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Role of individualised homoeopathic medicine in the management of disruptive mood dysregulation disorder - A case report
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Received: ,
Accepted: ,
How to cite this article: Moorthi SK, Chandran KC. Role of individualised homoeopathic medicine in the management of disruptive mood dysregulation disorder - A case report. J Intgr Stand Homoeopathy 2023;6:13-9.
Abstract
Disruptive Mood Dysregulation Disorder (DMDD) is a common behavioural dysfunction. The primary features of DMDD are chronic, non-episodic, persistent irritability and temper tantrums disproportionate with the trigger. We present a case of DMDD that was managed with homoeopathic medication and auxiliary measures. A 17-year-old male patient presented to the Psychiatry Outpatient Department of National Homoeopathy Research Institute in Mental Health with symptoms of anger outbursts, abusiveness, persistent irritable mood and laziness. The consultant psychiatrist diagnosed him with DMDD. He was treated with individualised homoeopathic medicine. The outcome was assessed at baseline and further using the Irritability — Parent/Guardian of child age 6–17 affective reactivity index (ARI). The patient’s ARI score reduced drastically within 2 months. His anger, abusiveness, propensity to hurt and irritability also reduced markedly. Behavioural aspects and social interactions showed good outcomes.Individualised homoeopathic medicine is useful in managing of DMDD by improving the susceptibility and modifying the patient’s state of reactivity.
Keywords
Disruptive mood dysregulation disorder
Affective reactivity index
Individualised homoeopathy
INTRODUCTION
Disruptive Mood Dysregulation Disorder (DMDD) was introduced as a new diagnosis in the 5th edition of the Diagnostic and Statistical Manual (DSM-5).[1] The core feature of DMDD is chronic, severe persistent irritability accompanied by severe temper outbursts, at least 3 times per week, that are out of proportion to provocation and inconsistent with the patient’s developmental level.[2,3]
DMDD is common among children presenting to paediatric mental health clinics. In the preschool cohort, the prevalence rate of DMDD using the entire DSM criteria, except for age of onset, was 3.3%. In a large nationally representative sample of adolescents, the prevalence rate of DMDD was 0.12%, after using strict criteria for its diagnosis.[4] Prevalence estimates of the disorder in the community are unclear.[2] DMDD appears to be more common in younger children[5] and there is some evidence that boys may be at greater risk than girls.[5,6] DMDD has been associated with poor parental mental health[7,8], low levels of parental support,[6] and high levels of parental hostility.[5] Other factors, such as grief, parental divorce and malnutrition or vitamin deficiencies are potential predisposing factors for the onset of disruptive behaviours.[2] The core symptoms of DMDD may be expressed behaviourally but the condition is considered to be a mood-based disorder and follow-up studies indicate a high risk for internalising disorders.[9] Children with DMDD are reported to be severely impaired and receive low ratings of social and global functioning.[5,10,11] Children who meet criteria for DMDD are also at high risk for poor long-term outcomes including multiple psychiatric diagnoses, poor educational attainment, engagement in illegal activities and impoverishment.[10] There is some evidence that these impairments and risks are conferred by DMDD status independently, that is, they persist after controlling for co-morbid oppositional defiant disorder (ODD), depression, anxiety, substance use disorders and attention deficit hyperactive disorder.[6,12]
The affective reactivity index (ARI) is most commonly used to assess irritability; it contains six symptom items and one impairment item. It has been validated in children of ages 6–17 years and is assessed for a minimum time frame of 6 months. The Level 2 — Irritability — Parent/Guardian of Child Age 6–17 is an adapted version of the ARI that assesses the pure domain of irritability. Each item asks the parent or guardian to rate the severity of their child’s irritability during the past 7 days. The raw scores on the first six items are summed to obtain a total raw score ranging from 0 to 12. Higher scores indicate greater severity of irritability.[13]
Chronic irritability, observed in DMDD, is severe and impairing for affected youth and their families, yet available treatment options are limited.[14] Pharmacotherapeutic treatment options of and chronic irritability include: antidepressants/selective norepinephrine reuptake inhibitors, mood stabilisers, psychostimulants, antipsychotics and alpha-2 agonists.[15] A systematic review from 2017 shows that cognitive behavioural therapy is effective for DMDD.[16]
Homoeopathy is one of the most suitable options for managing behavioural disorders, as they have a significant emotional component. Dr Samuel Hahnemann paid considerable attention to understanding mental illness. In his time, he was one of first physicians to see mentally ill patients as sick individuals who require empathy and proper medical care. According to him, the mind and body are not two absolutely separate entities but form an indivisible whole that is only distinguished for easy understanding. In the Organon of Medicine, Dr Hahnemann provides a detailed classification of the four types of mental illnesses. Mainly, aphorisms 215, 221, 224 and 225 pertain to the various types of mental illnesses that Dr Hahnemann perceived.
