Comparing Neurocognition,Social Cognition and Emotion Regulation in Youth with Disruptive Mood Dysregulation Disorder (DMDD) vs. Bipolar Disorder (BD)

Abstract

Objective

This study aimed to compare neurocognition, social cognition and emotion regulation of adolescents aged 12-18 years with bipolar spectrum disorder (BD) and disruptive mood dysregulation disorder (DMDD) to healthy adolescents.

Methods

The sample included 63 adolescents (21 BD, 21 DMDD, 21 healthy), matched for age and gender. Social cognition was assessed using the Faces, Eyes, and Faux Pas tasks. Neurocognitive performance was evaluated with the Wisconsin Card Sorting Test and Stroop Test, while emotion regulation was measured via the Difficulties in Emotion Regulation Scale and Affective Reactivity Index–Parent Form.

Results

Significant differences were detected among the groups in all three of the theory of mind tests: faces, eyes and faux pas test, and healthy adolescents received statistically significantly higher scores. Both the cognitive characteristics and emotion regulation skills of healthy adolescents were evaluated as better than those in the BD and DMDD groups.

Conclusions

Adolescents with BD and DMDD show impairments in social cognition, executive functioning, and emotion regulation. Integrating interventions targeting these areas into treatment plans may enhance psychosocial functioning and support better clinical outcomes for youth with BD and DMDD.

Plain Language Summary

This study compared how adolescents aged 12-18 with bipolar disorder (BD) or disruptive mood dysregulation disorder (DMDD) perform in areas of thinking skills, understanding social information, and managing emotions. These two groups were also compared with healthy adolescents. The study included 63 adolescents in total: 21 with BD, 21 with DMDD, and 21 healthy teens. Social cognition, thinking abilities and emotion regulation was evaluated in these adolescents. The results showed significant differences between the groups in all three social cognition tests. Adolescents belonging to BD and DMDD group showed poorer performance in cognitive abilities and emotion regulation. In conclusion, adolescents with BD and DMDD experience difficulties in social cognition, executive functioning, and emotion regulation. Adding interventions that focus on these areas to their treatment plans may help improve daily functioning and lead to better clinical outcomes.

Keywords

bipolar disorder disruptive mood dysregulation disorder emotion regulation social cognition theory of mind

Introduction

Disruptive Mood Dysregulation Disorder (DMDD) was introduced in the DSM-5 to characterize children aged 6–18 years who present with impairing, pervasive, persistent irritability/angry mood upon which developmentally and contextually inappropriate, recurrent temper outbursts are superimposed (APA, 2013). DMDD was designed in part to rectify the overdiagnosis of bipolar disorder (BD) in children and adolescents with chronic irritability (Evans et al., 2021; Gupta & Gupta, 2022), but it has been controversial. Reflecting these controversies, the ICD-11 includes the diagnosis of oppositional defiant disorder (ODD) with chronic irritability/anger instead of DMDD (Armstrong, 2021). Chronic irritability and temper outbursts are required for DMDD; in contrast, they are allowable but not required for BD (APA, 2013). Irritability is a common problem in child and adolescent psychiatry (Evans et al., 2023), and both DMDD and BD in youth tend to be associated with long-term impairment, underlining the importance of early detection and management (Copeland et al., 2014; Mulraney et al., 2021; Wozniak et al., 2022). Despite the importance of differentiating characteristics of irritability in DMDD and BD, empirical comparisons of these two disorders are quite limited (Findling et al., 2022; Fristad et al., 2016).

