Characteristics and Treatment Outcomes of Adolescents with Disruptive Mood Dysregulation Disorder in Psychiatric Residential Treatment Restricted; Files Only

Abstract

Disruptive Mood Dysregulation Disorder (DMDD) is a disorder of youth characterized by debilitating and chronic irritability, frequent and severe temper outbursts, and marked functional impairment. Because DMDD is a relatively new disorder, the scope of DMDD research has been limited and relatively little is known about what factors may influence DMDD’s development or trajectory and how to best treat the disorder. Additionally, to date, youth in psychiatric residential treatment, who are among those with the most severe DMDD presentations and may represent the most vulnerable among those with DMDD, have been underrepresented in DMDD research.

            Utilizing cross-sectional and longitudinal data from medical records of 94 adolescents with DMDD in psychiatric residential treatment, this study addressed three primary aims and five sub-aims.  Environmental risk factor exposures (Aim 1, e.g., household dysfunction factors) and cognitive functioning among adolescents with DMDD (Aim 2, e.g., inhibitory control) are described. Changes in irritability, temper outbursts, emotion regulation, and distress tolerance — key areas of dysfunction among youth with DMDD — following seven weeks of dialectical behavior therapy for adolescents (DBT-A) (Aim 3) are also described.

            Findings suggest that exposures to multiple environmental risk factors are common among youth with severe DMDD presentations. Additionally, results suggest substantial deficits in inhibitory control and more subtle deficits in cognitive flexibility and processing speed among the adolescents in the sample. Lastly, findings suggest DBT-A may be a promising approach for the treatment of the affective features of DMDD among those with the most severe DMDD presentations. Further research on environmental risk factors, cognitive functioning, and the use of DBT-A for the treatment of the DMDD among adolescents with severe DMDD presentations is warranted

Table of Contents

Dissertation Outline…………………………………………………………………………………….1

Chapter 1: Background………………………………………………………………………………...2

Introduction………………………………………………………………………………………………...2

Specific Aims……………………………………………………………………………………...2

Background……………………………………………………………………………………………….....5

Childhood Irritability……………………………………………………………………………...6

Bipolar Disorder or Severe Mood Dysregulation?…………………………...……………...7

Disruptive Mood Dysregulation Disorder………………………………………………….....10

Dialectical Behavior Therapy…………………………………………………………………....22

Present Study…………………………………………………………………………………………........27

Theoretical Framework………………………………………………………………………......28

Figure 1: Bioecological Model………………………………………………………………...............28

Chapter 2: Adolescents with DMDD Receiving Psychiatric Residential Treatment: 

Environmental Risk Factor Exposure……………………………………………………………...29

Abstract……………………………………………………………………………………………….........29

Introduction………………………………………………………………………………………….........30

Background…………………………………………………………………………………………….......31

Household Dysfunction Factors………………………………………………………………..31

Community Adversity Factors…………………………………………………………………..32

Factors in the Environment that Contribute to Unsafe, Unstable, Stressful,

and Emotionally Invalidating Environments.....……………………………………………32

Summary of Limitations and Gaps in the Literature……………………………………….33

Methods……………………………………………………………………………………………….........34

Measures………………………………………………………………………………………........35

Analyses……………………………………………………………………………………….........36

Results………………………………………………………………………………………………...........37

Descriptive Results……………………………………………………………………………......37

Logistic Regression Results…………………………………………………………………......38

Discussion………………………………………………………………………………………………......39

Limitations and Future Directions……………………………………………………………..41

Conclusion……………………………………………………………………………………………........43

Table 1 : Sample Characteristics………………………………………………………………………..44

Table 2: Environmental Risk Factor Exposure……………………………………………………….44

Table 3: Irritability Logistic Regression Models……………………………………………………..45

Table 4: Outburst in the First Month of Treatment Logistic Regression Models……………..46

Chapter 3: Neuropsychological Functioning of Adolescents with DMDD

in Psychiatric Residential Treatment…………………………………………………….............47

Abstract………………………………………………………………………………………………...........47

Introduction……………………………………………………………………………………………........48

Methods………………………………………………………………………………………………...........50

Measures…………………………………………………………………………………….............50

Analyses……………………………………………………………………………………..............52

Results……………………………………………………………………………………………….............52

Discussion…………………………………………………………………………………………..............53

Limitations and Future Directions………………………………………………………….......55

Conclusion……………………………………………………………………………………………..........56

Table 1: Demographics and Cognitive Functioning………………………………………………….57

Chapter 4: Dialectical Behavior Therapy for Adolescents with Disruptive Mood

Dysregulation Disorder in Psychiatric Residential Treatment……………………………...58

Abstract………………………………………………………………………………………………...........58

Background…………………………………………………………………………………………............59

Methods………………………………………………………………………………………………...........61

Setting……………………………………………………………………………………….............61

Sample……………………………………………………………………………………….............61

Measures…………………………………………………………………………………….............61

Analyses……………………………………………………………………………………..............63

Results……………………………………………………………………………………………….............66

Descriptive Results…………………………………………………………………………...........66

Table 1: Demographic and Clinical Characteristics…………………………………………..66

Outcomes Among the Full Sample……………………………………………………………....68

Table 2: Outcomes Among Full Sample………………………………………………………...68

Subgroup Analyses……………………………………………………………………………........69

Characteristics of Those With and Without an MCID………………………………………...69

Table 3: Outcomes Among the Severe and Extremely Severe Subgroups……………......70

Discussion……………………………………………………………………………………………….........71

Comparison to Previous DMDD Psychotherapy Studies……………………………………...74

Limitations and Future Directions……………………………………………………………......79

Conclusion……………………………………………………………………………………………...........80

Chapter 5: Summary…………………………………………………………………………….............81

Characteristics of Adolescents with DMDD in Residential Treatment…………………….........82

Environmental Risk Factor Exposure……………………………………………………….......82

Cognitive Functioning………………………………………………………………………..........83

DBT-A Treatment Outcomes………………………………………………………………..........84

Relationships Among Factors Explored in This Study………………………………………...........86

Environmental Risk Factor Exposure and Cognitive Functioning………………………….87

Environmental Risk Factor Exposure and DBT-A…………………………………………......87

Cognitive Functioning and DBT-A………………………………………………………….........89

Conclusion.....................................................................................................................90

References......................................................................................................................92

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School	Laney Graduate School
Department	Nursing
Degree	Ph.D.
Submission	Dissertation
Language	English
Research Field	Health Sciences, Mental Health Psychology, Clinical
Stichwort	Dialectical Behavior Therapy Disruptive Mood Dysregulation Disorder Adolescents
Committee Chair / Thesis Advisor	Kristy K. Martyn, Emory University
Committee Members	Melissa D. Pinto, University of California Irvine Janet R. Cummings, Emory University Melinda K. Higgins, Emory University

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