CASE REPORT
Patient information
A 17-year-old male patient, native of Kerala, admitted in a Government Delinquency Centre was referred to the OPD of National Homoeopathy Research Institute in Mental Health with the following behavioural changes since 7 years:
Anger outbursts whenever circumstances are not favourable to him
Lazy regarding his daily routine
Irritable mood most of the days
Using abusive words while quarrelling
Disobedient
Tendency to strike himself/others
Forsaken feeling.
History of presenting complaints
As narrated by the patient and caretaker, the complaints started when the patient was 10-year-old, after the death of his mother and elder sister. He started getting irritable easily and would start quarrels over minor reasons. There were severe anger outbursts when situations were not favourable to him. He used to shout violently and verbally abuse his father many times. He also tended to hurt himself and others. Therefore, his father sent him to the child care centre in Kerala at the age of 10 years, where he stayed till he was 15-years-old. No information is available about his attitude and behaviour in this centre. Meanwhile, the father re-married. After patient completed 10th standard, the father brought him back home. Both his step mother and father were alcoholics. They behaved rudely to him, so he could not stay there for more than 3 months. He ran away from home to a friend’s home. The friend’s family sent him to another child home for 4 months. Due to his irritability, unfriendly nature, sudden outbursts of anger and tendency to strike himself/others, he was referred to the Government delinquency centre in south India. There, he showed laziness in doing daily activities and displayed utter disobedience. When scolded for this reason, he often became violent. It was difficult to manage him there, so the caretakers brought him to our OPD. He was admitted in the IPD for further management.
Medical history
The patient had chickenpox at the age of 14 years.
Family history
Mother died in a road accident and successively, his elder sister died of renal failure when he was 9-years-old. There is no family history of psychiatric illness.
Personal history
Since he was brought up by care takers from the Government delinquency centre, history related to place of birth, nature of delivery, pregnancy history, birth and early development were missing.
Life space
The patient was the third-born of four children. During his childhood, there were frequent conflicts between his parents, so they got divorced. Patient does not remember his age when parents got divorced. Patient and his sister lived with father and his elder and younger brothers with mother. He was quite attached to his sister. Father used to punish them severely for trivial reasons. His mother died in an accident when he was 9-years-old; he learnt this indirectly from his father. He then lost his sister and could not stay with the step mother. He felt that no one cared for him.
He started schooling at the age of 3 years. He was very interested in studies and worked hard too. Usually, he scored good marks in class. He scored 72% marks in 10th grade examination. He used to write stories and liked to read novels.
Mental generals
Patient showed an introverted nature but had attention-seeking behaviour. According to the caretaker he was fairly affectionate when not in a negative mood. He does not like others criticizing him for his actions. If someone criticizes or reprimands him, he holds a grudge and avoids that person later. He likes consolation but feels there is no one to console him. He feels forsaken.
Physical generals
His appetite and thirst are good and eliminations are regular. He sleeps on the back and for 7–8 h every night. Patient desires sweets+ and fish+++. Patient is ambithermal.