Changes in EFs may be important for the development of mood disorders (Kaiser et al., 2024). EFs are a group of cognitive processes supporting goal-directed behavior and may include basic (i.e., attention, inhibitory control, working memory, set-shifting) as well as higher-order functions (i.e., planning, problem solving). EFs comprise of attention (focusing and maintaining focus on salient stimuli), fluency/processing speed (efficiency of information processing), set-shifting (shifting cognitive processes in accordance with variations in tasks/context), response inhibition (ignoring impulses and non-salient stimuli to attend tasks) planning (organizing tasks according to urgency and temporal demands) and working memory (short term maintenance and manipulation of salient information in memory) (Sadozai et al., 2024). EFs may be further subdivided as “cool” (i.e., those used in personally non-salient and neutral contexts) and “hot” EFs (i.e., those used in personally salient and emotional contexts such as emotion regulation) (Kouklari et al., 2024).

Youths at risk of BD were found to display impairment in processing speed, executive function, and sustained attention (Bora et al., 2024; Guglielmo et al., 2021). However, the cognitive profiles of youth with DMDD are less clear (Apicella et al., 2023; Brænden et al., 2023a; Sharifi et al., 2021). Previous studies have reported low IQ and adaptive abilities and reduced inhibitory control and set shifting (Apicella et al., 2023; Brænden et al., 2023a; Sharifi et al., 2021). Considering the transdiagnostic nature of cognitive problems among youth with psychopathology and the longitudinal and bidirectional associations between cognitive problems and symptoms among youth with mood disorders (Halse et al., 2022; Schweizer et al., 2020), further studies on the nature and correlates of cognitive problems among youth with DMDD and BD are clearly needed.

The associations between social cognition (SC), and various psychopathologies, have recently received increasing attention (Barnby et al., 2023; Schurz et al., 2021). SC consists of the reception, storage, and interpretation of social cues and may include recognizing the effects of facial and prosodic cues (emotion recognition), inferring others’ mental states (i.e., theory of mind, ToM), and sharing/understanding others’ emotional experiences (empathy) (Barnby et al., 2023; Schurz et al., 2021). In recent meta-analyses both adults and children with BD were found to display impaired SC in various domains including ER and ToM with medium to large effect sizes (Gillissie et al., 2022; Halac et al., 2021). The impairments were also observed in the euthymic period (Gillissie et al., 2022; Halac et al., 2021). Two recent studies on SC in children with DMDD reported that SC was impaired in at least one subgroup and that comorbid attention deficit/hyperactivity disorder (ADHD) further contributed to this impairment (Brænden et al., 2023b; Özyurt et al., 2024). However, to date, no study has compared SC between DMDD and BD. Moreover, both previous studies were conducted in children and may not reflect changes in SC during adolescence (Capella & Telzer, 2024). Neurocognitive processes, SC, and emotional control are also known to display complex bidirectional relationships which should be evaluated with further studies (Guglielmo et al., 2021; Kaiser et al., 2024).

Both adults and youth with BD display impaired ER (Halac et al., 2021; Oliva et al., 2023). Emotion dysregulation (ED) in BD may be especially prominent during mood alterations and in the presence of depressive symptoms and may also affect emotion recognition. According to a recent study of ED in youth with mood disorders, ED in MDD and BD may be partially dissociable and may include emotion appraisal and regulation in the former, while perception may be more impaired in the latter (Wu et al., 2024). Studies conducted on ED among youth with DMDD have reported weaker associations between the cognitive and affective domains of empathy (Özyurt et al., 2024) and either impaired or preserved emotion recognition abilities (Brænden et al., 2023a; Özyurt et al., 2024). Youths with DMDD may also have a hostile attribution bias to emotional stimuli which may be affected by the presence of depressive symptoms (Bos, 2024; Paulus et al., 2021). Adolescent irritability was found to be associated with reduced awareness of the needs, strategies, and goals related to ER, elevated impulsivity especially in emotionally salient situations, and higher rates of rumination (Bos, 2024; Brænden et al., 2023a; Elvin et al., 2024; Paulus et al., 2021). To date, few studies have evaluated ER problems in youth with DMDD and compared them to those with BD, and fewer still tried to discern relationships between neurocognitive processes, SC, and ED.

