When searching PubMedCentral for articles relevant to the proposed diagnosis of temper dysregulation disorder with dysphoria, I came across an interesting paper discussing controveries in the current DSM diagnosis of irritability. Temper dysregulation disorder with dysphoria, or its alternative name, severe mood dysregulation, was not mentioned, but a number of interesting issues were discussed, especially for the diagnosis of adults.
As the author states, there is no current DSM diagnosis for adults who show frequent anger or irritability but no aggressive behaviors. The two possibly relevant diagnoses, antisocial personality disorder and intermittent explosive disorder, after all, both require that the person has displayed acts of destruction or assault. I begin to believe that my (former, I might hope) diagnosis of impulse control disorder NOS, back in 2008, was an awkward attempt at categorizing my irritability somewhere. Of course, in my case, it wasn’t all that necessary, if my doctor had looked beyond the surface of the DSM-IV criteria for autism, but that’s not the point. The author, namely, contends it as a problem that irritability is spread out over so many non-specific diagnoses in adults, when in fact it is not a core feature of any of these diagnoses. For example, it is said to be a possible defining characteristic of a manic episode, when in reality most people in a manic phase are not primarily irritable. It is also a descriptor of generalized anxiety disorder, posttraumatic stress disorder, and pathological gambling, among others, all of which would not be diagnosable if the person were merely irritable. Lastly, it is a non-core feature of a huge number of disorders, such as ADHD, intellectual disability and dementia. It is not in the DSM criteria of any of these conditions, but it is very commonly seen in patients diagnosed with them.
There are several solutions proposed for this nonspecificity of irritability. One of them is to expand the category of mood disorders to include dysfunctional anger and anxiety. The author prefers dysfunctional anger over irritability, but I did not really understand why. The inclusion of a separate mood category for anger, however, could, in my opinion, be somewhat confusing, given that the author also proposes a number of changes that reflect the idea that adults can have behavioral disorders with irritability, too. How is one going to distinguish irritable moods from irritable behavior disorders?
The author proposes to expand the diagnosis of oppositional definant disorder to adults, and to move the diagnosis of intermittent explosive disorder into a new category of social behavior disorders. The reasoning behind the latter is rather weird: IED is currently listed as an impulse control disorder, but, since none of the other specific impulse control disorders are truly impulsive, IED has to move. Why does this fact suddenly make IED not an impulse control disorder but a behavior disorder?
The other proposal, to expand the diagnosis of ODD to adults, makes little sense to me, too. The reason is not that adults cannot possibly display inappropriate anger, or kind of egocentric reasoning like the fact that I don’t want to be labeled with a “behavior disorder”, but the context in which ODD is set. That is, ODD is clearly presumed to be a disorder of obedience to authority, while in reality the vast majority of people of all ages who are irritable, do not have the purpose of defying authority. This is one of my major problems with the diagnosis of ODD in general: if a child is often irritable, it is readily assumed that they are so on purpose, and that the specific purpose is to defy the power dynamics in which they live. It is already probleematic for children, but it is even more problematic for adults, because, in most real-life contexts, they are not supposed to be obeying someone else at all times. Of course, there are power structures in adult life, too – at college or work, with the police, etc. -, but they are not as clearly present as the conventional parent-child power dynamic. On the other hand, however, as soon as a person of any age enters the healthcare system, especially psychiatry, they enter a power dynamic. If ODD is expanded to include adults, will it not be abused to merely describe the “non-compliant” patient?
I do think a diagnostic category is warranted to describe severe irritability in people of all ages, but I already have a problem with the artificial distinction between irritable moods and irritable behaviors. If a patient is neither depressed nor manic, how can a clinician tell whether they are having an irritable mood or displaying “oppositional” behavior? In children, ODD and mood disorders often coincide – and they did before the large-scalde overdiagnosis of “pediatric bipolar”, I might say. This does not mean that all these children have classic depression: in fact, many display the irritable variant of current major depressive or dysthymic disorders. If irritability is included as a descripptor of mood disorders in people of all ages, or even as a separate mood disorder category, the water gets even muddier: will pretty much every adult with irritability then receive a comorbid diagnosis of ODD and a mood disorder with irritability? For children, the proposed TDD diagnosis might solve this – if it is not used as an excuse to label even more children not in need of labels at all -, but this disorder doesn’t apply to adults. So, what will we do with the irritable adult?: diagnose them with a “behavior disorder” regardless of their mood, diagnose even more people with mood disorders, diagnose them with both a “behavior disorder” and a mood disorder, eventually expand TDD to include adults – with all possible consequences not yet foreseeable -, or what? So far, it doesn’t seem like DSM-V is going to come up with a useful solution.
Safer DJ (2009), Irritable mood and the Diagnostic and Statistical Manual of Mental Disorders. Child and Adolescent Psychiatry and Mental Health, 3:35. Published online: October 24, 2009. doi: 10.1186/1753-2000-3-35. PMCID: PMC2773760
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