DSM-V draft available online for public comment
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DammitJanet
Well-Known Member
LOL...I have been engrossed for the past hour or so myself.
Interesting. I think the new temper disorder actually sounds spot on.
Interesting. I think the new temper disorder actually sounds spot on.
jcox
New Member
Yes I read this and I do not think my E will fit into that category. I think this will cause more issues in getting children who are complex like E diagnosed correctly. He fit the adult criteria for BiPolar (BP) I at age 3 (296.6). I think this will be one more opstical in getting our children the help they need. in my opinion E does not fit this criteria because he has profound ups and downs from mania to depression. I worry that once this diagnosis comes out children who clearly have BiPolar (BP) like E and are complex, complicated children to figure out might have yet one more thing to be misdiagnosed with. I am very concerned with this new diagnosis taking the place of children being diagnosed with BiPolar (BP) as some news articles I read today say the plan is.
Here is a list of what the DSM V diagnosis of Temper Disregulation Disorder will look like:
Temper Dysregulation Disorder with Dysphoria
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the B criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
That doesn't fit my E because he clearly has BiPolar (BP) ups and downs. I worry that this diagnosis might mistakenly be used in many children who were diagnosed with BiPolar (BP), which will lead to more complications in getting complex children like E the help they need.
Here is a list of what the DSM V diagnosis of Temper Disregulation Disorder will look like:
Temper Dysregulation Disorder with Dysphoria
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the B criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
That doesn't fit my E because he clearly has BiPolar (BP) ups and downs. I worry that this diagnosis might mistakenly be used in many children who were diagnosed with BiPolar (BP), which will lead to more complications in getting complex children like E the help they need.
DammitJanet
Well-Known Member
Well from what I take from reading this is just opposite. I think they are trying to clear up the fact that everyone has been trying to say that irritability and anger is mania in kids. They want to give another disorder so that if the kid is only exhibiting the irritability and anger but doesnt have the hypomania then they can be dxd with another severe disorder but not bipolar. They arent taking bipolar off the table for kids.
This could also be why some kids react to certain treatments with only a AP or with a SSRI when a truly BiPolar (BP) kid would go ape. Or would not being able to maintain at all.
This could also be why some kids react to certain treatments with only a AP or with a SSRI when a truly BiPolar (BP) kid would go ape. Or would not being able to maintain at all.
DammitJanet
Well-Known Member
LOL...I logged on and have been commenting away!
LittleDudesMom
Well-Known Member
Here's a great article about the history of TDD from NPR:
http://www.npr.org/templates/story/story.php?storyId=123544191&ft=1&f=1030
Sharon
http://www.npr.org/templates/story/story.php?storyId=123544191&ft=1&f=1030
Sharon
tessaturtle
New Member
I'm glad I looked at this post before posting my own! lol I was going to post the exact link that Sharon did. I heard the NPR story on my home from work today. And I do have to say, I have mixed thoughts about this. I do see what you are saying Janet. But I also have this fear that this will now add more fuel to the fire of those that still disbelieve that kids can have Bipolar. I also fear that now more kids will be diagnosed this new Temper disorder rather than Bipolar and have a tougher time convincing their school district to accomodate their special needs. My last (well for now LOL) thought is that again, back to those who don't believe or understand our difficult child's, now with a name like that "Temper Dysregulation Disorder"....it may bring to mind "temper tantrums" and back to that old thinking of blaming the parent.
LittleDudesMom
Well-Known Member
Having read the NPR article, I think that is probably what was going on with difficult child back in second grade when we experienced what I call the "dark times".
He began raging out of the blue. He had always been very impulsive and quite classically ADHD! His outbursts of anger were in response to stimuli and situations that other kids could cope with.
At one point, he was taking his adhd medications along with a fairly low dose (30mg) of remeron and a small dose (25mg) of seroquel.
As the years went on, we saw his "fuse" get a little longer. He began to handle things a little better. He was weaned, at my request, off the remeron and the seroquel before he began middle school.
