The film Angry Birds (2016) directed by Clay Kaytis and Fergal Reilly follows “Red,” voiced by Jason Sudeikis, through his hatching to maturity. When Red cracked through his shell he greeted the world possessing a facial gesture expressing his upset. Red is introduced and consistently portrayed, as a bird who struggles to manage his irritability and temper. Despite having initial benign interactions with others, Red becomes easily annoyed and defensive. His feelings quickly lead to a deterioration of composure where his behaviors devolve into tirades and physical tantrums. Consequently, Red finds himself in numerous conflictual experiences that frequently end poorly.

Angry Birds is an animated film that depicts the main character, Red, possessing symptoms consistent with the recent diagnostic addition within the Diagnostic and Statistical Manual(5th ed.; DSM–5; American Psychiatric Association, 2013) of disruptive mood dysregulation disorder (DMDD). The DSM–5 outlines the following criteria (p. 156):

A. Severe recurrent temper outbursts manifested verbally (e.g., verbal rages) and/or behaviorally (e.g., physical aggression towards people or property) that are grossly out of proportion in intensity or duration to the situation or provocation.

B. The temper outbursts are inconsistent with developmental level.

C. The temper outbursts occur, on average, three or more times per week.

D. The mood between temper outbursts is persistently irritable or angry most of the day, nearly every day, and is observable by others.

E. Criteria A–D must be present for twelve or more months. Throughout that time, the individual has not had a period lasting three or more consecutive months without all of the symptoms in Criteria A–D.

F. Criteria A–D are present in at least two or three settings and are severe in at least one of these.

The DSM–5 further notes that the onset of this diagnosis should be held until the age of six and withheld after the age of eighteen, as validity has not been established outside of the childhood age confines. A history or observation of symptoms must be present before the age of ten; and, there must be a lack of a distinct period lasting more than one day during which the full symptom criteria, except duration, for a manic or hypomanic episode is met. Individuals who experience chronic irritability that meet criteria to support the diagnosis of DMDD are children, as symptoms are likely to evolve due to maturation. Within the U.S., there is approximately a two to five percent prevalence range (DSM–5).

Chronic irritability, a pillar indicator of DMDD, has been previously associated with bipolar disorder as a symptom of pediatric mania in child populations. Research conducted at National Institute of Mental Health in contribution to the DSM–5 headed by Ellen Leibenluft, MD, finds that data does not support categorizing children with nonepisodic severe irritability as mania (Leibenluft, 2011). Rather, as such, clinicians are encouraged to consider the presence of symptoms that would support diagnoses of bipolar disorder, oppositional defiant disorder and intermittent explosive disorders; as these disorders may not coexist and are reserved to the criteria outlined within the DSM–5.

Though a diagnosis of DMDD is prohibited to coincide with the aforementioned conditions, DMDD has “extremely high” comorbid rates. In fact, it is atypical to find individuals whose symptoms meet qualifying criteria for DMDD in the absent of a second condition (DSM–5). Such diagnoses tend to include autism spectrum disorders, depression, attention-deficit/ hyperactivity disorder (ADHD) and anxiety.

Children who exhibit severe, chronic irritability experience significant impairment in their ability to function (Leibenluft, 2011). Symptoms can present as mood disorders and can be debilitating. For Red, he was in a great deal of chronic emotional pain. He experienced early childhood abandonment where he was hatched in a “lost and found” box in the deficit of caregivers. Once mature, he walked about the bird island irritable and lacking critical adaptive skills to generate effective, fulfilling relationships. As a result, he isolated himself in a home close to the shore in the absence of others. Most times, Red felt taunted by his community when referred to as “Eyebrows,” misunderstood and existed devoid of supportive connections with his fellow bird mates in spite of his desire to form relationships. When Red engaged with others, he possessed chronic low frustration tolerance and his emotions frequently manifested in behavioral tantrums. Individuals diagnosed with DMDD tend to require considerable treatment efforts (Rao, 2014). Symptoms can be severe; and may require medication and psychiatric hospitalizations. For Red, he was mandated to court ordered anger management class.

