD on tissue thin evidence and with no consideration of risk. A porous filter indeed. This highlights the obvious necessity for independent and evidence-based reviews (say by the Cochrane group) to ensure the scientific integrity and safety of DSM-5 suggestions.

by Peter Weiser | October 20, 2011 4:10 PM EDT

"The truly incredible thing about child psychiatrists is their inability to learn from their past experience of fad creation. These are the people who brought us the 3 main fads of the past 15 years -- childhood bipolar, attention deficit disorder, and autism. And now they recklessly suggest a potential fourth in DMDD. DSM-5 clearly needs some adult supervision with this thought in mind -- beware nosologists bearing new and untested child diagnoses."

Dr Frances, as a well known editor of DSM IV, as an administrator of a prestigious department at Duke and as a prolific scholar and writer in our field, I expect more from you than name calling of the professionals whose behavior you most want to change.
Peter Weiser, MD, JD

by Nicholas Cummings | November 04, 2011 12:39 PM EDT

I don't see children. I do so adults who have been obviously troubled since childhood, some of whom were diagnosed in childhood as having Bipolar Disorder, and some of whom were given this diagnosis as young adults. They often have no eividence of a cyclic or episodic disorder involving a pesistent abnormal mood, but do have chronic over-reactivity in terms of dysphoria or rage, as well as poor impulse control regardless of current mood. I have hopes that the DMDD diagnosis may give adult psychiatrists, as well as child psychiatrists, pause before diagnosing almost every mood problem as bipolar, and that it may actually decrease, rather than increase, overuse of antipsychotics.

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Should Temper Tantrums Be Made Into A DSM-5 Diagnosis?

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