Over the last two and a half years, great strides have been made in his ability to control himself. He seems to be able, most but not all of the time, to make clearer choices about how he reacts to situations that would have set him off uncontrollably in the past.
I took him for a two-day evaluation at our local teaching hospital and he actually saw the head of the department during his evaluation. She assured me that she saw no signs of mood disorder in difficult child.
Now, having read the NPR article, one thing leapt out at me. That TDD was, unlike bipolar, not something that will last a lifetime.
It really makes me believe that difficult child very well might have fit into the diagnostic criteria. The same medications were given him that are given kids with BiPolar (BP), albeit a lower dosage. So the medical treatment was the same but the need for continued medications was not.
Naturally this is all conjecture at this point! And he is definately a difficult child! He was one before the raging and is one now - just in a different way......
Just thinking.....
Sharon
He began raging out of the blue. He had always been very impulsive and quite classically ADHD! His outbursts of anger were in response to stimuli and situations that other kids could cope with.
At one point, he was taking his adhd medications along with a fairly low dose (30mg) of remeron and a small dose (25mg) of seroquel.
As the years went on, we saw his "fuse" get a little longer. He began to handle things a little better. He was weaned, at my request, off the remeron and the seroquel before he began middle school.
Over the last two and a half years, great strides have been made in his ability to control himself. He seems to be able, most but not all of the time, to make clearer choices about how he reacts to situations that would have set him off uncontrollably in the past.
I took him for a two-day evaluation at our local teaching hospital and he actually saw the head of the department during his evaluation. She assured me that she saw no signs of mood disorder in difficult child.
Now, having read the NPR article, one thing leapt out at me. That TDD was, unlike bipolar, not something that will last a lifetime.
It really makes me believe that difficult child very well might have fit into the diagnostic criteria. The same medications were given him that are given kids with BiPolar (BP), albeit a lower dosage. So the medical treatment was the same but the need for continued medications was not.
Naturally this is all conjecture at this point! And he is definately a difficult child! He was one before the raging and is one now - just in a different way......
Just thinking.....
Sharon
DammitJanet
Well-Known Member
Its on ABC nightly news. Lets see how it goes.
smallworld
Moderator
Just to clarify, Sharon, Remeron is an antidepressant and would not be used to treat bipolar disorder in children.
DammitJanet
Well-Known Member
Sharon...I think your difficult child would have fit that criteria as well. Actually, Im not so sure that Cory wouldnt either because he doesnt have the classic ups and downs of BP1. He can just be irritable as heck. One thing that did jump out to me was that you can have TDD and ADHD and I wonder if Cory did have those two together.
Makes you go humm.
Makes you go humm.
klmno
Active Member
Throwing my 2 cents in, LOL! I can see this work as both an advantage and disadvantage. The advantage could be that while so many kids are now getting the diagnosis of BiPolar (BP) and surely some of them really are, many might be misdiagnosed and this might help kids get diagnosis'd more accurately. The more accurate kids are diagnosis'd and ultimately helped as a result, the more credence the general public should give to the diagnosis of BiPolar (BP) or anything else in kids.
The possible disadvantages, along with those already mentioned, in my humble opinion, is this is just one more opportunity for incompetent professionals to misdiagnose. And it does get under my skin sometimes when I see diagnosis's that appear to be symptoms of other problems- like CD for instance. If a child has this temper disorder but no other underlying problem that could be causing (whether diagnosis'd or not), then is it really a mental illness? And how many would really fit into that category?
So, given those opinions of mine, it appears to me that the effectiveness of this is going to depend on the competency, abilities, and wisdom of the professional doing the diagnosis'ing. And that worries me. Look how many people spent years diagnosis'ing almost all difficult child's as ADHD just because of that one form we all have filled out that any difficult child ends up with "yesses" on, but in actuality these were symptoms of untreated problems in other areas- like BiPolar (BP).
So if we end up with a form that is meant to expose this new diagnosis and most of our difficult child's results will include the "yesses", then will the professionals stop looking at other causes, like many still do with ADHD? I'm just visualizing the sd psychiatric's using two forms now- one for ADHD and one for this and then trying to pigeon hole and sterotype based solely on those things. I know a true competent diagnosis is supposed to look at more than a form or two, but sd psychiatric's rarely do that. Of course the bigger issue is how the sd treats the child as a result of certain labels.
The possible disadvantages, along with those already mentioned, in my humble opinion, is this is just one more opportunity for incompetent professionals to misdiagnose. And it does get under my skin sometimes when I see diagnosis's that appear to be symptoms of other problems- like CD for instance. If a child has this temper disorder but no other underlying problem that could be causing (whether diagnosis'd or not), then is it really a mental illness? And how many would really fit into that category?
So, given those opinions of mine, it appears to me that the effectiveness of this is going to depend on the competency, abilities, and wisdom of the professional doing the diagnosis'ing. And that worries me. Look how many people spent years diagnosis'ing almost all difficult child's as ADHD just because of that one form we all have filled out that any difficult child ends up with "yesses" on, but in actuality these were symptoms of untreated problems in other areas- like BiPolar (BP).
So if we end up with a form that is meant to expose this new diagnosis and most of our difficult child's results will include the "yesses", then will the professionals stop looking at other causes, like many still do with ADHD? I'm just visualizing the sd psychiatric's using two forms now- one for ADHD and one for this and then trying to pigeon hole and sterotype based solely on those things. I know a true competent diagnosis is supposed to look at more than a form or two, but sd psychiatric's rarely do that. Of course the bigger issue is how the sd treats the child as a result of certain labels.
DammitJanet
Well-Known Member
Klmno, if there is no other underlying reason for the child to have the temper and anger outbursts, that would be the definition for the child to BE mentally ill. Not to exclude mental illness.
In other words, if the child was acting out because he was 8 years old and using drugs...he would not be mentally ill. If he was acting out and raging because he was being sexually abused...he would not be mentally ill. If he was 6 years old and sulky and depressed and mad and raging and throwing fits because his daddy or mommy had been deployed to war for 2 years...he would not be mentally ill.
But...if kiddo is doing all of the above without those stressors and you cant find any reason to explain the situation, then you can say, well, this is beyond the norm and most 5 or 6 or 7 year olds dont behave this way for this length of time in this situation and yes, this is mental illness.
In other words, if the child was acting out because he was 8 years old and using drugs...he would not be mentally ill. If he was acting out and raging because he was being sexually abused...he would not be mentally ill. If he was 6 years old and sulky and depressed and mad and raging and throwing fits because his daddy or mommy had been deployed to war for 2 years...he would not be mentally ill.
But...if kiddo is doing all of the above without those stressors and you cant find any reason to explain the situation, then you can say, well, this is beyond the norm and most 5 or 6 or 7 year olds dont behave this way for this length of time in this situation and yes, this is mental illness.
klmno
Active Member
Interesting perspective-
I was looking at it like if he's explosive due to inadequately treated depression or PTSD or whatever, then it is indicative of mental illness but the fear is that they would never look any deeper than this new diagnosis in order to uncover the depression or PTSD or whatever. (I'm one who views PTSD and addictions as mental illness.)
And, for the cases (whatever percentage that might be) where it is either a spoiled brat throwing a fit or the results of a society where people aren't allowed to discipline children without fear of false accusations of abuse so the kid goes amuck, is that child, too, going to get this diagnosis?
I can see tho that this could be similar to anxiety in regards to diagnosis'ing- sometimes anxiety is a result of a chemical imbalance Biological), sometimes it is the result of other issues (PTSD), and sometimes it is a stand-alone psycholigical issue.
ETA: Maybe I'm in a minority here by believing that most, but not all, kids who don't fit the norm in behavior expectations are mentally ill. I'm not sure what others' stance on this is. That doesn't mean I think it's the kid's fault, or the parent's- I think many times it's a result of our societal changes the past 20 years. Some of those changes have been good, but in my humble opinion, some have left parents and our kids living in a state of confusion.
