Summary
Anjey is an 11 years old Latvian boy; his family moved from Latvia to Ontario when he was 3 years old, and he has three older siblings – two brothers and one sister. As a child, he experienced emotional distancing from his parents, as they had often neglected their parental duty in favor of their professorial work. Additionally, they often exerted significant pressure on him, demanding academic success and establishing very strict rules.
During his childhood, Anjey was often bullied for being different from other children and experienced loneliness and isolation. He developed severe irritability and aggression as he approached adolescence. Anjey does not like to be touched, even by his siblings and parents; he gets angry easily, and tends to throw tantrums over small disagreements. He refuses to interact with his family on a deeper level and often argues with his parents in everyday decisions such as chores or grades. The overall atmosphere in the house is usually tense, and other siblings tend to avoid Anjey as to not provoke his. Anjey’s parents finally decided that their son required medical attention after he broke his old laptop in a fit of anger over being denied a new one. The therapist diagnosed Anjey with disruptive mood dysregulation disorder and proposed to enroll him in exposure-based cognitive behavioral therapy alongside narrative therapy.
DSM-5 Diagnostic Criteria
The diagnostic criteria for disruptive mood dysregulation disorder include chronic severe irritability that starts during childhood and persists for no less than 12 months. According to the National Institute of Mental Health (2022), “a child with DMDD experiences irritable or angry mood most of the day, nearly every day” (para. 2). Severe temper outbursts, either verbal or behavioral in nature, must occur three or more times per week and are out of control from parents or older siblings. Children with DMDD also usually have issues with everyday life at home, school, or with friends due to irritability (National Institute of Mental Health, 2022). American Psychiatric Association (2019) supplies that “irritability can appear as age-inappropriate temper outbursts and a sullen, grouchy mood” (para. 1). Healthcare providers use functional impairment and duration of the symptoms as the basis for diagnosis (American Psychiatric Association, 2019). Overall, the DSM-5 classifies DMDD as a type of depressive disorder, as children diagnosed with it struggle to regulate their moods and emotions in an age-appropriate way. As a result, children with this type of disorder show frequent outbursts of anger in response to frustration, both verbal and behavioral. Between outbreaks, they experience chronic, persistent irritability.
Etiology
Although the specific causes for disruptive mood dysregulation disorder have not been determined yet, there are several theories on the matter. Linke et al. (2020a) researched white matter of the brain in neurotypical children and children with bipolar disorder and disruptive mood dysregulation disorder. The study found that “aberrant white matter microstructure was associated with both categorical diagnosis and the dimension of irritability” (p. 1135). Thus, one can consider that certain abnormalities in the process of brain development are responsible for the occurrence of the disorder. Other theories discuss the influence of a family history of mental impairment and issues with brain chemicals on the possibility of developing disruptive mood dysregulation disorder. Moreover, certain social issues are also important to consider: in Anjey’s case, they might be the major factors that triggered the disorder.
Cultural Adaptation Issues
Klein et al. (2020) discuss the nature of the relationship between mental health of the 1st generation immigrant youth and their acculturation process – with regard to gender differences. All migrants, to one degree or another, face difficulties in interacting with local residents, whose behavior they are unable to predict. The study emphasizes that different acculturations patterns such as marginalizing, separation or integration, play a central role in the process of adjusting to a new environment, regardless of gender. Wu et al. (2018) support this claim, stating that acculturation orientation remains predictive for the mental health of future adults. Their research suggests that children who displayed higher levels of resilience in the face of cultural adaptation later showed better mental health characteristics. However, this resilience heavily depends on peer support from friends and family, which Anjey had been mostly denied during his childhood due to his parents’ business.
Berry and Hou (2017) specifically examined migrants who moved to Canada in their study, providing insight into the processes of acculturation for 2nd generation. Their study reports that integration strategy shows better results at acculturation for migrants, which, in turn, is associated with better mental health outcomes in adulthood. This hints to the suggestion that, perhaps, the acculturation strategy Anjey’s parents used was not efficient for him. Therefore, it is safe to conclude that migration and subsequent problems with acculturation in the past might have influenced Anjey’s condition today.
