Change in DSM-5: "Step in right direction"

The use of bipolar disorder diagnoses for children whose primary symptoms were manifested by irritability, rather than the traditional cyclical mood symptoms of adult bipolar disorder, has been a major concern in child psychiatry in recent years, says Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine, and Law and director of the Division of Law, Ethics, and Psychiatry at Columbia University College of Physicians & Surgeons in New York City.

"In the face of mounting evidence that many of these children did not share a common course, family history, and other characteristics with bipolar patients, it became clear that clinicians were really treating another kind of disorder," explains Appelbaum.

The disruptive mood dysregulation disorder (DMDD) category was created in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), to be published in May 2013, to give clinicians an alternative option for the diagnosis of this group of irritable children who are subject to behavioral outbursts, he explains.

There are legitimate concerns about the reliability with which the DMDD diagnostic criteria can be applied, given their poor performance in the DSM-5 field trials, says Appelbaum.

"However, it seems clear that the vast majority of children who would be eligible for the diagnosis of DMDD are distressed, dysfunctional, and in need of help — even if the precise label to be applied may not be clear," he says.

Whether the diagnosis will be applied inappropriately to children who are displaying normal behavioral variants will depend on the care with which clinicians — most of whom will be pediatricians and family practitioners, not child psychiatrists — apply the criteria, says Appelbaum.

"Although not a complete answer to the question of how we should understand the behavior of this group of children, DMDD seems to be a step in the right direction," he says.

Validity is concern

It is important to realize that about half of the DSM consists of "disorders" that may not be valid, cautions Roger Peele, MD, DLFAPA, chief psychiatrist at the Behavioral Health and Crisis Center of Montgomery County in Rockville, MD. "It is important to respect the DSMs, not worship them," he says.

The diagnostic entities in all of the DSMs are constructs that may not be the way nature has divided psychopathology, says Peele. "But we don't know how nature has divided psychopathology," he says. "So, we've divided up psychopathology into entities such as major depressive disorder, schizophrenia, and so forth that are educated guesses in about half of recent DSMs."

The other half are entities that are considered "valid," such as entities associated with the fact that if the etiological agent was not present, the disorder would not exist for the patient, says Peele.

The "not otherwise specified" (NOS) category in DSM-IV-TR and the "unclassified" category in DSM-5 — for patients whose presentation does not fit any of the established entities — might make it hard to say someone does not have a mental disorder if that individual is emotionally distressed or behaviorally disabled, adds Peele.

"Uses of recent DSMs have found that NOS is often the correct diagnosis. Yet, the less NOS, the better," says Peele. "So DSM-5 has added a few diagnoses, such as DMDD — an addition that we hope will decrease the use of NOS in children." n


  • Paul S. Appelbaum, MD, Dollard Professor of Psychiatry, Medicine, & Law/Director, Division of Law, Ethics, and Psychiatry, Columbia University College of Physicians & Surgeons, New York, NY. Phone: (212) 543-4184. E-mail:
  • Roger Peele, MD, DLFAPA, Chief Psychiatrist, Behavioral Health and Crisis Center, Montgomery County, Rockville, MD. Phone: (240) 777-3351. E-mail: