Disruptive Mood Dysregulation Disorder

Disruptive Mood Dysregulation Disorder (DMDD) is about emotional-behavioral management in children.  Reaching for more user-friendly semantics, FD refers to it as Calming Disorder, a seeming inability on the part of the child (hence the parent, too) to calm down.  DMDD is likely to be the latest flavor of the week, yet another label for children who are oppositional.  Willful.

We suppose that as these children age, as they grow into adults, they will be diagnosed as having Intermittent Explosive Disorder and treated with anger management.  Why we couldn't have used Intermittent Explosive Disorder with qualifiers: refer to children with a 1, adults with a 2, and a 1,2, or 3 to indicate the severity, is a mystery.  Perhaps the reason is that the temperament is chronic, not intermittent.

Here's the abstract.  I'll get to the article this week, but want to offer up a few thoughts regardless.  After all, they did ask me to be on the team to rewrite the DSM IV-TR.  Is it my fault that the page froze after checking "other" when asked for "type of license"?  I have two, and there was no way to communicate that. Calling in I was redirected, sent a new email.  But the link to the application didn't work a second time.

And life gets in the way.

Look for the article in PsychInfo if you have an academic affiliation. It might be on sale somewhere online if you don't.

Emotional dysregulation in disruptive behavior disorders.

Cole, Pamela M.; Zahn-Waxler, Carolyn

Cicchetti, Dante (Ed); Toth, Sheree L. (Ed), (1992). Developmental perspectives on depression.Rochester symposium on developmental psychopathology, Vol. 4., (pp. 173-209). Rochester, NY, US: University of Rochester Press, xix, 396 pp.

(The authors) present a view of disruptive behavior disorders as affective disorders and, from that perspective, discuss the emotional characteristics which are associated with the development of aggressive, antisocial behavior 
provide an overview of the disruptive behavior disorders, the history of the traditional segregation of behavior disorder from affective disorder, and the evidence and arguments for comorbidity of affective and disruptive disorders / consider possible developmental trajectories leading to these disorders / focus particularly on the role of emotion in early childhood and its implications for the development of deviant and aggressive behavior later in childhood and adolescence (PsycINFO Database Record (c) 2012 APA, all rights reserved)

Seems to me we are looking for the prodromal, or warning signs of sociopathy, a disorder that defines what we have referred to as almost psychopathic in previous posts.

Parents are right to worry when their kids have symptoms of DMDD: uncontrollable tantrums, aggressiveness, an inability to manage emotion, an absence of empathy.  When they are cruel.  Dr. Cole has published on empathy in the past, and I think she is on the mark if she is thinking we have to teach children, all children, empathy.

We're talking about it right now because the DSM V is due out in 2013.  Teams of researchers, revisionists, are making all kinds of changes to what we commonly call disorders.  For example, Asperger's, childhood disorder in the current DSM IV-TR, has been known for decades to be characteristic of adults, too.   It is thought to be a spectrum disorder, on the spectrum of autism, and may lose its status as a disorder exclusive to autism.

According to yesterday's Wall Street Journal (Shirley S. Wang), "Aspie's" are up in arms about being subsumed autistic.  Not everyone likes the thought of being autistic, even if it is high functioning.  Yet, most of the "Aspie's" I treat tell me that they are very much in their own world.  They see the point.  More likely however, Adult Asperger's Disorder will make it into the DSM V, at least that is my hope.  Just a guess.

But back to our new flavor.  When we first recognized Bipolar Disorder in children, it amounted to medication, usually too much.  Manic kids were oppositional, hard to control by definition, and they suffered swings, clear signs of childhood depression.  Thus meds saved the day, theoretically, although those of us who work with a family model are generally reluctant to make that referral.

Children with Disruptive Mood Dysregulation Disorder are likely going to be over-medicated, too.  It doesn't take much to over-medicate children.  They are growing and changing all of the time.  And they are mini-emotional time-bombs under normal circumstances.  Having a motor that tends to puff and smoke at the worst possible times, it is understandable that parents are looking for help, lots of help, from that god of psychiatry, Big Pharma.

Thus we can only hope that parents remain patient, able to calm themselves, and bring little Joey to therapy.  If you are such a parent, stay in the room and learn strategies from the doctor/therapist.  The tried and true holding technique, grabbing the little tyke and holding her tightly (without hurting her) until she calms down, works for some kids, but as one reader puts it so well, restraining the child is:

 a tried and true way to exert dominance, lose the child's trust, and create permanent emotional scars.