Childhood Bullying
At the end of the twentieth century, a special term that reflected more accurately a situation of violence in the educational environment was introduced – namely, bullying. Bullying is an issue of long-term violence, physical or psychological, performed by one person or a group, and directed against a person who is unable to defend themselves. Bullying can also be seen as a phenomenon that leads to serious psychological problems in the future. Children affected by it become anxious, irritable, they experience self-esteem and self-worth issues. Anjey reports having trouble at school in the past, as he was bullied heavily for being “different from others.” He states that verbal and often even physical violence has made his repulsive to other people’s touch, and he does not like to be in close contact with anyone. Therefore, it is important to address the issue of childhood bullying in counseling.
Strøm et al. (2017) investigate specifically the long-term consequences of bullying in their study. Moreover, the authors also consider how the effect of bullying victimization influences psychosocial adjustment in adults, as well as if shame has a mediating role in the relationship between it and mental health outcomes. Strøm et al. (2017) conclude that, indeed, the trauma from childhood bullying victimization has a lasting and a severe negative effect on the future adults’ mental health. Moreover, there is also a need to investigate the shame’s role as a mediator of it further. deLara (2019) supports the claim that childhood bullying provides psychological distress that lasts into adulthood. The study’s analysis revealed such specific consequences of bullying as deterioration of mental well-being and relationship and trust issues. Seeing as Anjey obviously struggles with both aspects, and does not have trustful and fulfilling relations with his parents, it is clear that childhood bullying inflicted psychosocial damage on his.
Prevalence Rates
There is not much information on the prevalence rates of DMDD in children and adolescents. However, a study conducted by Boujerida et al. (2022) attempted to determine the prevalence and psychometric properties of DMDD among adolescents of 12-15 years old in clinical setting. The research shows that “twelve participants (6.3%) met nine or more criteria and 11 youths (5.7%) met the three main criteria of DMDD, which suggests the likely presence of the disorder” (p. 1). The results emphasize that, while DMDD is not highly common among adolescents, those who have already been diagnosed with other mental disorders have a higher rate of presenting with DMDD later. Another research by Grau et al. (2018) outlines the prevalence of DMDD in adults who were diagnosed with it during their childhood. According to the authors, “12 (0.50 %) subjects reported elevated DMDD symptoms during adulthood, and 19 (0.79 %) reported elevated DMDD symptoms during primary school age” (p. 29). While the numbers are relatively low, the results still show evidence that DMDD tends to persist into adulthood, showing prominent symptoms of chronic irritability and aggressive behavior.
Impairment
The presence of DMDD significantly decreases the quality of child’s life and can affect their mental state in the future. National Institute of Mental Health (2022) reports that “DMDD can impair school performance and disrupt relationships with his or her family and peers” (para. 7). Children who suffer from DMDD struggle with social activities and building meaningful relationships, as they tend to avoid participating in communal events and making friends. Moreover, untreated DMDD increases risk of developing anxiety and depression in the future (National Institute of Mental Health, 2022). Finally, aggression and unsociable behavior might pose significant danger to a child’s safety, as it might make them more prone to recklessness and deviant activities.
Treatment
Exposure-Based Cognitive Behavioral Therapy
Cognitive behavioral therapy (CBT) is a method that highlights a person’s unconscious motivations, transfers them to a conscious level, and helps to change beliefs and behavior that cause neurotic and other pathological conditions. This type of therapy combines two scientific psychological approaches: cognitive and behavioral. The first states that psychological problems and neuropsychiatric disorders are caused by thoughts and beliefs, stereotypes of thinking acquired during life. The second argues that human behavior can be changed by encouraging desirable forms of action and not reinforcing undesirable behavior.
