DSM5破坏性心境失调障碍
作者: DSM / 11558次阅读 时间: 2014年8月11日
标签: DSM5 心境失调 抑郁症
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Disruptive Mood Dysregulation Disorder 破坏性心境失调障碍
296.99(F34.8)

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  1. 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。
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  2. 脾气爆发与其发育阶段不一致。
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  3. 脾气爆发平均每周3 次或3 次以上。
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  4. 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)。心理学空间/m{;\4z#pEMO
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  5. 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。心理学空间'O?\9Nu7Y q;O e

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  6. 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。
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  7. 首次诊断不能在6 岁前或18 岁后。心理学空间5X!?`0Z{y
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  8. 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。心理学空间"`#r7NM"? TC2x;sv]g

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  9. 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。心理学空间f.X\*\'pH,^jA"x
    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。
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  10. 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])。
    i(I:Gk W4T8tc,N0nw0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。心理学空间^zqWe7o'h3e

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  11. 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。
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7T{^E9kX)Bq5nR0Diagnostic Features
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qVE s"S)e0The 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).心理学空间kou1S1_Pp%wR2}"[

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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.

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qt6VqB0gh0Some 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.  

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5N6p X.qWF:PO)G0Prevalence心理学空间6Z1IE6]s1G

t0S.TnL u \0Disruptive 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.

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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.

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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.

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Risk and Prognostic Factors心理学空间\vVY oe_\6l(V

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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.

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vK1qA9{0Genetic 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.心理学空间)hjT,H5X4`!b

pj ~OP{*t4O p0Gender-Related Diagnostic issues

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Children presenting to clinics with features of disruptive mood dysregulation disorder are predominantly male. Among community samples, a male preponderance appears to be supported. This difference in prevalence between males and females differentiates disruptive mood dysregulation disorder from bipolar disorder, in which there is an equal gender prevalence.心理学空间l(H4b:e5Bb$j

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Suicide Risic

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8?q"tA|/x3eR0In general, evidence documenting suicidal behavior and aggression, as well as other severe functional consequences, in disruptive mood dysregulation disorder should be noted when evaluating children with chronic irritability.

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4?#A$mL!? UV}Y0Functional Consequences of Disruptive Mood Dysreguiation Disorder心理学空间Z#Ri/g)K4_&`.L

FY"wK.db'P~&h E n:e0Chronic, severe irritability, such as is seen in disruptive mood dysregulation disorder, is associated with marked disruption in a child's family and peer relationships, as well as in school performance. Because of their extremely low frustration tolerance, such children generally have difficulty succeeding in school; they are often unable to participate in the activities typically enjoyed by healthy children; their family life is severely disrupted by their outbursts and irritability; and they have trouble initiating or sustaining friendships. Levels of dysfunction in children with bipolar disorder and disruptive mood dysregulation disorder are generally comparable. Both conditions cause severe disruption in the lives of the affected individual and their families. In both disruptive mood dysregulation disorder and pediatric bipolar disorder, dangerous behavior, suicidal ideation or suicide attempts, severe aggression, and psychiatric hospitalization are common.

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Differential Diagnosis

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Because chronically irritable children and adolescents typically present with complex histories, the diagnosis of disruptive mood dysregulation disorder must be made while considering the presence or absence of multiple other conditions. Despite the need to consider many other syndromes, differentiation of disruptive mood dysregulation disorder from bipolar disorder and oppositional defiant disorder requires particularly careful assessment.

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Bipolar disorders.The central feature differentiating disruptive mood dysregulation disorder and bipolar disorders in children involves the longitudinal course of the core s}nTiptoms. In children, as in adults, bipolar I disorder and bipolar Π disorder manifest as an episodic illness with discrete episodes of mood perturbation that can be differentiated from the child's typical presentation. The mood perturbation that occurs during a manic episode is distinctly different from the child's usual mood. In addition, during a manic episode, the change in mood must be accompanied by the onset, or worsening, of associated cognitive, behavioral, and physical symptoms (e.g., distractibility, increased goal-directed activity), which are also present to a degree that is distinctly different from the child's usual baseline. Thus, in the case of a manic episode, parents (and, depending on developmental level, children) should be able to identify a distinct time period during which the child's mood and behavior were markedly different from usual. In contrast, the irritability of disruptive mood dysregulation disorder is persistent and is present over many months; while it may wax and wane to a certain degree, severe irritability is characteristic of the child with disruptive mood dysregulation disorder. Thus, while bipolar disorders are episodic conditions, disruptive mood dysregulation disorder is not. In fact, the diagnosis of disruptive mood dysregulation disorder cannot be assigned to a child who has ever experienced a fuU-duration hypomanie or manic episode (irritable or euphoric) or who has ever had a manic or hypomanie episode lasting more than 1 day. Another central differentiating feature between bipolar disorders and disruptive mood dysregulation disorder is the presence of elevated or expansive mood and grandiosity. These symptoms are common features of mania but are not characteristic of disruptive mood dysregulation disorder.心理学空间CgqFf