I think we had both lose the phrase, tried and true, unless we can qualify them well.

Make sure no one is hurt no matter what you do.  Corporal punishment won't work, will work against you.  And although we are capable of holding, able to restrain children, being three times their size, we have to be careful. Not every child responds well to that.  If they are older, best to work on communicating in words, or in art, or play if holding is violently rejected.

There are other ways to treat DMDD.  Engage other siblings, certainly a second parent if one is around, or grandparents, aunts and uncles.  Use friends.  Use your people.  If you have none, find a support group.  Call the National Alliance on Mental Illness, NAMI.

Lose the idea that this is something shameful.  Get more into the idea that it takes a village to raise a child, because it does.

Behavioral modification won't always work, but try it early, start very, very young.  Even a two-year old needs to know the power structure in the family, that he is not the boss of you.  As a parent, you are the boss.

All of this assuming that marital dynamics lend themselves to the therapy, that the child isn't learning aggression in the home, a very big assumption.  And that the dyad at the top, Mom and Dad, or Mom and Mom, or Dad and Dad, have to have something of a working relationship themselves, must communicate, agree on a treatment plan.

It is most likely that children who will be diagnosed with DMDD, unfortunately, are identified patients, that their families are the patient, really, and that only a fraction, a tiny fraction of the children diagnosed in nursery, kindergarten, or elementary school, whichever system has booted them out, have the disorder.  If you hear the news: This child needs a psychiatric evaluation--it may not mean Disruptive Mood Dysregulation Disorder, no matter who slaps on the label.

I'll put myself out there and suggest that as a first line of attack, families need to find a good family therapist, not a psychiatrist, and leave the primary care physician alone about medicating the child.

When it is obvious that a child is dangerous, on the other hand, a team approach is surely necessary, with a primary care doctor, a child psychiatrist (go find one, good luck), and a therapist.  Sometimes  even hospitalization might be necessary.  Or so they're saying in the news today.

therapydoc

Things Run in Threes

Three quick stories, the types of things that roll around in this therapist's head during the course of a day.

Jesse Jackson Jr.

The Legend, the Dad, Jesse Jackson Sr.

 (1) Jesse Jackson Jr's Mood Disorder  


Our biggest local news is that Illinois Congressman Jesse Jackson, Jr., son of the legendary political figure and civil rights leader, Jesse Jackson, Sr., is in Arizona receiving intensive medical treatment in a residential facility.  Rumors are flying that the congressman is there for alcohol or drug addiction, but the official word is much less exciting.  He's suffering from a mood disorder.

It was really annoying yesterday, if you listened to the news on radio.  Every third sentence had to be about this story.  Forget privacy, forget respect.  He's suffering from depression, and he can't work and why can't it be left at that? This shouldn't be the most catastrophic or interesting story of the day!  Hasn't some terrorist been stopped mid-air in China?

Then today it comes up in therapy not once, but twice, patient's versions of:  I knew, he had it!  I could just tell.  One week gaunt, the next week perky.  Then listless, then . . .nothing about Jesse in the news for months!  And now, THIS! 

And I realized that it is a good thing.   It is a good thing that psychiatric illness is normalized on the news, that we can talk about it, that people recognize depression, especially, as a fairly common illness, not something that can be helped if only we (a) just worked out! (b) ate right, (c) married into the right family, etc., etc.  It happens to everyone, depression, which is what these broadcasts recognize.  Or more importantly, to me, a cutting edge population, the clinical population, feels less alone.  They are the people in the know, and they are telling us, what's what.  Delicious.

(2)  Adult Asperger's and Depression

This one explains so much!

Years ago I had a patient with Adult Asperger's, and have seen many since then.  Once you know what to look for, it isn't hard to pick it up.  Not that this is a common diagnosis, but 1 in 250 isn't exactly one in a million. Ever since Baron-Cohen came out with a better test for Adult Asperger's, more and more people with this compelling disorder are coming to therapy.