The behaviorist part of CBT considers behavior as a set of reactions to environmental stimuli – for example, in Anjey’s case, his irritability has developed as a response to parental neglect and social abuse. One of the basic concepts of behaviorism is positive and negative reinforcement. Positive reinforcement, or encouragement, is applied when the individual has done the right thing, and helps reinforce the desired form of behavior. Negative reinforcement implies a negative reaction to the undesirable behavior of the trainee. Meanwhile, cognitivism in CBT focuses on mental processes: how people perceive, think, remember, learn, solve problems, and where they direct their attention. Cognitions are any thoughts and ideas that influence the individual’s attitude towards themselves and the external environment. Cognitive approach considers it inefficient to work only with a person’s behavior to solve their psychological problems. With Anjey, simply correcting his aggressive tendencies and teaching his not to throw tantrums would not bring long lasting effects. First, the therapist would need to identify beliefs, ideas, and thoughts that make his act destructively or feel discomfort towards others. Then, with continuous mental exercises and mindful approach, the therapist can help Anjey get rid of these cognitions, and only then work on the behavioral aspect.
The search for and awareness of automatic thoughts is the basis of the CBT method. Evolutionarily automatic thoughts are necessary so that humans can quickly respond to changes in the environment. These thoughts trigger emotional responses and influence behavior accordingly. In order to understand why Anjey’s state has developed into chronic irritability, it is necessary to identify what kind of thought caused this change. Anjey has learned that there is a significant possibility that his environment would be hostile to him due to bullying while also accepting that his parents would not protect or comfort him. Thus, his emotional responses turned into aggression, irritability, and repulsion to touch to prevent him from being hurt by other people. The therapist should suggest looking for quick thoughts in order to process them and direct Anjey’s judgments into rationality.
The task of the CBT therapist is to identify cognitive distortions that negatively affect the client’s quality of life and help develop rational, constructive thought patterns in their place. For this, exposure can be used effectively, as study by Linke et al. (2020) suggests. Linke et al. (2020) state that “this mechanism-driven treatment is based on the pathophysiological model of irritability that postulates two underlying mechanisms: heightened reactivity to frustrative nonreward, and aberrant approach responses to threat” (p. 320). It is especially useful for treating phobias and fears – such as Anjey’s repulsion to touch. Exposure would help him learn not to avoid physical contact altogether, but to experience it in a healthy and productive manner.
Anjey does not tolerate touching even from his family members who would not harm his, as opposed to his bullies. With the exposure technique, the therapist could attempt to initiate physical contact, then stop, and begin to observe Anjey’s reaction. When his anxiety rises, he should do exercises with the therapist to help him cope with his fear of being touched. As the initial reaction is successfully managed, Anjey and the therapist can move on to the next step: the therapist would touch him for a short amount of time. They would work again on the rising irritation and anxiety using coping mechanisms and mindfulness techniques. The intensity of the situation would gradually increase until Anjey acquires all the necessary skills to be aware and rationally assess his irritation, as well as to cope with it healthily.
Narrative Therapy
In its broadest sense, narrative therapy is a conversation in which people tell the therapist various stories of their lives. For narrative therapists, “a story” means some events tied in certain sequences at certain time intervals and thus brought into a state of a plot endowed with meaning. This approach is based on the assumption that people are interpreting beings. Constantly experiencing an endless sequence of events, they strive to see them interconnected and explainable, giving them certain meaning. The narrative here is like a thread interweaving various events scattered in time and space into a story. The narrative approach would be the most useful for this case’s conceptualization, as it allows the person to separate the context and see these stories not as defining, but as situational. It provides the opportunity to look for other, more positive stories, hidden under the problematic ones, and establish connections between them.