Mental status examination
The mental status examination of the patient at the time of admission, 3 months after and 6 months after treatment are being mentioned in [Table 1].
| Domains | Time of admission | 3rd month | 6th month | End of 1 year |
|---|---|---|---|---|
| General appearance and behaviour | Uncooperative and rapport was poor | Cooperative and rapport established | Cooperative and well-established rapport | Cooperative and well-established rapport. |
| Psychomotor activity | Mildly increased | Adequate | Adequate | Adequate |
| Eye to eye contact | Sporadic | Maintained | Maintained | Maintained |
| Speech | Reduced | Adequate | Adequate | Adequate |
| Affect | Appropriate | Appropriate | Appropriate | Appropriate |
| Mood | Irritable | Stable | Stable | Stable |
| Thoughts | Idea of helplessness | Idea of helplessness | Nil | Nil |
| Perceptual disorder | Nil | Nil | Nil | Nil |
| Illusions | Nil | Nil | Nil | Nil |
| Orientation to time, place and person | Well-oriented | Well-Oriented | Well-Oriented | Well-Oriented |
| Memory | Good | Good | Good | Good |
| General information and intelligence | Good | Good | Good | Good |
| Attention and concentration | Reduced | Reduced | Good | Good |
| Abstract thinking | Good | Good | Good | Good |
| Judgement | Impaired | Impaired | Good | Good |
| Insight | Grade 2 | Grade 2 | Grade 6 | Grade 6 |
Differential diagnosis
Considering all the presenting complaints with absence of features like seizures, substance abuse and manic/irritable/ expansive mood, the consultant psychiatrist diagnosed the patient with DMDD per the DSM V Diagnostic guidelines.
ODD and DMDD share the symptoms of chronic negative mood and temper outbursts. However, the severity, frequency and chronicity of temper outbursts are more severe in individuals with DMDD than those with ODD. It can be differentiated from ODD in the matter that the diagnosis of DMDD requires severe impairment in at least in one setting (e.g., home, school, or among peers), unlike ODD.
DMDD can be differentiated from bipolar disorders based on the longitudinal course of the core symptoms. Bipolar disorders present as episodic illness with discrete episodes of mood perturbation.
Intermittent explosive disorder (IED) also needs to be differentiated from DMDD. Unlike DMDD, IED does not require persistent disruption of mood between outbursts. In addition, IED requires only 3 months of active symptoms, in contrast to the 12-month requirement for a diagnosis of DMDD.[17]
Therapeutic intervention
Individualised homoeopathic medicine was prescribed to the patient, according to the symptom similarity. No other adjunctive therapies were used. Repertorisation was done with RADAR OPUS 2.0, using Synthesis Repertory, as this case was rich in generals and characteristic particulars.[18,19] Mental general, physical general and particulars were considered for the repertorisation. The repertorisation chart is shown in [Figure 1].
- Symptom totality used for repertorisation.
We differentiated among Carcinosinum, Sulphur, Calcarea carbo and Natrum mur, as these were highest in the repertorial chart. Carcinosinum subjects have a history of prolonged fright, fear, or unhappiness. They are fastidious and sympathetic.[20] Here, the patient showed strong hatred and was unsympathetic, ruling out carcinosinum. Sulphur subjects are extroverted, philosophical and indisposed to everything and selfish; moreover, sulphur is thermally extremely hot.[21] The principal defensive reaction of Calc carb is withdrawal arising from insecurity, but it is not like the introverted nature of Nat mur. The Calc carb patient shows bashfulness and timidity and physically they are obese. Fear and apprehension are well marked in Calc carb.[22]
During the development of acute symptoms, Pulsatillla 200C was also prescribed for an acute episode of rhinitis. Medicines were administered orally with sac lac as the vehicle. The repetition schedule is mentioned in [Table 2].