Tony Atwood

I found a list of affirmations in Tony Atwood's book, The Complete Guide to Asperger's Syndrome,  and brought it to work with me one day.  The patient read through it and told me that it didn't matter. The depression people like him have (depression is often associated with Asperger's) is born of deficiencies that might improve, but will never be overcome (we shall overcome): misunderstanding social norms, not knowing the intentions of others, cluelessness about people's expectations, a sense of isolation ingrained over a lifetime.  No amount of affirmation, I deserve respect for being different! can change this.

And yet, like other AAA patients, his sense of humor has me on the floor.

He shows me a link to a tee shirt he found online that says,  I'm not rude. . .I have Asperger's, and he tells me he could never wear it.  Too embarrassing.  We talk at length about his sense of despair, his inability to hit the mark, socially. his inability to put words on feelings his whole life. He hasn't got feelings so much as rationale.  His rationale, and only his, since empathy he tells me, for someone like him, is like Greek to a Jew.

(3) The Runaway Train of Depression

We talk a lot about how depression can feel like a runaway train.  Women in particular can't stop the crying, especially if they are suffering before menses, PMS.  It's like, sure, we're depressed.  But our bodies have to cope with our hormones, too?  Or is it all, hormonal.  Feels like that, sometimes.

It doesn't matter, really.  What matters is the feeling that this is unstoppable, that the tears will never dry, a feeling of loss of control, a feeling of serious crazy.  Insanity. What is crazy if not lack of control?  Nothing.  A person feels as close to insane with these feelings.  It is not unlike the insanity people with Asperger's feel, like they are aliens, can't speak this unintelligible language, the language of social cues.

Segue to Asperger's just a moment, because it can be so depressing (my last referral had no idea he had the diagnosis, came in with suicidal ideation).  Why do they want to be together in groups! What's with these get-togethers?  Ridiculous.  This is how it feels to have Asperger's, and this is how it feels under depression.)

Even imitating the natives, it is hard to be one of them-- both conditions.  But merely having Asperger's, being unable to read what is expected, not knowing what anyone wants from you if it is not spelled out, a person does feel out of control, a mistake will happen at any moment in a social situation.

And it does.  Insanity, not unlike the insanity we feel when we can't "manage" our emotions, especially sadness.  We're supposed to be able to do that, right?  Manage them!  And guess what?  Sometimes, that's impossible.

So what is the cure for this craziness?  For both crazinesses.  For the runaway train, those tears that don't stop?  People who are in a relationship can, and often do, ask a partner to hold them.  Holding therapy is nothing new.  We use it for kids all the time.  Kid has a tantrum?  Hold him.  Kid is sad?  Hold him.  And let the child determine when it is time to let go.

Same for a woman, or a man, weeping, thinking depression is insanity, off the charts, unstoppable.  If she can get someone to hold her, if he can get someone to hold him, it helps.

There's usually a problem with that, however, which is that sometimes the trigger for the tears is something that this partner said, or something not done.  So asking for a hug puts a vulnerable individual in a position of potential rejection.  They just argued.  Timing is bad.

This is where I say, Own the craziness.  Just like with Asperger's.  Own that you feel out of touch, insane, that you are in a crazy place and it is nobody's fault, least of all that partner's.  Even if it is, you don't say that, not if you want to neutralize the fight and start over, get the drug, the feeling of human arms around you.

That's the cure.  It really is.  One of them, at least.

therapydoc

Borderline and Jealous

Switch the biological sexes and relationship labels to make them politically correct.
Like "wife" can be "partner" or "spouse."

"Man can be woman." "Woman", "man". That sort of thing.

Sometimes a guy will bring a woman to marital therapy because he's jealous and angry, ready to leave the relationship. She just wants to go out with her friends. And chutzpah of chutzpah, doesn't necessarily answer the phone. The argument is on-going.

She's very responsible when she goes out, hardly even drinks, really. She doesn't use cocaine. She comes home in a great mood, albeit late, and she might even feel sort of loving. But inevitably, he's angry.

Why? He's done this many times, comes home really drunk. She's not even coming home drunk. She's the designated driver.

While she's gone he tries hard not to picture guys hitting on her, but it's REALLY hard to do that. Worse, because she's naïve about men (at least he thinks so) he thinks she'll put herself in an uncompromising position. She's out late, very late.

What kind of a girl stays out so late, anyway?

Let me tell you. All kinds of people are out at all kinds of hours. Some people actually work midnight or late shifts, and when they're finished with their jobs it's hard for them to go right home and go to sleep. They need a life, too.

