A New Diagnosis for Explosive Behavior

Explosive behavior — rage behavior — is the single most difficult behavior we have in child psychiatry. If I had a magic wand, and I could do one thing to change mental health for children, that would be the behavior that I would take care of. But we don’t have a way to label that behavior. If you do a search for outbursts, there are about 10 different terms that get used in Pub Med. And they get different articles. So we don’t have an agreed-upon term for it.

This is the problem that has led to Disruptive Mood Dysregulation Disorder (DMDD), the new disorder adopted in the DSM-5.

The concept is based on work by Dr. Ellen Leibenluft, who studies bipolar disorder at the NIMH. Dr. Leibenluft developed the concept of severe mood dysregulation as a condition distinct from the typical episodic manic and depressive behavior in bipolar disorder.

It’s really important to understand whether bipolar disorder in kids is something that’s episodic, the way it is in adults, or whether there is a special form of severe irritability with explosive outbursts that is a special subtype of bipolar disorder. So she launched a body of work, starting in about 2000, to look at it symptomatically, longitudinally, therapeutically, and in terms of the neurocircuitry, to see if there’s a difference between children with chronic irritability and explosive outbursts and ADHD-type symptoms, versus episodic mania and depression.

Her data would suggest that they are two different issues. And the psychiatrists working on the DSM-5 had been concerned with the fact that bipolar disorder has been over-diagnosed. So the new DMDD diagnosis is based on Dr. Leibenluft’s distinction between the two.

Having a definition of this behavior is a positive thing. As a clinician who runs an inpatient service, who takes care of kids like this, it’s been extremely frustrating not being able to have something that captures the severity of these explosive outbursts. If we haven’t settled on a way of labeling something, we don’t have a way of really gathering a database to be able to address the important question of how to treat it.

But there’s also a danger with DMDD — it makes you think it’s one condition. The fact is, you get explosive outbursts with ADHD, with ODD, with mania, with depression, with autism, with anxiety, with schizophrenia, with intermittent explosive disorder.

Explosive behavior is like fever. If you have a fever of 105, you know the kid is sick, but you don’t know what the kid is sick with. And so, to me, those explosive outbursts mean this child is in deep trouble. But what he’s in trouble with really needs a diagnostic assessment. And my concern about disruptive mood dysregulation disorder is people are going to say, “That’s it.” Brain slammed shut. They’re not going to think diagnostically. Which has actually been the biggest problem with bipolar disorder. People say, “Oh! Bipolar disorder.” Brain slams shut. Nobody thinks further, diagnostically.

My suggestion to the DSM-5 committee was to say, “Let’s make it as a modifier. Let’s have attention deficit disorder with explosive outbursts. Let’s have autism with explosive outbursts.” That way you don’t overlook what might be the primary condition behind disruptive mood dysregulation disorder. About 75 to 80% of those kids have ADHD / ODD. I know that. People around for the birth of this condition may know that. But 10 or 15 years from now, people aren’t going to know that. They’re going to say, “Oh, look at this new condition.” And they may not be treating the ADHD that underpins it, and they may be missing a really important opportunity.