| Date of visit | Indication for prescription | Medicine with doses, repetition | Changes in symptomatology | ARI Score |
|---|---|---|---|---|
| June 27, 2019 | Reportorial totality with consultation of Materia Medica | Natrum muriaticum 200/1 dose followed by placebo for 7 days | NA | 12 |
| July 04, 2019 | Anger and Irritability | Natrium muriaticum 200/1 dose followed by Placebo for 7 days. | Tendency to hurt and sudden anger outburst are reduced mildly Feel helplessness |
7 |
| July 11, 2019 | Anger and irritability. | Natrium muriaticum 200/1 dose followed by Sac lac for placebo for 7 days. | Anger and irritability–reduced. Tendency to hurt and sudden anger outburst are reduced moderately | 6 |
| July 17, 2019 | Dry cough<night, during sleep. Sensation of something in the throat, nasal obstruction-alternate sides, suffocated feeling<lying down | Pulsatilla 200/2 doses | Disobedient Irritable and anger – reduced Tendency to hurt himself and others-reduced. Feel helplessness |
6 |
| July 25, 2019 | Anger and irritability. Disobedient and feel helpless | Natrium muriaticum 200/1 dose followed by Sac lac for placebo for 7 days | Disobedient, easy change of mood. Feel helpless. Remaining complaints have got reduced well. He got recovered from his acute complaints. | 5 |
| August 01, 2019 | Feel helpless. | Placebo for 7 days | Anger and irritability reduced markedly. Disobedience-reduced. Patient is remaining calm. | 3 |
| August 08, 2019 | Improvement persisting. | Placebo for 7 days | Disobedience reduced. Mood stable, improvement shown in sociability and communicative. There is no anger outburst | 2 |
| August 15, 2019 | Feels better. Improvement persisting. | Placebo for 7 days | Able to control his anger, calm. Stable mood | 0 |
| August 22, 2019 | Improvement persisting. | Placebo for 7 days | No behavioural changes were noticed | 0 |
| August 30, 2019 | Improvement persisting. | Placebo for 7 days | No behavioural changes were noticed | 0 |
| September 05, 2019 | Improvement persisting. | Placebo for 7 days | No behavioural changes were noticed | 0 |
| September 12, 2019 | Improvement persisting. | Placebo for 7 days | No behavioural changes were noticed | 0 |
| September 19, 2019 | No specific complaints. Improvement persisting. | Placebo for 7 days | Cheerful mood | 0 |
| September 24, 2019 | No specific complaints. Improvement persisting | Nat mur 200/4 doses (SOS) Along with Placebo for 30 days |
Discharged with marked improvement | 0 |
| October 24, 2019 | Anger and Irritability | SOS was taken Nat mur 200/4 doses (SOS) Followed by Placebo for 30 days |
Few anger episodes after reaching back to Delinquency Centre from slight provocation. But showing anger towards staff as he can’t tolerate contradiction from them. However, there is no hurting tendency. | 1 |
| December 04, 2019 | No specific complaints. Improvement persisting. Sociability and commutation was improved well. |
SOS not taken. Nat mur 200/3 doses (SOS) followed by placebo for 30 days | Anger -Nil Irritability -Nil Changeable mood -Nil Generals are good. Studying Well. Regularly attending the classes, he is obedient. |
0 |
| January 07, 2020 | Asymptomatic | SOS not taken. Nat mur 200/3 doses (SOS) followed by placebo for 30 days | Socially and functionally well. | 0 |
| July 16, 2020 | Disease in remission (From the month of February to July patient continued follow-up and we found that disease was in remission. During this period, patient was under placebo and Natrum mur 200 was prescribed as SOS, but he had not taken it.) | 0 | ||
Follow-up and outcomes
Patient outcomes were assessed using the Level 2— Irritability—Parent/Guardian of Child Age 6–17 [Table 2]. The patient showed significant improvement within 2 months of intervention.
