The new diagnosis should also facilitate exploration of the disorder's etiology, she added.
Although consensus favors creating the new diagnosis, the name “temper dysregulation disorder with dysphoria” remains tentative. “We're still in the name market,” Dr. Leibenluft said.
The following nine criteria have been proposed for the new diagnosis:
1. TDD is characterized by severe, recurrent temper outbursts in response to common stressors. Outbursts manifest verbally, in behavior, or both, and include verbal rages and physical aggression.
Reactions are grossly disproportionate in intensity or duration to the provocation and are inconsistent with developmental level.
2. Temper outbursts occur three or more times a week, on average.
3. Mood between temper outbursts is persistently negative: irritable, angry, sad, or any combination of these. The negative mood is observable by parents, teachers, peers, or others.
4. Criteria 1–3 have been present for at least 12 months; during that time, the person was not without criteria 1–3 for more than 3 months at a time.
5. Temper outbursts and negative mood occur in at least two settings, such as home, school, or with peers, and must be severe in at least one setting.
6. Chronological age is at least 6 years old, or an equivalent developmental level.
7. Onset occurs before age 10 years.
8. TDD should be excluded if in the past year there never was a distinct period, lasting more than 1 day, during which an abnormally elevated or expansive mood was present most of the day, and the abnormally elevated or excessive mood was accompanied by onset or worsening of three of the “B” criteria of mania, such as grandiosity or inflated self-esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal-directed activity, or excessive involvement in activities with high potential for painful consequences. (Abnormally elevated mood is distinct from developmentally appropriate mood elevation, such as in the context of a highly positive life event or its anticipation.)
9. The behaviors do not occur exclusively during a psychotic or mood disorder (such as major depressive disorder, dysthymic disorder, or bipolar disorder), and are not better explained by another mental disorder (such as pervasive developmental disorder, posttraumatic stress disorder, or separation anxiety). The diagnosis of TDD can coexist with oppositional defiant disorder, ADHD, conduct disorder, and substance use disorders. Symptoms do not directly result from the physiological effects of a drug of abuse, or are secondary to a medical or neurologic condition.
Nonsuicidal Self-Injury
NSSI involves much less controversy. Currently, the DSM-IV connects self-mutilation to borderline personality disorder and links it with recurrent suicidal behavior, Dr. Shaffer said.
A new diagnostic entity makes sense because about half of these self-mutilation cases do not meet criteria for borderline personality disorder; the self-inflicted damage differs from suicide attempts; misperception of NSSI events as suicide attempts leads to inappropriate treatment; and correct categorization of these patients should aid research.
NSSI episodes and suicide attempts differ by the methods used, a higher repetition rate with NSSI, broader comorbidity with NSSI, a stronger link between NSSI and peer experience, and a difference in lethality (that is, death from NSSI cutting is very rare).
The following four criteria have been proposed for NSSI, according to Dr. Shaffer:
1. On 5 or more days in the past year, the person has engaged in intentional, self-inflicted damage to the surface of his or her body of a sort likely to induce bleeding, bruising, or pain, using methods such as cutting, burning, stabbing, hitting, or excessive rubbing.
Unlike body piercing or tattooing, the damage is done for purposes that are not socially sanctioned, and with an expectation that the injury will involve only mild or moderate physical harm. Either the patient reports no suicidal intent, or the lack of intent can be inferred by the patient's frequent use of a method known through experience to have no lethal potential. The behavior is not of a common or trivial nature, such as picking at a wound or nail biting.
2. The intentional injury associates with at least two of the following four characteristics:
▸ Negative feelings or thoughts – such as depression, anxiety, tension, anger, generalized distress, or self criticism – are present immediately prior to the self-injurious act.
▸ A period of preoccupation with the intended behavior is present prior to engagement in the act.
▸ There is a frequent urge to perform self-injury, even if the urge is not acted upon.
▸ The self-injury occurs with a purpose, such as relief from a negative feeling, cognitive state, or interpersonal difficulty or the induction of a positive feeling. The patient anticipates that the relief or positive feeling will occur either during or immediately after the self-injury.