A mother brings her 3-year-old son to the doctor because she is worried that he might be harming himself by constantly banging his head on the wall. He has been exhibiting this behavior for a few months. She is also worried because he has started to speak less than he used to and does not respond when his name is called. He seems aloof during playtime with other children and seems to have lost interest in most of his toys. What is the most likely diagnosis?

Attention deficit hyperactivity disorder

A 25-year-old woman comes to the physician because of sadness that started 3 weeks after her daughter was born. Her daughter is now 9 months old and usually sleeps through the night, but the patient still has difficulty staying asleep. She has not returned to work since the birth. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Depression with peripartum-onset

A 31-year-old female presents to her primary care physician with mild anxiety and complaints of mood swings lasting several months. The patient reports that the mood swings affect her work and personal relationships. In addition, she complains of increased irritability, breast tenderness, bloating, fatigue, binge-eating, and difficulty concentrating for 10 days prior to her menstrual period. The patient's symptoms increase in severity with the approach of menses but resolve rapidly on the first day of menses. She states that she is very sensitive to criticism of her work by others. She also snaps at her children and her husband. She has tried yoga to unwind, but with limited improvement. She is concerned that her behavior is affecting her marriage. The patient has no past medical history, and has regular periods every 24 days. She has had two normal vaginal deliveries. She uses condoms for contraception. Her mother has major depressive disorder. The physical exam is unremarkable. What is the most appropriate next step in the treatment of this patient?

Selective serotonin reuptake inhibitors (SSRIs)

Nonserotonergic antidepressants

Oral contraceptive and nonsteroidal anti-inflammatory drugs (NSAIDs)

Gonadotropin-releasing hormone (GnRH) agonists

A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?

Maternal obstetric complications

An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type

Intermittent explosive disorder

A 15-year-old boy is referred to a child psychologist because of worsening behavior and constant disruption in class. He has received multiple reprimands in the past 6 months for not doing the homework his teacher assigned, and he refuses to listen to the classroom instructions. Additionally, his teachers say he is very argumentative and blames other children for not letting him do his work. He was previously well behaved and one of the top students in his class. He denies any recent major life events or changes at home. His past medical history is noncontributory. His vital signs are all within normal limits. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

Antisocial personality disorder

A parent-teacher conference is called to discuss the behavior of a 9 year-old boy. According to the boy's teacher, he has become progressively more disruptive during class. When asked to help clean up or read out-loud, he replies with "You're not the boss of me." or "You can't make me." He refuses to participate in gym class, but will play the same games during recess. He gets along with and is well-liked by his peers. His mother reports that her son can "sometimes be difficult," but he is helpful around the house and is very good playing with his 7-year-old sister. What is the most likely diagnosis?

Antisocial personality disorder

Disruptive mood dysregulation disorder for USMLE Step 3: High-Yield Psychiatry Lessons

DMDD - The Angry Kid

Core feature: Chronic, severe, persistent irritability in children, distinct from episodic mania in bipolar disorder.
Dx Criteria:
- Severe recurrent temper outbursts (verbal/behavioral) ≥3x/week.
- Mood between outbursts is persistently irritable or angry.
- Symptoms present for ≥12 months in ≥2 settings (e.g., home, school).
- Onset before age 10; diagnosis not before 6 or after 18.
Tx:
- 1st Line: Psychotherapy (CBT), parent management training.
- 2nd Line: Stimulants, SSRIs, or atypical antipsychotics.

⭐ The DMDD diagnosis was introduced to avoid the overdiagnosis of pediatric bipolar disorder.

Diagnosis - The Grumpy Criteria

A. Severe Recurrent Temper Outbursts: Verbal rages or physical aggression grossly out of proportion to the situation.
C. Frequency: Outbursts occur on average ≥3 times per week.
D. Mood Between Outbursts: Persistently irritable or angry most of the day, nearly every day; observable by others.
E. Duration: Criteria present for ≥12 months, without a symptom-free period of ≥3 consecutive months.
F. Setting: Symptoms are present in at least two of three settings (home, school, peers) and are severe in at least one.
G/H. Age Criteria:
- Onset before age 10.
- Diagnosis not made before age 6 or after 18.

⭐ DMDD cannot coexist with bipolar disorder. If a manic/hypomanic episode ever occurs, the diagnosis must be changed to bipolar disorder.

Differential Dx - Separating the Sulks

Bipolar Disorder: DMDD lacks the distinct, episodic nature of mania or hypomania. Irritability in DMDD is persistent and chronic, not cyclical.
Oppositional Defiant Disorder (ODD): While both have temper outbursts, DMDD requires a persistently irritable or angry mood between the outbursts. ODD does not.
Intermittent Explosive Disorder (IED): IED involves impulsive aggressive outbursts that are grossly out of proportion, but it does not feature the constant negative mood of DMDD.

⭐ A diagnosis of DMDD cannot coexist with ODD or bipolar disorder. If criteria for both are met, only the diagnosis of DMDD is assigned for children.

Management - Taming the Tantrums

Psychotherapy is first-line: Comprehensive approach involving the child and caregivers.
- Parent management training (PMT)
- Cognitive-behavioral therapy (CBT) for emotional regulation & anger management
Pharmacotherapy for severe symptoms or failed psychotherapy:
- Target comorbidities first (e.g., ADHD).

⭐ While classified as a depressive disorder, stimulants (e.g., methylphenidate) are often the initial medication choice to manage irritability and comorbid ADHD symptoms before considering SSRIs.

High‑Yield Points - ⚡ Biggest Takeaways

Characterized by chronic, severe, persistent irritability and a baseline angry or irritable mood.

Features frequent temper outbursts (verbal or behavioral) that are grossly out of proportion, occurring ≥3 times/week.

Symptoms must be present for ≥12 months in at least 2 settings (e.g., home, school).

Symptom onset is before age 10; diagnosis is not made before age 6 or after age 18.

Differentiated from bipolar disorder by the absence of distinct manic or hypomanic episodes.

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