Disruptive Mood Dysregulation Disorder (DMDD)

• Depressive disorders are a group of conditions marked by a persistent sad, empty, or irritable mood, significantly impairing an individual's ability to function.
• The range of depressive disorders include:
  • Disruptive Mood Dysregulation Disorder
  • Major Depressive Disorder
  • Persistent Depressive Disorder
  • Premenstrual Dysphoric Disorder

Disruptive Mood Dysregulation Disorder (DMDD)

• DMDD is characterized by severe, recurrent temper outbursts that are disproportionate to the situation.
• Outbursts manifest verbally and/or behaviorally, and contrast with the expected developmental level.
• Temper outbursts occur, on average, three or more times per week
• The mood between outbursts is persistently irritable or angry most of the day, nearly every day and is observable by others.
• These symptoms must be present for 12 or more months, with no absence longer than 3 consecutive months.
• Symptoms are present in at least two of three settings and are severe in at least one.
• The initial diagnosis should not occur before age 6 or after age 18.
• Onset must occur before 10 years old.
• A manic or hypomanic episode must not have been experienced for more than 1 day.
• Behaviors should not arise exclusively during a major depressive episode and are not better explained by another mental disorder.
• Symptoms are not attributable to the physiological effects of a substance or another medical/neurological condition.
• DMDD cannot coexist with oppositional defiant disorder; only a DMDD diagnosis is given if criteria for both are met.
• DMDD symptoms originate from bipolar disorder diagnosed in children in DSM IV-TR, and are separated in DSM-5.
• Affected children typically develop unipolar depressive or anxiety disorders later in life.
• Males exhibit have a higher sex ratio (affected males vs affected females) in clinical samples.

Etiology of DMMA

• Psychosocial factors may include:
  • Psychological abuse/neglect
  • Parental psychiatric disorder
  • Limited parental education
  • Single-parent household
  • Early trauma
  • Death of a parent or parental grief
  • Divorce
  • Malnutrition caused by a disruptive family
• Biological factors may include:
  • Family history of depression
  • Deficits in information processing

Major Depressive Disorder (MDD)

• Five or more of the following symptoms must be present for at least 2 weeks exhibiting a change from previous functioning to diagnose MDD:
  • Depressed mood
  • Anhedonia (loss of interest/pleasure)
  • Significant weight loss/gain or appetite changes
  • Insomnia/hypersomnia nearly every day
  • Psychomotor agitation or retardation nearly every day
  • Fatigue
  • Feelings of worthlessness or excessive guilt
  • Diminished ability to think or concentrate
  • Suicidal ideation/attempt
• The symptoms must cause clinically significant distress or impairment in functioning.
• The episode is not attributable to a substance or medical condition.
• It is not better explained by schizoaffective disorder and does not overlap with other psychotic disorders.
• There must never have been a manic or hypomanic episode.

Specifiers for MDD

• With Anxious Distress: the individual suffers from anxiety as an additional dysfunction.
• With Mixed Features: depressive episodes show some manic symptoms.
• With Melancholic Features: extreme depressive symptoms occur (e.g., loss of pleasure in all activities).
• With Atypical Features: mood can be brightened up using positive events.
• With Mood-Congruent Psychotic Features: delusions or hallucinations relate to the current episode's themes.
• With Mood-Incongruent Psychotic Features: delusions or hallucinations are irrelevant to the episode's themes.
• With Catatonia: catatonic behavior is displayed during depressive episode.
• With Peripartum Onset: depressive symptoms begin during pregnancy or within 4 weeks of delivery.
• With a Seasonal Pattern: episodes occur during certain times of the year.
• MDD is more prevalent among women than men.
• Single, divorced, and widowed women experience more depression than their male counterparts.
• Men face a heightened risk of developing depression after a marital split.
• Women may experience hyperphagia (excessive eating), hypersomnia (excessive sleeping), interpersonal sensitivity, and gastrointestinal symptoms.
• Men are more likely to report maladaptive coping strategies such as substance misuse, risk-taking, or poor impulse control.
• MDD is associated with high mortality, often due to suicide.
• Onset likelihood is during puberty, with later life onset being uncommon.
• Three-month-old babies can exhibit depression signs (sad faces, slow movement, responsiveness).
• The presentation or "look" of depression evolves with age.

