'Explosive Outbursts' Need a Diagnostic Home: Expert Would like to See Label Added as Modifier in the DSM-5, Perhaps to Conditions Such as ADHD

By Otto, M. Alexander | Clinical Psychiatry News, March 2011 | Go to article overview

'Explosive Outbursts' Need a Diagnostic Home: Expert Would like to See Label Added as Modifier in the DSM-5, Perhaps to Conditions Such as ADHD


Otto, M. Alexander, Clinical Psychiatry News


LOS ANGELES -- Psychiatrists need to find a better diagnostic home for children who have explosive outbursts, according to Dr. Gabrielle A. Carlson.

They happen in children with all kinds of psychiatric diagnoses, but no good diagnostic description captures the pervasiveness of the problem, said Dr. Carlson, director of child and adolescent psychiatry at Stony Brook (N.Y.) University.

In some places, explosive outbursts earn children diagnoses of bipolar disorder, though they might otherwise lack classic symptoms.

And although some explosive children meet the criteria for temper dysregulation disorder with dysphoria (TDD), a diagnosis being considered for the DSM-5 ("New Pediatric Diagnoses Proposed for DSM-5," Clinical Psychiatry News, December 2010, p. 1), TDD would exclude children with many common psychiatric problems, including autism, depression, and posttraumatic stress disorder, Dr. Carlson said at the meeting, sponsored by the American Academy of Child and Adolescent Psychiatry.

Children with these common diagnoses can have rages, too. "What about those kids?" she asked.

Intermittent explosive disorder isn't a good fit, either, because it requires the absence of other psychiatric disorders, she said.

Modifying the Problem

Finding a diagnostic home for kids with explosive anger is more than an academic concern.

It matters because "explosive outbursts are the most serious, compelling problem we have in child psychiatry," often the reason why children are institutionalized, Dr. Carlson said.

"Until we've got a good label for [the problem], we are not going to have the [Food and Drug Administration] going after the indication; we are not going to have grants from the [National Institute of Mental Health] studying it," she said.

Dr. Carlson said she believes the solution is including a "with explosive outbursts" modifier in the DSM-5 to add to comorbid conditions such as attention-deficit/hyperactivity disorder. But the idea is not likely to make it into the upcoming version of the diagnostic manual. Dr. Carlson said she has been told by those involved in the revision that such a modifier would likely go unused by clinicians.

She proposed the idea to Dr. David Shaffer, the Columbia University professor of child psychiatry who serves as head of the DSM-5 childhood disruptive disorder work group.

In an interview, Dr. Shaffer confirmed that Dr. Carlson had, indeed, proposed the idea in an e-mail. In general, modifiers "come to be seen as subsidiary or a consequence to the parent diagnosis," he said in response to Dr. …

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