Everyone constantly uses narratives to reflect on their own experience. Thus, it often happens that people who come into counseling interpret their experience through the prism of problem stories. Anjey states that he feels alienated from his family, supposedly aligning this feeling with his “inability” to attract his parents’ attention in the past, when he needed it most. This is evident in the way he talks about his home life, stating that he feels unprompted anger during any interaction with his parents while simultaneously sensing fear from his siblings. Such a narrative points to a repetitive trauma from his childhood that keeps happening again and again. Negative experiences become like a magnifying glass through which people – and Anjey, specifically – look at the world. Within this framework, focusing in the perception of the present occurs only on certain things – those that fit the traumatic story. Anjey might simply not be able see anything else in his experience that suggests otherwise, thus keeping to his anger as the only effective method of resolving any issue.
The therapist would be able to separate negative and positive stories when they and Anjey will begin to analyze the experience brought by everything that happened to Anjey. In narrative therapy, this process is called externalization. It can start with the following questions to ask: how long have these feelings of alienation been living in his head? when did they first surfaced? what happened to Anjey then? These questions are supposed to make the difference between Anjey’s real life and how he imagined it to be clearer. While studying Anjey’s case further, the therapist might also try to find hints of alternate – positive – stories to catch on. For example, he was always quite lonely, both during his childhood and older age; however, there were still people whom he befriended. The therapist may begin to develop this story: how did he decide to open up to other people? What prompted their friendship and how it proceeded? There is a lot of room for thought here, and the conclusions Anjey draws might help him understand himself better.
References
American Psychiatry Organization. (2019). Irritability in children can be more than just a bad mood. Web.
Berry, J. W., & Hou, F. (2017). Acculturation, discrimination and wellbeing among second generation of immigrants in Canada. International Journal of Intercultural Relations, 61, 29-39.
Boudjerida, A., Labelle, R., Bergeron, L., Berthiaume, C., Guilé, J., & Breton, J. (2022). Development and initial validation of the disruptive mood dysregulation disorder questionnaire among adolescents from clinic settings. Frontiers in Psychiatry, 13.
DeLara, E. W. (2018). Consequences of childhood bullying on mental health and relationships for Young Adults. Journal of Child and Family Studies, 28(9), 2379-2389.
Grau, K., Plener, P. L., Hohmann, S., Fegert, J. M., Brähler, E., & Straub, J. (2018). Prevalence rate and course of symptoms of disruptive mood dysregulation disorder (DMDD). Zeitschrift Für Kinder- Und Jugendpsychiatrie Und Psychotherapie, 46(1), 29-38.
Klein, E. M., Müller, K. W., Wölfling, K., Dreier, M., Ernst, M., & Beutel, M. E. (2020). The relationship between acculturation and mental health of 1st Generation Immigrant Youth in a representative school survey: Does gender matter? Child and Adolescent Psychiatry and Mental Health, 14(1).
Linke, J. O., Adleman, N. E., Sarlls, J., Ross, A., Perlstein, S., Frank, H. R.,… Brotman, M. A. (2020a). White matter microstructure in pediatric bipolar disorder and disruptive mood dysregulation disorder. Journal of the American Academy of Child & Adolescent Psychiatry, 59(10), 1135-1145.
Linke, J., Kircanski, K., Brooks, J., Perhamus, G., Gold, A. L., & Brotman, M. A. (2020b). Exposure-based cognitive-behavioral therapy for disruptive mood dysregulation disorder: An evidence-based case study. Behavior Therapy, 51(2), 320-333.
National Institute of Mental Health. (2022). Disruptive mood dysregulation disorder. Web.
Strøm, I. F., Aakvaag, H. F., Birkeland, M. S., Felix, E., & Thoresen, S. (2018). The mediating role of shame in the relationship between childhood bullying victimization and adult psychosocial adjustment. European Journal of Psychotraumatology, 9(1), 1418570.
Wu, Q., Ge, T., Emond, A., Foster, K., Gatt, J., Hadfield, K.,… Wouldes, T. (2018). Acculturation, resilience, and the mental health of migrant youth: A cross-country comparative study. Public Health, 162, 63-70.