Although results of accumulating studies have helped to differentiate DMDD from BD, there is no consensus on the diagnostic assessment and treatments for DMDD (Zhang et al., 2024). Recent meta-analyses and reviews suggest atomoxetine, stimulants, atypical antipsychotics, selective serotonin reuptake inhibitors (SSRIs) and lithium may be employed in DMDD on an individualized basis and according to comorbid diagnoses (Orsolini et al., 2024). Among non-pharmacological interventions parent management training, cognitive behavioral therapy dialectical behavior therapy seem to benefit DMDD (Kalvin et al., 2025).) For pediatric BD mood stabilizers, atypical antipsychotics, family focused treatment, cognitive behavioral therapy, interpersonal and social rhythm therapy, motivational interventions and dialectical behavior therapy may be effective (Liu et al., 2022). Studies on inter-relationships between neurocognition, SC and ER problems in youths with DMDD and BD and further characterization of irritability may allow more specific interventions to address irritability and aggression in youth with those disorders.

Therefore, the aim of the current study is,

a. To investigate EFs of youths with DMDD and BD with Stroop Color Word (SCWT, attention, processing speed, response inhibition) and Wisconsin Card Sorting (WCST, set-shifting) tests

b. To investigate SC of youths with DMDD and BD with Reading the Mind in the Eyes (RMET), Faces (FT) and Faux-Pas (FPT) tests

c. To evaluate differing facets of ED in youths with DMDD and BD with the Difficulties in Emotion Regulation Scale (DERS) and Affective Reactivity Index- Parent form (ARI-P)

d. To compare the results with those of healthy adolescents.

Materials and Methods

Study Center, Sampling, and Ethics

Participants consisted of consecutively admitted patients between the ages of 12 and 18 years who were diagnosed with DMDD (DSM-5 296.99, ICD-10 F34.8) and BD (Bipolar I and II, DSM-5, F 31.77-78 and F 31.81; ICD F 31.77-78 and F31.81) between May 2023 and May 2024 in the Child and Adolescent Psychiatry Department of the study center. The diagnoses of DMDD and BD were made in accordance with the DSM-5 criteria (APA, 2013). Exclusion criteria for the case group included the presence of chronic medical disorders, a clinical diagnosis of autism spectrum disorder, intellectual disability (according to developmental/academic history and clinical examination), past or current epilepsy, brain injury, and cerebral palsy. Age- and sex-matched children who applied to the pediatric outpatient clinics of the same hospital within the study period with minor physical symptoms (e.g., common cold, rhinitis), did not have chronic medical conditions, and were free of lifetime psychopathology formed the control group. Flow chart of the study is given in Figure 1.

Participants were evaluated using the Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL) implemented by blinded professionals (Ünal et al., 2019). All participants completed a battery of tests that assessed their neurocognitive processes and SC and ER skills in a fixed order.

IRB approval for the study was obtained from the Clinical Trials Ethics Committee (Date:10.05.2023, No:2023/15-02). Verbal and written assents of adolescents and written informed consent from the mothers who participated in the study were obtained prior to enrollment. All study procedures were performed in accordance with the Declaration of Helsinki and the local laws and regulations.

Measurements

Sociodemographic Data Form

This form was prepared by the researchers to collect information about the socio-demographic characteristics of the children and parents. The participants’ ages, genders, socioeconomic levels, academic achievements, peer relationships, and their parents’ ages, and educational, marital, and vocational status were entered into the form by the clinicians.

Children’s Depression Rating Scale-Revised (CDRS-R)

The CDRS-R, developed by Poznanski et al., is a clinician-administered semi-structured interview assessing symptoms of depression during the previous two weeks. It is based on the Hamilton Depression Rating Scale used for adults, and was originally developed for children aged 6-12 years although it was later found to be valid and reliable for adolescents (Mayes et al., 2010). The CDRS-R is a 17-item, five- or seven-point likert-type scale with a range of 17-133 for total scores. The rating was conducted by the clinician via interviews with the child and parent. A score ≥40 indicates depression, whereas a score ≤28 is often used to define remission (minimal or no symptoms). The Turkish version has been previously validated and is reliable (Guney et al., 2018).

