- 严重的反复的脾气爆发,表现为言语(例如,言语暴力)和/或行为(例如,以肢体攻击他人或财物) ,其强度或持续时间与所处情况或所受的挑衅完全不成比例。
- 脾气爆发与其发育阶段不一致。
- 脾气爆发平均每周3 次或3 次以上。
- 几乎每天和每天的大部分时间,脾气爆发之间的心境是持续性的易激惹或发怒,旦可被他人观察到(例如,父母、老师、同伴)。
- 诊断标准A-D的症状已经持续存在12个月或更长时间,在此期间,个体从未有过连续3 个月或更长时间诊断标准A-D中的全部症状都没有的情况。
- 诊断标准A 和D 至少在下列三种(即在家、在学校、与同伴在一起)的两种场景中存在,且至少在其中一种场景中是严重的。
- 首次诊断不能在6 岁前或18 岁后。
- 根据病史或观察,诊断标准A-E 的症状出现的年龄在10岁前。
- 从未有超过持续1天的特别时期,在此期间,除了持续时间以外,符合了躁狂或轻躁狂发作的全部诊断标准。
注:与发育阶段相符的情绪高涨,例如遇到或预期到一个非常积极的事件发生,则不能被视为躁狂或轻躁狂的症状。 - 这些行为不仅仅出现在重性抑郁障碍的发作期,且不能用其他精神障碍来更好地解释(例如,孤独症[自闭症]谱系障碍、创伤后应激障碍、分离焦虑障碍、持续性抑郁障碍[心境恶劣])。
注:此诊断不能与对立违抗障碍、间歇性暴怒障碍或双相障碍并存,但可与其他精神障碍并存,包括重性抑郁障碍、注意缺陷/多动障碍、品行障碍和物质使用障碍。若个体的症状同时符合破坏性心境失调障碍和对立违抗障碍的诊断标准,则只能诊断为破坏性心境失调障碍。如果个体曾有过躁狂或轻躁狂发作,则不能再诊断为破坏性心境失调障碍。 - 这些症状不能归因于某种物质的生理效应,或其他躯体疾病或神经疾病。
Diagnostic Features
The core feature of disruptive mood dysregulation disorder is chronic, severe persistent irritabihty. This severe irritability has two prominent clinical manifestations, the first of which is frequent temper outbursts. These outbursts typically occur in response to frustration and can be verbal or behavioral (the latter in the form of aggression against property, self, or others). They must occur frequently (i.e., on average, three or more times per week) (Criterion C) over at least 1 year in at least two settings (Criteria E and F), such as in the home and at school, and they must be developmentally inappropriate (Criterion B). The second manifestation of severe irritability consists of chronic, persistently irritable or angry mood that is present between the severe temper outbursts. This irritable or angry mood must be characteristic of the child, being present most of the day, nearly every day, and noticeable by others in the child's environment (Criterion D).
The clinical presentation of disruptive mood dysregulation disorder must be carefully distinguished from presentations of other, related conditions, particularly pediatric bipolar disorder. In fact, disruptive mood dysregulation disorder was added to DSM-5 to address the considerable concern about the appropriate classification and treatment of children who present with chronic, persistent irritability relative to children who present with classic (i.e., episodic) bipolar disorder.
Some researchers view severe, non-episodic irritability as characteristic of bipolar disorder in children, although both DSM-IV and DSM-5 require that both children and adults have distinct episodes of mania or hypomania to qualify for the diagnosis of bipolar I disorder. During the latter decades of the 20th century, this contention by researchers that severe, nonepisodic irritability is a manifestation of pediatric mania coincided with an upsurge in the rates at which clinicians assigned the diagnosis of bipolar disorder to their pediatric patients. This sharp increase in rates appears to be attributable to clinicians combining at least two clinical presentations into a single category. That is, both classic, episodic presentations of mania and non-episodic presentations of severe irritability have been labeled as bipolar disorder in children. In DSM-5, the term bipolar disorder is explicitly reserved for episodic presentations of bipolar symptoms. DSM-IV did not include a diagnosis designed to capture youths whose hallmark symptoms consisted of very severe, nonepisodic irritability, whereas DSM-5, with the inclusion of disruptive mood dysregulation disorder, provides a distinct category for such presentations.
Prevalence
Disruptive mood dysregulation disorder is common among children presenting to pediatric mental health clinics. Prevalence estimates of the disorder in the community are unclear. Based on rates of chronic and severe persistent irritability, which is the core feature of the disorder, the overall 6-month to 1-year period-prevalence of disruptive mood dysregulation disorder among children and adolescents probably falls in the 2%-5% range. However, rates are expected to be higher in males and school-age children than in females and adolescents.
Development and Course
The onset of disruptive mood dysregulation disorder must be before age 10 years, and the diagnosis should not be applied to children with a developmental age of less than 6 years. It is unknown whether the condition presents only in this age-delimited fashion. Because the symptoms of disruptive mood dysregulation disorder are likely to change as children mature, use of the diagnosis should be restricted to age groups similar to those in which validity has been established (7-18 years). Approximately half of children with severe, chronic irritability will have a presentation that continues to meet criteria for the condition 1 year later. Rates of conversion from severe, nonepisodic irritability to bipolar disorder are very low. Instead, children with chronic irritability are at risk to develop unipolar depressive and/or anxiety disorders in adulthood.
Age-related variations also differentiate classic bipolar disorder and disruptive mood dysregulation disorder. Rates of bipolar disorder generally are very low prior to adolescence (<1%), with a steady increase into early adulthood (l%-2% prevalence). Disruptive mood dysregulation disorder is more common than bipolar disorder prior to adolescence, and symptoms of the condition generally become less common as children transition into adulthood.
Risk and Prognostic Factors
Temperamental.Children with chronic irritability typically exhibit complicated psychiatric histories. In such children, a relatively extensive history of chronic irritability is common, typically manifesting before full criteria for the syndrome are met. Such prediagnostic presentations may have qualified for a diagnosis of oppositional defiant disorder. Many children with disruptive mood dysregulation disorder have symptoms that also meet criteria for attention-deficit/hyperactivity disorder (ADHD) and for an anxiety disorder, with such diagnoses often being present from a relatively early age. For some children, the criteria for major depressive disorder may also be met.
Genetic and physiological.In terms of familial aggregation and genetics, it has been suggested that children presenting with chronic, non-episodic irritability can be differentiated from children with bipolar disorder in their family-based risk. However, these two groups do not differ in familial rates of anxiety disorders, unipolar depressive disorders, or substance abuse. Compared with children with pediatric bipolar disorder or other mental illnesses, those with disruptive mood dysregulation disorder exhibit both commonalities and differences in information-processing deficits. For example, face-emotion labeling deficits, as well as perturbed decision making and cognitive control, are present in children with bipolar disorder and chronically irritable children, as well as in children with some other psychiatric conditions. There is also evidence for disorder-specific dysfunction, such as during tasks assessing attention deployment in response to emotional stimuli, which has demonstrated unique signs of dysfunction in children with chronic irritability.