Will disruptive mood dysregulation disorder reduce false diagnosis of bipolar disorder in children?

OBJECTIVES: The frequency of diagnosis of bipolar disorder has risen dramatically in children and adolescents. The DSM-V Work Group has suggested a new diagnosis termed disruptive mood dysregulation disorder (DMDD) (formerly temper dysregulation disorder with dysphoria) to reduce the rate of false diagnosis of bipolar disorder in young people. We sought to determine if the application of the proposed diagnostic criteria for DMDD would reduce the rate of diagnosis of bipolar disorder in children. PATIENTS AND METHODS: Eighty-two consecutively hospitalized children, ages 5 to 12 years, on a children's inpatient unit were rigorously diagnosed using admission interviews of the parents and the child, rating scales, and observation over the course of hospitalization. RESULTS: Overall, 30.5% of inpatient children met criteria for DMDD by parent report, and 15.9% by inpatient unit observation. Fifty-six percent of inpatient children had parent-reported manic symptoms. Of those, 45.7% met criteria for DMDD by parent-report, though only 17.4% did when observed on the inpatient unit. CONCLUSION: Although DMDD does decrease the rate of diagnosis of bipolar disorder in children, how much depends on whether history or observation is used.

Liquid risperidone in the treatment of rages in psychiatrically hospitalized children with possible bipolar disorder.

OBJECTIVE: To examine the safety and efficacy of liquid risperidone to reduce duration of rages in children with severe mood dysregulation (SMD) or possible bipolar disorder (BP). METHOD: The sample included 151 consecutive admissions of 5-12 year old children to a psychiatric inpatient unit. Diagnostic information and history of prior rage outbursts were obtained at admission. In hospital, a first rage was treated with seclusion. If a second rage occurred, the child was offered liquid risperidone to help him/her regain control. Durations of unmedicated and last medicated rage were compared. Rage frequency in children with SMD and several definitions of BP were compared. RESULTS: Although 82 of 151 admissions were prompted by rages, rages occurred during only 49 hospitalizations and occurred more than once in only 24. In 16 multiply medicated children, duration of rages dropped from a baseline of 44.4 +/- 20.2 min to 25.6 +/- 12.5 min at the child's last dose. Neither SMD nor any definition of BP influenced rage response in this small sample. The average liquid risperidone dose was 0.02 mg/kg. All but two children also took atypical antipsychotics daily. In the evaluation of medicated rage episodes with standard rating scales, no extrapyramidal side effects, akathisia, or abnormal involuntary movements were observed, and the rate of sedation/sleepiness (7/67 = 10.4%) was similar and not significantly different from that observed during nonmedicated episodes (8/46 = 17.4%). CONCLUSIONS: Liquid risperidone may be a safe and effective way to shorten the duration of rage episodes regardless of diagnosis. However, definitive conclusions cannot be drawn in the absence of a placebo control as children were also receiving other behavioral and psychopharmacologic treatments.

The behavioral organization, temporal characteristics, and diagnostic concomitants of rage outbursts in child psychiatric inpatients.

Angry outbursts, sometimes called rages, are a major impetus for the psychiatric hospitalization of children. In hospitals, such outbursts are a management problem and a diagnostic puzzle. Among 130 4- to 12-year-olds successively admitted to a child psychiatry unit, those having in-hospital outbursts were likely to be younger, have been in special education, have had a preadmission history of outbursts, and to have a longer hospital stay. Three subsets of behaviors, coded as they occurred in 109 outbursts, expressed increasing levels of anger; two other subsets expressed increasing levels of distress. Factor structure, temporal organization, and age trends indicated that outbursts are exacerbations of ordinary childhood tantrums. Diagnostically, children with outbursts were more likely to have language difficulty and a trend toward attention-deficit/hyperactivity disorder. Outbursts of children with anxiety diagnoses showed significantly more distress relative to anger. Outbursts were not especially associated with our small sample of bipolar diagnoses.

Rages--what are they and who has them?

OBJECTIVE: The purpose of this study was to examine rages and define their associated clinical and diagnostic conditions systematically. Children's severe anger outbursts, sometimes called "rages," have been associated with many disorders, including mania, "severe mood dysregulation," and oppositional defiant/conduct disorder. Although reactive aggression has been studied extensively, there are almost no data on this important and disabling clinical phenomenon. METHOD: A total of 130 different 5-12 year olds were hospitalized over 151 consecutive admissions were evaluated diagnostically with information from parents, children, doctors, nursing staff, and teachers. Rages were operationally defined as agitated/angry behaviors requiring seclusion or medication because the child could not be verbally redirected to "time out." Rage behaviors were categorized as they occurred with the specially designed Children's Agitation Inventory. Hypotheses were that rages would be associated with prior treatment failure, and that children with rages would have the most co-morbidities, including learning/language disorders. We did not expect narrow-phenotype bipolar disorder to be specifically associated with rages. RESULTS: Of 130 children, 71 (54.6%) were admitted for rages. Preadmission rages and admission taking an atypical antipsychotic significantly predicted the subsequent number of in-hospital rages. Attention-deficit/hyperactivity disorder with learning/language disorder significantly predicted the occurrence and number of rages. Bipolar disorder was the referring diagnosis in 17/49 (34.7%) admissions with rages and 15/102 (14.7%) of admissions without rages (odds ratio [OR] 3.05, confidence interval [CI] 1.36, 6.80). However, a consensus diagnosis of bipolar disorder occurred in 5 (9.1%) of the sample with rages and 5 (5.8%) in the rest of admissions. CONCLUSIONS: Psychiatrically hospitalized children with multiple rages have complex, chronic neuropsychiatric disorders and have failed prior conventional treatment. One third of children with rages had been given a bipolar diagnosis prior to admission. However, only 9% of children with rages were given that diagnosis after careful observation.