Young Mania Rating Scale (YMRS)

The YMRS is an eleven item, likert-type scale that evaluates the symptoms of mania over the previous 48 hours or week, according to clinical observations and patient reports (Young et al., 1978). The scores varied between 0 and 60 (≤12: remission, 13-19: minimal symptoms, 20-25: mild mania, 26-37: moderate mania, 38-60: severe mania). The Turkish version of the YMRS has previously been found to be valid and reliable (Karadağ et al., 2002).

Affective Reactivity Index-Child and Parent Forms (ARI-P)

The ARI is a scale developed for the evaluation and monitoring of irritability according to the reports of children and parents. The scale evaluates irritability for the last six months and the resulting impairment in a seven-item, three-point Likert-type format, with total scores ranging between 0-12. Both the original scale and the Turkish version were previously found to be reliable and valid (Kocael, 2015; Stringaris et al., 2012). The parental form (ARI-P) was used in this study.

Kiddie Schedule for Affective Disorders and Schizophrenia Present and Lifetime Version (K-SADS-PL)

The K-SADS-PL is a semi-structured diagnostic interview evaluating current and lifetime psychopathology among children and adolescents, which was updated to reflect the DSM-5 criteria (Kaufman et al., 2016). The Turkish version of the K-SADS-PL has been previously validated and found to be reliable (Ünal et al., 2019). Blinded, trained children and adolescent psychiatrists conducted the interviews with the study participants. The Kappa value for DMDD in the Ünal et al. (2019) study was reported as 0.70. This value was found to be 0.76 in the current study. DMDD was diagnosed by clinical interviews according to DSM-5 criteria along with the K-SADS-PL-DMDD module in this study.

Difficulties in the Emotion Regulation Scale (DERS)

The DERS was developed to evaluate ER problems and ED among adolescents (Neumann et al., 2010). It consists of 36 five-point Likert-type items across six domains with a score range from 36 to 180. The subscales are goals, strategies, impulsivity, awareness, clarity, and non-acceptance (Neumann et al., 2010). The goals domain evaluates the purpose of initiating behaviors (with increasing points indicating difficulties in initiating behavior), while the strategies domain evaluates strategies used for ER (with increasing scores indicating difficulties in using effective strategies). The remaining domains included awareness/clarity in emotional responses and acceptance of negative feelings, with increasing scores denoting elevated problems (Neumann et al., 2010). The Turkish version was previously found to be reliable and valid (Sarıtaş-Atalar et al., 2015). In this study, the adolescents completed the DERS.

Neurocognitive Tests

Stroop Color Word Test- TBAG Form

The Stroop Color Word Test (SCWT) was first developed in the 1930s as an experimental task (Spreen & Strauss, 1998). The SCWT-TBAG (TUBITAK Basic Sciences Research Group) form was created with combining the original test with the Victoria form and is included in the BILNOT Battery (Karakas & Dincer, 2011). SCWT reflects selective and focused attention, response inhibition, resistance to interference, and information processing speed (Karakas & Dincer, 2011; Selnes, 1991). SCWT-TBAG was found to be reliable and valid in Turkish children and adolescents (Spreen & Strauss, 1998). Among youth 12-13 years old, the mean durations of SCWT-1, 2, 3, 4 and 5 were 10.9 ± 0.4, 13.4 ± 0.7, 16.9 ± 0.5, 26.9 ± 1.0 and 41.7 ± 1.7 seconds; respectively. Mean errors in SCWT were 1.4 ± 0.5 for youth in this age (Karakas & Dincer, 2011).