I was looking at it like if he's explosive due to inadequately treated depression or PTSD or whatever, then it is indicative of mental illness but the fear is that they would never look any deeper than this new diagnosis in order to uncover the depression or PTSD or whatever. (I'm one who views PTSD and addictions as mental illness.)
And, for the cases (whatever percentage that might be) where it is either a spoiled brat throwing a fit or the results of a society where people aren't allowed to discipline children without fear of false accusations of abuse so the kid goes amuck, is that child, too, going to get this diagnosis?
I can see tho that this could be similar to anxiety in regards to diagnosis'ing- sometimes anxiety is a result of a chemical imbalance Biological), sometimes it is the result of other issues (PTSD), and sometimes it is a stand-alone psycholigical issue.
ETA: Maybe I'm in a minority here by believing that most, but not all, kids who don't fit the norm in behavior expectations are mentally ill. I'm not sure what others' stance on this is. That doesn't mean I think it's the kid's fault, or the parent's- I think many times it's a result of our societal changes the past 20 years. Some of those changes have been good, but in my humble opinion, some have left parents and our kids living in a state of confusion.
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smallworld
Moderator
Here are my thoughts about the new label Temper Dysregulation Disorder:
First, I agree with Tessa that I don't like the name because it brings to mind temper tantrums set off by bad parenting. The kind of rages our difficult children exhibit go way beyond any temper tantum a two-year-old throws and have no rhyme nor reason to their origin. From having experienced rages in my household for 5 years, I do believe they emanate from deep inside the brain and are almost seizure-like in their origin. Calling them temper dysregulation diminishes their severity in my mind.
Second, researchers at NIMH in Bethesda, Maryland, have been studying a disorder that they have termed Severe Mood Dysregulation, which I think is similar to TDD (I happen to like the term SMD better than TDD). They think it is distinct from BiPolar (BP) and have been testing whether it responds to medications that BiPolar (BP) doesn't respond to -- ADHD stimulants (like Ritalin) and SSRI antidepressants (like Celexa). Although I believe my own kids might fit better with a SMD diagnosis than a BiPolar (BP) diagnosis, I don't believe they would do all that well with stimulants and SSRIs.
Which brings me to my third point. TDD does not address the whole issue of kids who take SSRIs and become manic. This is an all-too-frequent problem (two just in my family, and a third who became disinhibited), and psychiatrists don't know what to make of it or how to treat it long-term. My son J was rxed Zoloft at age 11 and had a manic reaction after 3 weeks. Even though we discontinued Zoloft that night, he didn't settle down for weeks until Depakote was introduced. He later had manic reactions to four SSRIs/SNRIs, even with mood stabilizers on board. What does this mean for a diagnosis? What does this mean for treatment?
J is now 16 and in an Residential Treatment Center (RTC) in Utah. His Residential Treatment Center (RTC) psychiatrist is not convinced he has BiPolar (BP) (based on psychological testing and history) and weaned him from his mood-stabilizing medications (Lamictal and Seroquel). And guess what? His mood is stable, although he is still struggling with anxiety that he is working on therapeutically. This is by no means the end of the road for J, diagnostically, medically or therapeutically. We are still trying to find our way.
Is it possible that there are kids out there who don't have BiPolar (BP) or TDD? Like mine?
First, I agree with Tessa that I don't like the name because it brings to mind temper tantrums set off by bad parenting. The kind of rages our difficult children exhibit go way beyond any temper tantum a two-year-old throws and have no rhyme nor reason to their origin. From having experienced rages in my household for 5 years, I do believe they emanate from deep inside the brain and are almost seizure-like in their origin. Calling them temper dysregulation diminishes their severity in my mind.
Second, researchers at NIMH in Bethesda, Maryland, have been studying a disorder that they have termed Severe Mood Dysregulation, which I think is similar to TDD (I happen to like the term SMD better than TDD). They think it is distinct from BiPolar (BP) and have been testing whether it responds to medications that BiPolar (BP) doesn't respond to -- ADHD stimulants (like Ritalin) and SSRI antidepressants (like Celexa). Although I believe my own kids might fit better with a SMD diagnosis than a BiPolar (BP) diagnosis, I don't believe they would do all that well with stimulants and SSRIs.