The Modified Naranjo Criteria for Homeopathy — Causal Attribution Inventory were used for assessing the likelihood of a causal relationship between homeopathic intervention and clinical outcome [Table 3]. The strength of association between the medicine and outcome was assessed using the following criteria: Definite: ≥9; probable 5–8; possible 1–4; and doubtful ≤0.[21] The base Modified Naranjo Criteria are provided in [Table 3].
| Base Modified Naranjo Criteria | ||||
|---|---|---|---|---|
| S. No. | DOMAINS | YES | NO | NOT SURE/ NOT APPLIC ABLE |
| 1. | Was there an improvement in the main symptom or condition for which the homoeopathic medicine was prescribed? |
+2 | -1 | 0 |
| 2. | Did the clinical improvement occur within a plausible timeframe relative to the medicine intake? |
+1 | -2 | 0 |
| 3. | Was there an initial aggravation of symptoms? | +1 | 0 | 0 |
| 4. | Did the effect encompass more than the main symptom or condition (i.e., were other symptoms ultimately improved or changed)? |
+1 | 0 | 0 |
| 5. | Did overall wellbeing improve (suggest using validated scale)? |
+1 | 0 | 0 |
| 6(a). | Direction of cure: did some symptoms improve in the opposite order of the development of symptoms of the disease? |
+1 | 0 | 0 |
| 6(b). | Direction of cure: did at least two of the following aspects apply to the order of improvement of symptoms: From organs of more importance to those of less importance From deeper to more superficial aspects of the individual From the top downwards |
+1 | 0 | 0 |
| 7. | Did ‘old symptoms’ (defined as non-seasonal and non-cyclical symptoms that were previously thought to have resolved) reappear temporarily during the course of improvement? |
+1 | 0 | 0 |
| 8. | Are there alternative causes (other than the medicine) that-with a high probability- could have caused the improvement? (consider known course of disease, other forms of treatment and other clinically relevant interventions) |
-3 | +1 | 0 |
| 9. | Was the health improvement confirmed by any objective evidence? (e.g. lab test, clinical observation, etc.) | +2 | 0 | 0 |
| 10. | Did repeat dosing, if conducted, create similar clinical improvement? |
+1 | 0 | 0 |
Maximum score: 13, minimum score: -6
The patient showed considerable improvement in the domains of irritable mood and social interaction. After getting discharged, he joined the Indian Institute of Infrastructure and Construction in the Kollam District. He attended a training course in plumbing and is now gainfully employed.
DISCUSSION
DMDD falls under the fourth category of Hahnemannian classification of mental diseases. They are diseases kept up by emotional causes such as anxiety, worry, frustration and frequent fear fright.[22]
In this case, the disease may have originated from his dysfunctional family and upbringing. Alteration in the state of mind narrated by the patient and bystander as well as the observations made by the physician was considered for the analysis of the case. After analysis, a totality was constructed to determine a suitable remedy with repertorisation.
Several published papers show the usefulness of homeopathy in managing different child and adolescent psychiatric conditions, especially those involving behavioural issues such as aggression and violence as a stand-alone treatment.[23-25]
In the foot note to aphorism 229 in the Organon of Medicine, Dr Hahnemann mentions that treatment of the violent insane maniac and melancholic can take place only in an institution specially arranged for their treatment and not within their family circle. Since the patient was extremely irritable, he was admitted in the IPD and administered Nat mur 200C. Adequate repetition of the remedy improved his mood and behaviour, after which he was discharged. This clearly shows that homoeopathic approach with proper selection of medicine, potency and repetition has yielded promising results in this case. The most significant limitation of this case report is that we cannot determine the long-term outcome yet, despite the fact that the patient has not had an episode since 9 months. Long-term follow-up, along with further analysis is required.
CONCLUSION
The case report gives us new insight and confidence into managing DMDD exclusively with homoeopathic treatment. Timely intervention prevented the patient’s deterioration into chronic psychiatric illness by improving the susceptibility and modifying the state of reactivity.
Acknowledgments
The authors are thankful to Dr K. C. Muraleedharan, Officer In-charge and Dr N. D. Mohan, Head of the Dept. of Psychiatry. They are also obliged to the participant and the care givers for their valuable inputs, which made the study possible.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent.
Conflicts of interest
There are no conflicts of interest.
Financial support and sponsorship
Nil.
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