The Wisconsin Card Sorting Test (WCST)

WCST is a test reflecting set-shifting which is defined as the flexibility in responses due to changes in reinforcement (Spreen & Strauss, 1998). It is the most commonly used set-shifting task in humans. The participant is asked to sort response cards according to one of three classification modes (color, form, and number). The rule is acquired using the feedback provided after each response. After a fixed number of correct matches, the rule is changed, and the participant must shift to a new mode of classification. WCST was found to be valid and reliable in Turkish children and adolescents and was included in the BILNOT Battery. Among Turkish youth aged 12- 13 years, means for WCST correct responses, total errors, perseverative error rate and categories completed were 68.9 ± 1.7, 31.2 ± 3.7, % 15.7 ± 1.7 and 5.3 ± 0.3 (Karakas & Dincer, 2011). WCST administration was computerized in this study.

Social Cognition (ToM, Emotion Recognition, Mentalizing, and Social Rules)

To determine the particular characteristics of SC, we used three different tasks: RMET, FT, and FPT. All tests were applied by clinicians to adolescents in a fixed order.

Reading the Mind in the Eyes Test (RMET)

The RMET evaluates one’s ability to understand mental states and emotions by observing eye expressions. It was initially developed in 1997 and was later revised. It is frequently used in studies that evaluate the relationship between SC and psychopathology (Greenberg et al., 2023). A Turkish reliability study of the test was conducted in 2011, and later Girli established the reliability and validity of the pediatric and adult versions. Mean scores in Turkish children were reported as 16.5 (Girli, 2014; YILDIRIM et al., 2011).

Faces Test (FT)

The FT was developed by Ekman in 1972 to evaluate facial emotion recognition skills (Ekman & Friesen, 1976). The test was previously used with Turkish children and was found to be reliable and valid with a score range of 0 to 19 (Percinel et al., 2018).

The Faux-Pas Test (FPT)

The FPT was developed to evaluate the recognition of social blunders, which necessitates advanced levels of mentalization and knowledge of social rules (Baron-Cohen et al., 1999). The Turkish version was previously found to be reliable and valid with a score range of 0 to 10 in faux-pas stories and mean scores were found as 6.3 ± 2.4 (Şahin et al., 2020).

The instruments used in the study are summarized in Supplemental Table 1, and the acronyms used throughout the manuscript are listed in Supplemental Table 2.

Statistical Analysis

Statistical analysis was conducted using the Statistical Package for the Social Sciences (IBM Corporation, Armonk, NY, USA), version 22 for Windows TM, and with JASP [JASP Team (2024). JASP (Version 0.19.0), Computer software]. Variables were controlled for the assumptions of normal distribution using the Shapiro–Wilk test. Continuous variables were summarized as means and standard deviations or medians and interquartile ranges (IQR), according to assumptions of normality and presence of outliers. Categorical variables are summarized as counts and frequencies. The chi-squared test was used to compare categorical variables between the study groups. Likelihood ratio or Yates’ corrections and Fisher’s exact test were used as needed. Psychometric measures were compared across groups using a multivariate analysis of variance (MANOVA) with follow-up univariate ANOVAS. Pillai’s trace or Wilk’s lambda were used according to equality of covariance matrices and in error variances. Post-hoc comparisons were conducted with Tamhane T2 or Scheffe tests. Correlations were evaluated with Spearman’s test. Mediation analyses were conducted in JASP using the delta method for standard errors and normal theory for confidence intervals and employing maximum likelihood estimators. Lastly, and as a hypothesis generating analysis, we evaluated the performance of machine learning (with support vector machine, SVM) using z scores of YMRS, CDRS, processing speed (as reflected in SCWT duration), DERS-Total, ARI-P and WCST-categories completed, total errors, perseverative error rate and number of correct responses. The SVM model was trained on 51 jack-knife samples and tests on 12 samples. P was set at .05 (two-tailed). The effect sizes for the significant findings are also reported.

