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Adding the Diagnosis of Temper Dysregulation Disorder to DSM-5

Adding the Diagnosis of Temper Dysregulation Disorder to DSM-5

The DSM-5 Childhood and Adolescent Disorders Work Group has proposed adding a new diagnosis called temper dysregulation disorder with dysphoria (TDD). The core features of TDD are pervasive irritable and/or sad mood and recurrent, severe anger outbursts, both of which must be consistently present for at least 1 year. The temper outbursts must be grossly out of proportion to the situation; be inconsistent with developmental level; and occur, on average, 3 or more times per week. The negative mood must be present nearly every day. The mood and temper outbursts must be present in at least 2 settings (in school, at home, or during social activities with peers) and be severe in at least 1 setting. Age must be at least 6 years, and the onset must be before age 10.

Information from the DSM-5 Web site indicates that the rapid increase in the frequency of the diagnosis of bipolar disorder in children and adolescents was a major driving force in the creation of TDD.1,2 TDD would provide a diagnostic “home” for youths who have chronic irritability and explosive anger outbursts, thereby reducing the chance that they might receive a diagnosis of bipolar disorder.

The DSM-5 Web site openly acknowledges the fact that research on TDD is in its early stages and that scientific support for it as a separate diagnostic entity is limited.1,2 The Web site also notes that the substantial overlap of TDD with oppositional defiant disorder (ODD) makes it unlikely that these 2 diagnoses have a distinct pathophysiology.

These issues—among others—raise this question: Is the addition of a new diagnosis such as TDD to DSM-5 the best way to manage the issue of classification of youths with chronic, severe irritability and potential misdiagnosis of bipolar disorder?

Understanding TDD

TDD would be different from most other diagnoses in DSM-5, in that all of its core diagnostic criteria are shared by other DSM disorders. There are no signs or symptoms that are unique to TDD. Criterion A, irritable and/or sad mood, is part of the diagnostic criteria for many disorders in child psychiatry: dysthymic disorder, major depressive disorder, bipolar disorder, generalized anxiety disorder, posttraumatic stress disorder, and ODD. Criterion B, severe tem-per outbursts, is a behavioral manifestation of irritable mood; these outbursts can be present in all of the preceding disorders, and temper outbursts are part of the DSM-IV criteria for ODD and for intermittent explosive disorder.

Some would liken irritability in child psychiatry to fever in general medicine: even if it is severe and chronic, it can be a symptom of many different illnesses. Because chronic irritability is a symptom and temper outbursts are evidence of that symptom, TDD may be conflating a symptom with a syndrome.

The diagnostic criteria attempt to address the lack of specificity by advising physicians not to diagnose TDD when the irritability and temper outbursts occur exclusively during the course of a mood or psychotic disorder or when the outbursts are not better accounted for by another disorder. However, TDD can coexist with diagnoses such as ODD, attention-deficit/hyperactivity disorder (ADHD), conduct disorder, and substance use disorder.

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