NEW YORK – The still-in-development DSM-5 contains two new child psychiatric diagnoses.
The Childhood and Adolescent Disorders Work Group designed one of the new diagnoses, temper dysregulation disorder with dysphoria (TDD), to include many children who were previously diagnosed with severe mood dysregulation or pediatric bipolar disorder. The second new diagnosis, from the ADHD and Disruptive Behavior Disorders Work Group, uses nonsuicidal self-injury (NSSI) to distinguish a pattern of self-inflicted damage to the body surface (usually by cutting) vs. suicide attempts. The goal of both new diagnoses is to refine patient identification and better assess appropriate treatments, said work group members in a session on pending changes to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) at the meeting.
Temper Dysregulation Disorder With Dysphoria
Creation of TDD grew from a need to “do something about the severe mood dysregulation and very irritable child, which has had no good home in DSM-IV,” said Dr. Ellen Leibenluft, chief of the Section on Bipolar Spectrum Disorders at the National Institute of Mental Health (NIMH). Lack of a good diagnostic home for this disorder “may be why it is often diagnosed as bipolar disorder,” she said.
But “categorization as a disruptive behavior disorder does not do justice to the mood and anxiety disorders” these patients have.
“Physicians diagnose these patients as [having] bipolar disorder and therefore conclude that stimulants and SSRIs [selective serotonin reuptake inhibitors] are 'contraindicated,'” which leads to the prescription of atypical antipsychotics or – less often – mood stabilizers, Dr. Leibenluft said. But no treatment trial has focused on the patients proposed to have TDD, making its optimal treatment unclear.
The new TDD diagnosis also creates a niche for patients who are “numerous, much more common than [patients with] typical bipolar disorder. They are a very important group that needs psychotherapy, medications, and services.
A diagnosis of oppositional defiant disorder and attention-deficit/hyperactivity disorder does not justify the amount of services they need and does not do justice to their mood and anxiety disorder,” she said.
The new diagnosis “will sensitize people to a syndrome that had previously not been recognized or had been very difficult to code. My hope is that [the new diagnosis of TDD] will decrease the number of kids who get labeled with bipolar disorder who may not be at risk for bipolar disorder,” said Dr. David Shaffer, professor of child psychiatry and chief of the division of child psychiatry at Columbia University in New York.
“It will also free up the treatment options in an important way. At the moment, [these patients] are often denied antidepressants and stimulants with the assumption that it will make them flip into a manic episode, although the evidence for that is very scanty.
“I think [a diagnosis of TDD] will have an impact on the way these kids are managed, and I suspect they'll be managed much more effectively and the period of their illness will be greatly shortened.
“Most of us who see these kids for second opinions usually diagnose anxiety or dysthymia, and we usually see a good response quite quickly to an antidepressant,” Dr. Shaffer said in an interview.
In addition, “what is regrettable about the diagnosis 'bipolar disorder NOS [not otherwise specified]' is borrowing a term from another disorder with no evidence of linkage,” he said during the session. “Using the term bipolar disorder, you assign a lifelong diagnosis with many implications for the family and for the future social adaptation of the child. Evidence from retrospective analyses of adult bipolar patients does not support a link.”
“The feeling by members of DSM-5 is that the diagnosis of pediatric bipolar disorder is misapplied and made too loosely,” said Dr. Daniel S. Pine, chief of the Section on Development and Affective Neuroscience at the NIMH. “The fundamental problem is that this is a large group of kids who are not getting services.
“Until there are systematic treatment studies, we won't know” how to best manage these patients, and the new diagnosis definition is an important step toward undertaking systematic treatment studies, Dr. Pine said.
Some psychiatrists in the DSM-5 work group who came up with the TDD diagnosis argued for defining these patients as having oppositional defiant disorder with a specifier for their number of outbursts per week, their inter-outburst mood, and their impairment. But this solution has drawbacks, Dr. Leibenluft said: Clinicians don't use specifiers, the disorder is better categorized in the DSM-5 mood section rather than in the disruptive behavior disorders section, and the relatively high prevalence of the condition justifies a new diagnosis.