So they aren't all loose women and men closing the bars early in the morning.

Ah, he tells me. His wife doesn't work a late shift.

But, she tells him, not everyone is out to hit on her or anyone else's wife. Most people, at 2 or 3 a.m. are getting quietly sloshed.

So I talk to her and learn that indeed, she does adore her guy, and has no interest in other men or other women, for that matter. (She is out with the girls, after all).

Our guy understands that. He gets it. His rational brain tells him exactly why she's out with her friends at this hour. She didn't get to act out at all as a kid, always wanted to socialize but couldn't, and now she's all grown up and, insert expletive here, she's going to do what she wants as an adult.

You go, girl, I believe is the expression.

He tells me that he flips between loving her more than anything in the whole world and trusting her, following our visits, usually, to over the top, unstoppable, painful jealousy and rage, not caring what happens to her, wishing she'd drop dead, or at least leave him, put him out of his misery.

And all over a coupla' beers.

He himself makes the connection that it is because he loves and trusts her, because he knows that she's the one he wants for partner, mother of his children, lover, and friend, that he becomes wildly anxious when he fears she may be in the process of abandoning him, cheating on him.

What we have here is psychotic anxiety and rage that is triggered by a fear of abandonment. These fears have to be worked on, you know. You can't let them fester forever.

Anxiety that's to the point of psychotic inhibits rational thinking. One's thoughts have no basis in reality but they feel very real.

What to do?

Well, marital therapy, obviously. She has to reassure him and to develop some kind of behavioral strategy that will chill him out. And he has to work on his abandonment issues, and his impulse control, rationally go over a few of the symptoms of Borderline Personality Disorder, see if they fit. And if they do, get to work on them.

If she doesn't want to make the proverbial call to him from the bar, always had to call her mommy and can't do it anymore, she can plant a note or two in the apartment that tells him that she's looking forward to coming home late at night.

That would be CODE for something nice.

He would get it.

If she's the romantic type, then she can be obvious about it, tell him how she loves his 4 a.m. shadow, stuff like that.

In a relationship therapy I'd have her be the one to reassure him, to hold him more. It's hard, I know, to hold someone who is angry.

He has to learn, clearly, to contain that anxiety and never to display anger (we err on the exaggeration here).

For those of you who like to see the feedback loops, how behaviors and messages in marriage reinforce problems rather than "correct" them, take a look at this one.

Guy and his girl are doing fine, he loves her, they're not fighting. → She wants to go out with her friends to have fun and he's okay with it, not real okay, but okay. →

She goes out, has a great time, but her phone is on vibrate and she doesn't want to call him. She's talking with friends. Those of you who know how intimate friendship can be know that answering the phone can be a REAL pain if someone's in the middle of something→

His natural anxiety and insecurity begin to rise→ His thoughts go to places that reinforce his natural anxiety and insecurity, i.e., she could be hurt, raped, at that moment someone could be holding a gun to her head or touching her in places that he feels are off limits to everyone but himself→

He begins to call her every ten minutes, entertains the notion of going out to find her → His anxiety is unbearable and morphs into anger. After all, anger and anxiety use the same arousal system, the Central Nervous System. We all have one. →

His thoughts go to angry thoughts, What do I need this bitch for in my life, she's nothing but trouble, she has no respect for herself, none for our marriage, she doesn't deserve me →

He goes from that to thinking that marrying her was a really bad idea, that she isn't the one for him, that he would rather be alone than feel the way he feels, think the thoughts he's thinking →

And oh, by the way, another girl would appreciate him more in every way→ Maybe, he thinks, he should give her some of her own medicine, cheat on her, or simply not come home→

His wife comes home, he's exhausted himself with his thoughts, sleeps on the couch, doesn't even say hello to her →

He sees me the next day, tells me all of it, still really angry, by the way, ready to end the marriage→

In therapy we keep it rational, go with what's real, the fact that she adores him, it is he who can't handle the separation when she goes out, and his thoughts and emotions →

Oh, and by the way, it's not as if he doesn't give her grief. He hasn't been the perfect mate at the end of the day. →

We arrange for him to work it out with her, he leaves calm→ the whole thing starts all over again. They do fine for awhile, love each other, don't fight. →

Then she goes out and it starts all over again.

So it makes sense to look at more than the behavior, obviously, to force the psychology, the why, here.

therapydoc

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