Etiology of MDD

• Biological factors:
  • MDD in a first-degree family member correlates to a 40% increased chance.
  • Exposure to reproductive life stages for women (premenstrual, postpartum, perimenopause).
  • Hyperactivity in the HPA axis is associated with severe depression, psychotic features, and suicidal risk.
  • Low levels of dopamine and serotonin.
  • Low hippocampal volume.
• Psychosocial factors:
  • Neuroticism
  • Stressful life events
  • Adverse childhood experiences, such as sexual abuse
  • Low income
  • Limited formal education
  • Racism and other forms of discrimination

Theories About Depression

• Learned Helplessness Theory: depression follows hopelessness regarding coping with difficult life events.
• This theory proposes that internal, stable, and global depressive attributional styles lead to depression: Internal: attributing negative events to personal failings. Stable: believing negative events will persist ("additional bad things will always be my fault"). Global: attributions extend across a wide range of issues.
• Aaron Beck's Negative Cognitive Styles: Individuals with depression will exhibit negative thinking about themselves, the world, and their future (depressive cognitive triad).
• Cognitive distortions/errors include: Arbitrary Inference: emphasizing negative aspects over positive ones. Overgeneralization: concluding a negative event will occur based on a minor issue. These negative cognitive styles are contagious.
• Aaron Beck's Negative Schema is evidenced as: Self-blame Schema: where the individual thinks that they are responsible for every negative event. Negative Self-Evaluation Schema: where they believe they cannot do anything correctly.

Grief and MDD

• Acute Grief: the initial grieving stage includes depressive symptoms, anxiety, denial, numbness, and suicidal ideation for 6 months to 1 year or more.
• Integrated Grief: acceptance of death and adjustment to loss has occurred.
• Complicated Grief: individual becomes impaired through maladjustment and suicidal ideations increase.
• Grief comes with feelings of emptiness and loss.
• MDD presents as persistent sadness tied to self-criticism and pessimism, rather than focusing on the deceased person.
• Sadness in grief tends to decrease over time, occurring in waves when remembering the deceased.
• Self-esteem is preserved during grief, while it is significantly affected in MDD.
• Suicidal ideations in grief relate to "joining" the deceased, whereas ideations in MDD stem from worthlessness, hopelessness, anhedonia, etc.

Persistent Depressive Disorder (PDD)

• PDD diagnosis includes a depressed mood for most of the day, for at least 2 years where:
  • In children and adolescents, mood may be irritable, with a duration of at least 1 year.
• While depressed, two or more of are present:
  • Poor appetite or overeating
  • Insomnia or hypersomnia
  • Low energy or fatigue
  • Low self-esteem
  • Poor concentration or difficulty making decisions
  • Feelings of hopelessness
• During a 2-year (or 1 year for children/adolescents) disturbance, the person has never been symptom-free for over 2 months.
• Major depressive disorder criteria may be continuously present for 2 years.
• There must never have been a manic or hypomanic episode.
• The disturbance is not better explained by other psychotic disorders.
• Symptoms must cause clinically significant distress or impairment in social, occupational, or other important areas of functioning.
• Symptoms are not attributable to substance or medical condition.
• Subtypes of PDD include: With pure dysthymic syndrome: where full criteria for a major depressive episode have not been met in at least the prior 2 years. With persistent major depressive episode: full criteria for a major depressive episode have been met throughout the preceding 2-year period (chronic major depressive episode). With intermittent major depressive episodes (double depression).
• Depression in PDD remains relatively unchanged over long periods, sometimes 20 to 30 years or more.
• It is considered more severe, with higher rates of comorbidity, less responsiveness to treatment, and a slower improvement rate.
• Onset is often insidious.
• It’s more common in high-income countries and among females.

