Disruptive mood dysregulation disorder — branching viva

Opening

Examiner: An eight-year-old is in your clinic with severe outbursts three or four times a week and a chronically grouchy, easily annoyed mood at home and school for over a year. His parents want medication and have read he may be bipolar. How do you frame this assessment? ^[1]

Candidate: I would treat this as a possible disruptive mood dysregulation disorder and a safety concern first. I would take a structured, multi-informant history — child, parents and school — map the picture against the DSM-5-TR criteria, and explicitly exclude a manic or hypomanic episode before discussing any treatment or medication. ^[1]

Branch 1 — diagnosis

Examiner: What criteria make it DMDD rather than ordinary tantrums or defiance? ^[1]

Candidate: Severe, recurrent temper outbursts grossly out of proportion and developmentally inconsistent, occurring at least three times a week; a chronic irritable or angry mood most of the day, nearly every day; onset before age ten; duration at least twelve months with no symptom-free stretch over three months; present in two or more settings and severe in at least one; and the child is aged six to eighteen. Both the outbursts and the chronic baseline irritability must be present. ^[1]

Examiner (probe): Why multi-informant? ^[2]

Candidate: The cross-setting requirement cannot be established from one source, children and parents each miss part of the picture, and teachers see function and peer behaviour the family does not. School collateral is essential to the diagnosis. ^[2]