What Is DMDD? Disruptive Mood Dysregulation Disorder Explained

Disruptive mood dysregulation disorder (DMDD) is a childhood condition marked by a persistently irritable or angry mood almost every day, combined with severe temper outbursts that happen around three or more times a week, in more than one setting, for at least a year. It is not ordinary tantrums and it is not bipolar disorder. DMDD was added to the diagnostic manual (DSM-5) in 2013. This page explains the criteria, how the diagnosis is made, what the outlook tends to be, and how it is treated.

Safety comes first

DMDD sits inside our wider guide to bipolar disorder and mood problems in teens and children, which explains how clinicians tell these conditions apart.

Why DMDD exists

Before 2013, many children with constant irritability and explosive behavior were diagnosed with bipolar disorder, even though they did not have distinct manic episodes. The American Psychiatric Association added DMDD to DSM-5 "to address concerns about potential overdiagnosis and overtreatment of bipolar disorder in children." It describes children up to age 18 with persistent irritability and frequent episodes of extreme behavioral dyscontrol. The history behind this is told in Can a child have bipolar disorder?.

DMDD symptoms

NIMH and the DSM-5 criteria describe the core symptoms this way:

• Severe temper outbursts, verbal (screaming, rages) or physical (aggression toward people or property), averaging three or more times a week.
• Outbursts that are far out of proportion to the situation and do not fit the child’s developmental level.
• Chronically irritable or angry mood most of the day, nearly every day, between outbursts, noticeable to others.
• Outbursts happening regularly for at least 12 months.
• Problems in more than one setting, such as home, school and with peers.

The between-outburst mood is what sets DMDD apart from a child who simply has frequent tantrums. Parents often describe "walking on eggshells" because the child is irritable almost all the time, not only when something goes wrong.

The DSM-5 criteria, including the age rules

The full DSM-5 criteria, as reproduced in a 2016 review by Baweja and colleagues, add several requirements:

• Outbursts occur on average three or more times per week.
• Symptoms have lasted 12 months or more, with no break of three months or longer without them.
• Symptoms are present in at least two of three settings (home, school, with peers) and severe in at least one.
• Onset is before age 10.
• The diagnosis is not made for the first time before age 6 or after age 18.
• There has never been a distinct period of more than one day in which the full symptoms of mania or hypomania were present.
• The symptoms are not better explained by another condition, such as autism, PTSD, separation anxiety or persistent depressive disorder, and are not caused by a substance or medical condition.

A note on ages. NIMH’s DMDD brochure says youth with DMDD "are diagnosed between the ages of 6 and 10." That wording differs from the DSM-5 rule, which requires symptoms to begin before 10 but allows the first diagnosis anywhere from 6 to 18. We use the DSM-5 framing here: a 14-year-old whose irritability began at age 8 can receive a first DMDD diagnosis.

What DMDD cannot be diagnosed alongside

Under DSM-5, DMDD cannot coexist with bipolar disorder, oppositional defiant disorder (ODD) or intermittent explosive disorder (IED). If a child meets criteria for both DMDD and ODD, only DMDD is diagnosed. If a child has ever had a manic or hypomanic episode, the diagnosis is bipolar disorder, not DMDD. DMDD can, however, occur with ADHD, anxiety and depression.

The key differences from bipolar disorder, with a comparison table, are on our page DMDD versus bipolar disorder. If anger is the main concern in an older teen or adult with bipolar disorder, see bipolar disorder and anger.

How DMDD is diagnosed

There is no lab test for DMDD. A clinician builds the picture from a detailed history with the parents and the child, reports from school, how long the pattern has lasted and where it shows up, and a careful look for other explanations. That includes asking about any past periods that sounded like mania, since those would point to a different diagnosis, and screening for anxiety, depression, ADHD, trauma, learning problems and sleep problems.

Expect the clinician to ask when the irritability started, how often outbursts happen in a typical week, and whether there have been months without them. A simple log of outbursts (date, setting, trigger, how long it lasted) for a few weeks before the appointment is very helpful.

What happens over time

NIMH notes that youth with DMDD are at higher risk of developing anxiety and depression later on. They are not, on current evidence, on a path toward bipolar disorder. Research on children with severe chronic irritability (the research forerunner of DMDD) found that very few developed mania over about two years of follow-up: 1 of 84 children, compared with 58 of 93 children who had bipolar disorder.

That course is reassuring in one way and important in another. It means early treatment should watch closely for anxiety and depression as a child gets older, and that a DMDD diagnosis is not a stepping stone to a bipolar one.

How DMDD is treated

According to NIMH, psychotherapy is often tried first, and there is no medication approved by the FDA specifically for DMDD. Approaches include:

• Cognitive behavioral therapy (CBT) to help the child understand and manage frustration and anger, and to build coping skills.
• Parent training, which NIMH describes as teaching parents and caregivers more effective ways to respond to irritable behavior, such as anticipating situations that tend to set off outbursts and working ahead to head them off.
• School support, coordinated with teachers so the child gets the same approach across settings.

When symptoms remain severe, clinicians may use medication for specific parts of the picture, off-label. NIMH lists stimulants (often when ADHD is also present), antidepressants (sometimes for irritability, anxiety or depression) and atypical antipsychotics (generally for severe aggression) as options clinicians consider. NIMH adds that therapy usually comes first with medication added later, although some children start both at once. Each medicine has its own risks, so these decisions belong with a clinician who knows the child well.

At Willow & Stone

DMDD by definition begins before age 10. Willow & Stone sees patients 10 and older, so younger children are referred to a child psychiatry specialist, while older children and teens can be evaluated through our teen and adolescent psychiatry service. When bipolar disorder is the question instead, see bipolar disorder treatment at Willow & Stone.

Common Questions

Sources & Further Reading

• NIMH: Disruptive Mood Dysregulation Disorder (NIH Pub. 23-MH-8119, 2023)
• NIMH: Disruptive Mood Dysregulation Disorder (DMDD) topic page (reviewed Dec 2024)
• Baweja R et al. Disruptive mood dysregulation disorder: current insights. Neuropsychiatr Dis Treat, 2016
• American Psychiatric Association: Highlights of Changes from DSM-IV-TR to DSM-5 (2013)
• NIMH: Bipolar Disorder in Children and Teens (NIH Pub. 23-MH-8081, 2023)

This article is general education, not a diagnosis or advice for your situation. Do not start, stop, or change a medication without talking to the clinician who prescribes it; stopping a mood stabilizer suddenly can trigger relapse.