COUCH IN CRISIS
DSM5 Temper Dysregulation—Good Intentions, Bad Solution
by Allen Frances, MD | 21 April 2010
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Sometimes you spot a serious problem and figure out a very well-intended solution, only to discover eventually that your solution created as much trouble as the original problem. The workers on DSM5 have spotted an enormously worrying problem—the wild overdiagnosis of childhood bipolar disorder (BD) which has led to a massive increase in the use of antipsychotic and mood stabilizing medications in children and teenagers.
Something clearly needs to be done to correct this. The proposed DSM fix—a new diagnosis called "Temper Dysregulation with Dysphoria"—is meant to provide a less risky diagnostic home for the kids currently misdiagnosed as bipolar. Unfortunately, "temper dysregulation" is just the kind of unhappy solution that you later come to greatly regret. It is a makeshift proposal, with considerable risks, and a disqualifying conceptual problem.
How is it makeshift? As the DSM5 Work Group candidly admits, the research evidence on this new diagnosis is remarkably thin, based on the very recent work of just one research group. Virtually nothing is known about its likely prevalence in the general population; whether it can be distinguished reliably from normal developmental or situational irritability; its relation to other disorders that present with temper outbursts; its course; its preferred treatments; and the tradeoff between treatment response and adverse complications.
The criteria set for "temper dysregulation" require: 1) severe recurrent temper outbursts in response to common stressors; 2) occurring at least three times a week; 3) for at least a year; 4) in someone who is persistently irritable.
The definition was created largely ad hoc with no systematic testing (outside that one research program) of the performance characteristics of the items to determine how they would play if in wide general use. It is loosely written and in fact contains no exclusion for use in adults (which I assume is an oversight).
Why is such a makeshift solution being given any serious consideration? The Work Group freely admits that the scientific rationale is completely inadequate. Their proposal rests exclusively on 2 real and pressing clinical needs: 1) to reduce the overdiagnosis and over treatment of BD; and, 2) to do something to help the considerable suffering that these temper outbursts cause the children themselves, their parents and teachers, and society at large.
But is this attempted fix itself highly risky and likely to set off its own cascade of unfortunate unintended consequences? The biggest problem with the proposal is that it is not nearly restrictive enough. While trying to rescue kids who are now misdiagnosed as bipolar, it will undoubtedly open the door to the misdiagnosis of normal kids who happen to be temperamental or in difficult family circumstances. Every effort must be made to distinguish "mental disorder" level temper problems (that cause clinically significant distress and impairment) from those that are within the limits of a normal, but difficult, temperament experiencing the aches and pains of growing up.
This is hard to do. First off, there is enormous variability in what are considered appropriate expressions of temper across kids, across developmental periods, across families, and across subcultures. The definition of "severe" will likely vary greatly depending on the tolerance of the clinician, family, school, and peer group. "Stressors" that trigger the episodes may be minimal in some cases, remarkably provoking of readily understandable temper reactions in others. Family fights that are based in interpersonal problems will be translated into individual psychopathology. Finally, in the heat of battle, it will be forgotten that kids often do outgrow a developmentally or situationally triggered temperamental period in their lives.
In expert hands, it is conceivable that the diagnosis might be contained to achieve just its intended goal of reducing the diagnosis of BD; but in the real world many diagnoses are made by primary care clinicians who have limited expertise in psychiatry and little time with each patient, are dealing with harried family members who want a quick solution to a pressing problem; and are influenced by drug company salespeople. My experience tells me that this makeshift diagnosis may well become very popular and will spread to normal kids who would do a lot better without treatment.
"Temper Dysregulation" also shares very difficult-to-define boundaries with about a dozen other mental disorders. It would be excluded in the differential diagnosis with major depressive, dysthymic, bipolar, schizophrenic, autistic, separation anxiety, and posttraumatic stress disorders. It would be allowed to coexist with oppositional, conduct, attention deficit, and substance use, creating an artificial comorbidity with them and raising the risk of unnecessary and inappropriate treatment. For example, many drug-abusing teenagers will meet the criteria for Temper Dysregulation. Most often, the preferred intervention should be dealing with the substance problem, not adding a medication.
This brings us to the risks of treatment for this prematurely concocted diagnosis. Unfortunately, it is inevitable that this will often consist of atypical antipsychotic drugs because these are heavily marketed and may be helpful in reducing some forms of explosive temper outbursts. But their beneficial effects in some must be balanced against their very great dangers when widely used for the many. These medications often cause enormous and rapid weight gain, increasing the risk of diabetes, medical complications, and reduced life span. Their use in severely disturbed kids raises its own set of serious clinical and ethical questions, but it can be justified in extremely exigent circumstances. Their use in kids who are having disturbing (but essentially "normal") developmental or situational storms or are irritable for other reasons (e.g. substance use, ADD) would be disastrous—but it will happen and probably often.
What is the conceptual problem? "Temper Dysregulation" describes a single symptom, not a complete syndrome. It is at the same level of abstraction as fever or suicide—it can occur as part of the presentation of any number of disorders, but is not a separate disorder in and of itself. In the distant past, psychiatry used to classify by symptoms but found this to be cumbersome and much less satisfying than our current serviceable, if limited, syndromal approach.
What is the solution? Severe, recurring, and persistent temper outbursts are a crucially important clinical and societal problem and deserve special attention. But given the limited state of current knowledge, it is premature to regard Temper Dysregulation as an independent coherent syndrome that would solve more problems than it would cure. There are two far better ways for DSM5 to attempt to address this problem.
DSM5 could add a specifier, "With Explosive Outbursts,” whenever this is a prominent part of the presentation of all of the dozen or so conditions in the differential diagnoses. Or it could add the specifier just to Oppositional Defiant Disorder and attempt to use this as a default away from BD. Or "temper problems" could be one of the cross cutting dimensions, if these make it into DSM5. Each of these possible conventions would make the point that temper outbursts are (again like fever or suicidal thoughts) nonspecific symptoms of many disorders, not a specific and separate disease.
The criteria and text of DSM5 should be as commendably clear as are the drafts that there are serious problems caused by the current practice of overdiagnosis of childhood BD. Specific guidelines should be recommended that would attempt to preempt the loose noncriteria based diagnostic habits that have recently gained such unwarranted purchase.
These steps alone will, of course, not solve the dangerous "epidemic" of childhood BD. There are limits to what DSM5 can do in this regard. The NIMH and FDA may have to step up their involvement. There is a pressing need for an educational campaign to professionals and to the public to highlight the risks of overuse of atypical antipsychotics and to recommend caution in diagnosis and treatment of kids with temper outbursts. Much more research funding should be directed to this area. Funding for the study of explosive behavior has been inadequate in the past because it is an inherently difficult research topic, but the huge public health significance of widespread antipsychotic use should now give it a priority for national debate.
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