Disruptive Mood Dysregulation Disorder (DMDD) Wyatt was a 12-year-old boy referr

Disruptive Mood Dysregulation Disorder
(DMDD)
Wyatt
was a 12-year-old boy referred by his psychiatrist to an adolescent partial
hospitalization program because of repeated conflicts that have frightened both
classmates and family members. According to his parents, Wyatt was moody and
irritable, with frequent episodes of being a “raging monster”, it had become
almost impossible to set limits. Most recently, Wyatt had smashed a closet door
to gain access to a video game that had been withheld to encourage him to do
homework. At school, Wyatt was noted to have a hair-trigger temper, and had
recently been suspended for punching another boy in the face after losing a
chess match.
Wyatt
had been an extremely active young boy, running “all the time.” He was also a
“sensitive kid” who constantly worried that things might go wrong. His
tolerance for frustration had been less than that of his peers, and his parents
quit taking him shopping because he would predictably become distraught
whenever they did not buy him whatever toys he wanted.
Grade school reports indicated
fidgetiness, wandering attention, and impulsivity. When Wyatt was 10 years old,
a child psychiatrist diagnosed him as having ADHD, combined type. Wyatt was
referred to a behavioral therapist and started taking methylphenidate, with an
improvement in symptoms. By fourth grade, his moodiness became more pronounced
and persistent. He was surly, complaining that life was “unfair.” Wyatt and his
parents began their daily limit-setting battles at breakfast while he delayed getting
ready for school, and then-by evening-continued their arguments about homework,
video games, and bedtime. These arguments often included Wyatt screaming and
throwing nearby objects. By the time he reached sixth grade, his parents were tired,
and his siblings avoided him.
According to Wyatt’s parents, he had
no problems with appetite, and although they fought about when he would go to
bed, did not appear to have a sleep disturbance. He appeared to find pleasure
in his usual activities, maintained good energy, and had no history of elation
or grandiosity, or decreased need for sleep lasting more than a day. Although
they described him as “moody, isolated, and lonely,” his parents did not see
him as depressed. They denied any history of hallucinations, abuse, trauma, suicidality,
homicidal ideation, a wish to self-harm, or a premeditated wish to harm others.
He and his parents denied he had ever used alcohol or drugs. Medical history
was unremarkable. Family history was notable for anxiety and depression in the
father, alcoholism in the paternal grandparents, and possible untreated ADHD in
the mother. On interview, Wyatt was mildly
anxious yet easy to engage, his body twisted back and forth as he sat in the
chair. In reviewing his temper outbursts and physical aggression, Wyatt said,
“It’s like I can’t help myself. I don’t mean to do these things. But when I get
mad, I don’t think about any of that. It’s like my mind goes blank.” When asked
how he felt about his outbursts, Wyatt looked sad and said earnestly, “I hate
when I’m that way.” If he could change three things in his life, Wyatt replied,
“I would have more friends, I would do better in school, and I would stop
getting mad so much.”
Wood, W.C. (2014). Case 4.1, Moody and
irritable. In J.W. Barnhill (Ed.), DSM-5 Clinical Cases (pp. 73- 76).
Arlington, VA: American Psychiatric Association Publishing. Questions for
Case Study
1. What would be the primary focus of your initial work with
the client/family?
2. What further information do you need regarding the client’s
irritability and impact on family? 3. What symptoms and data support the diagnosis of DMDD? 4. How are DMDD and bipolar different?
5. What do you think is the communication style of this family
on the basis of the data provided?
6. What type of therapy would you recommend for the individual
and what would be the goals of therapy?
7. What type of therapy would you recommend for the family and
what would be the goals of therapy?
8. What medication and treatment recommendations would you
order?
9. What are your biases about children such as this client?
10. What recommendations/services should you include in
discharge planning for the client?