Initially, Red struggled to adopt interventions to reduce his irritability and outbursts. Red and the group were introduced to various treatment techniques and provided a model of methods that one can adopt to reduce symptoms by the group leader, Matilda (voiced by Maya Rudolph), who diligently self-monitored her emotions and behaviors. In response to stimuli that provoked her, she proactively initiated “time-outs” to deescalate, and encouraged mindfulness techniques such as “come back into the now.” Behavioral interventions historically have been based in operant conditioning models where such interventions have included minimizing attention to undesirable behaviors, “praising positive and prosocial behavior, and punishing oppositional, destructive or aggressive behavior through the use of ‘time-out procedures’” (Johns & Levy, 2013, p. 281). However, Johns and Levy (2013) published a case study that suggests the dysregulated individual may benefit from taking a “time in” as characterized by a recognition of ruptures as they arise, observing and interpreting what the person is expressing emotions, responding to feelings and behaviors in a “firm and kind manner” and assisting to help calm the person before a repair is attempted. For clinicians and caregivers, engaging the individual exhibiting difficulty navigating their emotions with “warmth, calmness and predictability” coupled with allowing oneself a “time out” to approach the situation efficiently proved beneficial (Johns & Levy, 2013).

Medication management has also been a recommended treatment option. With foci of reducing irritability and both verbal and behavioral outbursts, children with DMDD have been treated with stimulant medications as well as new generation antipsychotics (Carlson, 2013). For individuals who have a comorbid diagnosis of ADHD, stimulant use has been found to reduce levels of irritability in children (Watts, 2015). With medication as a treatment option, there remain unanswered questions regarding whether medication is the best treatment option, when to prescribe and how to treat severe mood dysregulation (Leibenluft, 2011.) As such, psychotherapy and behavioral techniques “also should be considered in treating DMDD, particularly given their impairment in many social domains” (Rao, 2014, p. 122.).

There remains much to learn regarding DMDD. As this is a childhood disorder, understanding this diagnosis as individuals mature is an area where increased research can assist clinicians in diagnostics and intervention strategies. Findings have been promising that “show that irritability is significantly associated with both emotional and behavioral disorders cross sectionally during adolescents but is related only to depressive disorders and generalized anxiety” by the measured age of thirty-three rather than the presence of intermittent explosive disorder within a study performed by Stringaris, Cohen, Pine, and Leibenluft (2009). As such, individuals diagnosed with DMDD may have a greater risk of experiencing future symptoms of unipolar depression and anxiety disorders rather than bipolar disorder (Watts, 2015). Currently, there continues to be “important research gaps [that] include the continuity between severe irritability in youth and adult phenotypes” (Leibenluft, 2011, p. 138). Further, there are existing questions of whether behavioral problems related to irritability taper by adulthood whereas emotional difficulties related to irritability continue remain present. In the event behavioral outbursts and irritability continue into adulthood, such as in Red’s bird life experience, is a diagnosis of major depressive disorder or generalized anxiety disorder sufficient to encapsulate presenting symptoms? Will a diagnosis of DMDD in the future persist like other childhood disorders may (i.e. ADHD), or would a new diagnosis be required to properly capture symptoms of DMDD in adulthood? As research continues to flourish in this area in concert with the diagnosis being utilized in practice, there is hope that questions will be answered in the service of best treating our patients.

References

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Carlson, G. A. (2013). The dramatic rise in neuroleptic use in children: Why do we do it and what does it buy us? Theories from inpatient data 1988–2010. Journal of Child and Adolescent Psychopharmacology, 23, 144–147. http://dx.doi.org/10.1089/ cap.2013.2331

Johns, A., & Levy, F. (2013). ‘Time-in’ and ‘time-out’ for severe emotional dysregulation in children. Australasian Psychiatry, 21, 281–282. http://dx.doi.org/10.1177/ 1039856212475327

Leibenluft, E. (2011). Severe mood dysregulation, irritability, and the diagnostic boundaries of bipolar disorder in youths. The American Journal of Psychiatry, 168(2), 129–142.http://dx.doi.org/10.1176/appi.ajp.2010.10050766

Rao, U. (2014). DSM-5: Disruptive mood dysregulation disorder. Asian Journal of Psychiatry, 11, 119–123. http://dx.doi.org/10.1016/j.ajp.2014.03.002

Stringaris, A., Cohen, P., Pine, D. S., & Leibenluft, E. (2009). Adult outcomes of youth irritability: A 20-year prospective community-based study. The American Journal of Psychiatry, 166, 1048–1054. http://dx.doi.org/10.1176/appi.ajp.2009.08121849

Watts, V. (2015, September 17). How to diagnose and treat disruptive mood dysregulation disorder. Psychiatric News.http://dx.doi.org/10.1176/appi.pn.2015.8b11