Etiology for PDD

• Biological Factors:
  • Heredity
  • Abnormal functioning of brain regions such as the prefrontal cortex, anterior cingulate, amygdala, and hippocampus.
• Psychosocial Factors:
  • Higher levels of negative affectivity (neuroticism)
  • Parental loss or separation
  • Childhood adversity

Premenstrual Dysphoric Disorder (PMDD)

• In the majority of menstrual cycles, at least five symptoms must be present in the final week before menses onset.
• Symptoms start improving within a few days after menses onset, and become minimal or absent in the week postmenses. At least one of the following symptoms must be present:
  • Marked affective lability
  • Marked irritability, anger, or increased interpersonal conflicts
  • Marked depressed mood, hopelessness, or self-deprecation
  • Marked anxiety or tension
• One or more of the following symptoms must additionally be present, to reach a total of five symptoms when added to symptoms from the criteria above:
  • Decreased interest in usual activities
  • Subjective difficulty in concentration
  • Lethargy
  • Marked change in appetite
  • Hypersomnia or insomnia
  • Sense of overwhelm or loss of control.
  • Physical symptoms such as breast tenderness or swelling, joint or muscle pain, sensation of bloating or weight gain.
• Symptoms cause clinically significant distress or interference with work, school, social activities, or relationships.
• The disturbance is not merely an exacerbation of another disorder's symptoms.
• Criterion A should be confirmed by prospective daily ratings during at least two symptomatic cycles.
• Symptoms are not attributable to a substance or another medical condition.
• Symptoms cease after menopause, cyclical hormone replacement can trigger the reexpression of symptoms.
• Delusions and hallucinations in the late luteal phase of the menstrual cycle are rare.
• The heritability of the disorder remains unclear.
• Psychosocial factors:
  • Stress
  • Interpersonal trauma
  • Seasonal changes
  • Gender role of women

Suicide

• Altruistic Suicide: is a "formalized" suicide approved by a culture for the betterment of others (e.g., hara-kiri in Japan).
• Egoistic Suicide: is due to loss of social support.
• Anomic Suicide: is due to the loss of a valuable aspect in life.
• Fatalistic Suicide: is caused by the loss of control over one's destiny.
• Nock and Kessler classified suicide as:
  • Attempters who intend to die by suicide.
  • Gesturers who attempt suicide as manipulation to influence someone or to communicate a cry for help.
• Indicators of suicidality include:
  • Suicidal ideation
  • Suicidal plans
  • Suicidal attempts
• Sigmund Freud theorized that the cause of suicide and depression is introjected hostility.
• Females attempt suicide 3 times more often than males.
• Males commit suicide 4 times more often than females.
• Males tend to choose more violent methods than females.
• Risk factors of suicide include:
  • Family history of suicide or suicidal attempts
  • Extremely low serotonin levels
  • Psychological disorders (e.g., depression, substance use disorders)
  • Extreme stress
  • Exposure to media reporting on suicide
  • Perception of being a burden and diminished sense of belonging leading to hopelessness
  • Sensation-seeking among teens
  • Impulsivity
• Treatment includes:
  • Preventing access to dangerous means/items
  • No-suicide contracts
  • Hospitalization
  • Cognitive-behavioral interventions

Treatments for Depressive Disorders

• Biological Interventions include:
  • Antidepressants such as Selective-Serotonin Reuptake Inhibitors (SSRIs), Mixed Reuptake Inhibitors, Tricyclic Antidepressants, Monoamine Oxidase (MAO) Inhibitors and Lithium
  • Electroconvulsive Therapy
  • Transcranial Magnetic Stimulation
• Psychosocial Interventions include:
  • Cognitive-Behavioral Therapy
  • Interpersonal Psychotherapy

Disruptive Mood Dysregulation Disorder (DMDD) involves severe, recurrent temper outbursts that are disproportionate to the situation. These outbursts manifest verbally or behaviorally, contrasting with developmental expectations. A persistently irritable or angry mood is observable between outbursts.