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Oppositional defiant disorder.While symptoms of oppositional defiant disorder typically do occur in children with disruptive mood dysregulation disorder, mood symptoms of disruptive mood dysregulation disorder are relatively rare in children with oppositional defiant disorder. The key features that warrant the diagnosis of disruptive mood dysregulation disorder in children whose symptoms also meet criteria for oppositional defiant disorder are the presence of severe and frequently recurrent outbursts and a persistent disruption in mood between outbursts. In addition, the diagnosis of disruptive mood dysregulation disorder requires severe impairment in at least one setting (i.e., home, school, or among peers) and mild to moderate impairment in a second setting. For this reason, while most children whose symptoms meet criteria for disruptive mood dysregulation disorder will also have a presentation that meets criteria for oppositional defiant disorder, the reverse is not the case. That is, in only approximately 15% of individuals with oppositional defiant disorder would criteria for disruptive mood dysregulation disorder be met. Moreover, even for children in whom criteria for both disorders are met, only the diagnosis of disruptive mood dysregulation disorder should be made. Finally, both the prominent mood symptoms in disruptive mood dysregulation disorder and the high risk for depressive and anxiety disorders in follow-up studies justify placement of disruptive mood dysregulation disorder among the depressive disorders in DSM-5. (Oppositional defiant disorder is included in the chapter "Disruptive, Impulse-Control, and Conduct Disorders.") This reflects the more prominent mood component among individuals with disruptive mood dysregulation disorder, as compared with individuals with oppositional defiant disorder. Nevertheless, it also should be noted that disruptive mood dysregulation disorder appears to carry a high risk for behavioral problems as well as mood problems.

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9Z n-k [1\#k.cZ0Attention-deficit/hyperactivity disorder, major depressive disorder, anxiety disorders, and autism spectrum disorder.Unlike children diagnosed with bipolar disorder or oppositional defiant disorder, a child whose symptoms meet criteria for disruptive mood dysregulation disorder also can receive a comorbid diagnosis of ADHD, major depressive disorder, and/or anxiety disorder. However, children whose irritability is present only in the context of a major depressive episode or persistent depressive disorder (dysthymia) should receive one of those diagnoses rather than disruptive mood dysregulation disorder. Children with disruptive mood dysregulation disorder may have symptoms that also meet criteria for an anxiety disorder and can receive both diagnoses, but children whose irritability is manifest only in the context of exacerbation of an anxiety disorder should receive the relevant anxiety disorder diagnosis rather than disruptive mood dysregulation disorder. In addition, children with autism spectrum disorders frequently present with temper outbursts when, for example, their routines are disturbed. In that instance, the temper outbursts would be considered secondary to the autism spectrum disorder, and the child should not receive the diagnosis of disruptive mood dysregulation disorder.

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lX/M\ v3Tb*p0Intermittent explosive disorder.Children with symptoms suggestive of intermittent explosive disorder present with instances of severe temper outbursts, much like children with disruptive mood dysregulation disorder. However, unlike disruptive mood dysregulation disorder, intermittent explosive disorder does not require persistent disruption in mood between outbursts. In addition, intermittent explosive disorder requires only 3 months of active symptoms, in contrast to the 12-month requirement for disruptive mood dysregulation disorder. Thus, these two diagnoses should not be made in the same child. For children with outbursts and intercurrent, persistent irritability, only the diagnosis of disruptive mood dysregulation disorder should be made.

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Comorbidity

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f'kzvj0Rates of comorbidity in disruptive mood dysregulation disorder are extremely high. It is rare to find individuals whose symptoms meet criteria for disruptive mood dysregulation disorder alone. Comorbidity between disruptive mood dysregulation disorder and other DSM-defined syndromes appears higher than for many other pediatric mental illnesses; the strongest overlap is with oppositional defiant disorder. Not only is the overall rate of comorbidity high in disruptive mood dysregulation disorder, but also the range of comorbid illnesses appears particularly diverse. These children typically present to the clinic with a wide range of disruptive behavior, mood, anxiety, and even autism spectrum symptoms and diagnoses. However, children with disruptive mood dysregulation disorder should not have symptoms that meet criteria for bipolar disorder, as in that context, only the bipolar disorder diagnosis should be made. If children have symptoms that meet criteria for oppositional defiant disorder or intermittent explosive disorder and disruptive mood dysregulation disorder, only the diagnosis of disruptive mood dysregulation disorder should be assigned. Also, as noted earlier, the diagnosis of disruptive mood dysregulation disorder should not be assigned if the symptoms occur only in an anxietyprovoking context, when the routines of a child with autism spectrum disorder or obsessive- compulsive disorder are disturbed, or in the context of a major depressive episode.

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