Which brings me to my third point. TDD does not address the whole issue of kids who take SSRIs and become manic. This is an all-too-frequent problem (two just in my family, and a third who became disinhibited), and psychiatrists don't know what to make of it or how to treat it long-term. My son J was rxed Zoloft at age 11 and had a manic reaction after 3 weeks. Even though we discontinued Zoloft that night, he didn't settle down for weeks until Depakote was introduced. He later had manic reactions to four SSRIs/SNRIs, even with mood stabilizers on board. What does this mean for a diagnosis? What does this mean for treatment?
J is now 16 and in an Residential Treatment Center (RTC) in Utah. His Residential Treatment Center (RTC) psychiatrist is not convinced he has BiPolar (BP) (based on psychological testing and history) and weaned him from his mood-stabilizing medications (Lamictal and Seroquel). And guess what? His mood is stable, although he is still struggling with anxiety that he is working on therapeutically. This is by no means the end of the road for J, diagnostically, medically or therapeutically. We are still trying to find our way.
Is it possible that there are kids out there who don't have BiPolar (BP) or TDD? Like mine?
klmno
Active Member
SW, as you know my son has had some of those experiences and is not on medications right now and his situation is pretty much the same as you described about J (from a mental health and therapuetic standpoint- what they are trying now anyway).
But it appears to me that expanding the Mood Disorder not otherwise specified and categories classified as Mood Disorders might be the best approach. Right now it's generally seen as either depression, one class of BiPolar (BP), or they aren't sure yet (MS not otherwise specified), but I'm not so sure that there isn't a third scenario in there somewhere- like kids who are somewhere along those lines and easily diagnosis'd that way, respond to MS's to a certain extent but react Occupational Therapist (OT) AD's, explosive because, as you and I KNOW, we never found the real effective treatment whether that was therautic, medications, or methods at sd and well for me at least, home. But with everything in me, I believe my son has a mood disorder. I can't honestly say that I believe he's BiPolar (BP). The one thing I can say is that whether he is or isn't, his medications never stabilized him enough to make it worth it. I think his periods of stability would have been there even without the medications. When he wasn't stable, they never reeled him in and some combinations made things worse.
I'm not an expert of course, but there are a WHOLE lot of kids and families that have gone down this same path with similar results.
But it appears to me that expanding the Mood Disorder not otherwise specified and categories classified as Mood Disorders might be the best approach. Right now it's generally seen as either depression, one class of BiPolar (BP), or they aren't sure yet (MS not otherwise specified), but I'm not so sure that there isn't a third scenario in there somewhere- like kids who are somewhere along those lines and easily diagnosis'd that way, respond to MS's to a certain extent but react Occupational Therapist (OT) AD's, explosive because, as you and I KNOW, we never found the real effective treatment whether that was therautic, medications, or methods at sd and well for me at least, home. But with everything in me, I believe my son has a mood disorder. I can't honestly say that I believe he's BiPolar (BP). The one thing I can say is that whether he is or isn't, his medications never stabilized him enough to make it worth it. I think his periods of stability would have been there even without the medications. When he wasn't stable, they never reeled him in and some combinations made things worse.
I'm not an expert of course, but there are a WHOLE lot of kids and families that have gone down this same path with similar results.
tiredmommy
Well-Known Member
What does this mean:
The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
What would cause the symptoms then? Will insurance companies refuse payment for treatment?
The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
What would cause the symptoms then? Will insurance companies refuse payment for treatment?
smallworld
Moderator
It means the temper dysregulation is not from drug abuse or from a medical condition (like migraines) or from a neurological conditon (like seizures). I don't think it relates at all to whether insurance will pay; I think it's merely trying to define what constitutes TDD and what doesn't.
The psychiatrists who drafted the DSM-V believe the temper dysregulation is a brain disorder.
The psychiatrists who drafted the DSM-V believe the temper dysregulation is a brain disorder.