Results

Clinical and Demographical Characteristics of the Participants

Within the study period, 21 youths with BD (n = 15, 71.4 % BP-I with the remainder being BP-II) and an equal number of youths with DMDD and controls were enrolled for a total of 63 adolescents. Mean ages (16.0 ± 1.2 years for BD, 15.7 ± 1.8 for DMDD, and 15.3 ± 1.6 for controls) as well as sex ratios (females, 52.4 % BD, 47.6 % DMDD, 52.4 % controls) were similar across groups (Kruskal Wallis χ 2 = 1.2, p = 0.554 and χ 2 = 0.1, p = 0.938; respectively). Depressive symptoms of youth with BD and those with DMDD according to CDRS-R were 35.0 ± 4.1 and 35.7 ± 3.0, respectively. Manic symptoms were found to be 7.9 ± 1.1 and 7.3 ± 1.0; respectively according to YMRS for these groups. Both CDRS-R and YMRS showed no difference among groups (t [36.6] = 0.2, p = 0.832 and t [40.0] = 1.8, p = 0.087; respectively, t test for independent groups). Comorbid diagnoses among those with DMDD (n = 11, 52.4 %) were more frequent than those with BD (n = 7, 33.3 %) although not reaching significance (χ 2 = 0.9, p = 0.350, Yates’ correction). The most common comorbidity was attention deficit hyperactivity disorder (DMDD; n = 8 (38.1%), BD; n = 4 (19%)). The sociodemographic characteristics of the groups are listed in Table 1.

Table 1.

Sociodemographic Features of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

n (%)		DMDD (n = 21)	BPD (n = 21)	Controls (n = 21)	χ2/p^a	E.S.
Academic achievement	Poor	3 (14.3)	6 (28.6)	0 (0.0)	13.5/0.009	0.33
	Mediocre	9 (42.9)	6 (28.6)	3 (14.3)
	Superior	9 (42.9)	9 (42.9)	18 (85.7)
Peer relations	Poor	9 (42.9)	7 (33.3)	2 (9.5)	6.1/0.048	0.31
Peer relations	Good	12 (57.1)	14 (66.7)	19 (90.5)	6.1/0.048	0.31
Maternal education	Primary school or lower	5 (23.8)	5 (23.8)	3 (14.3)	1.0/0.985	-
	Secondary school	4 (19.1)	4 (19.1)	5 (23.8)
	High school	7 (33.3)	7 (33.3)	8 (38.1)
	University or higher	5 (23.8)	4 (19.1)	5 (23.8)
Maternal vocation	Housewife	3 (14.3)	3 (14.3)	2 (9.5)	1.7/0.790	-
	Artisan	2 (9.5)	4 (19.1)	5 (23.8)
	Civil servant	16 (76.2)	14 (66.7)	14 (66.7)
Paternal vocation	Artisan	10 (47.6)	12 (57.1)	11 (52.4)	0.4/0.826	-
Paternal vocation	Civil servant	11 (52.4)	9 (42.9)	10 (47.6)	0.4/0.826	-
Paternal education	Primary school or lower	7 (33.3)	8 (38.1)	4 (19.1)	2.3/0.895	-
	Secondary school	6 (28.6)	5 (23.8)	7 (33.3)
	High school	5 (23.8)	5 (23.8)	7 (33.3)
	University or higher	3 (14.3)	3 (14.3)	3 (14.3)
Family status	Nuclear	16 (76.2)	18 (85.7)	14 (66.7)	2.1/0.350	-
Family status	Separated/divorced/widower	5 (23.8)	3 (14.3)	7 (33.3)	2.1/0.350	-
Socioeconomic status	Low	5 (23.8)	5 (23.8)	2 (9.5)	8.6/0.071	0.26
	Middle	13 (61.9)	16 (76.2)	19 (90.5)
	High	3 (14.3)	0 (0.0)	0 (0.0)

^aChi-square test with Likelihood Ratio, Yates’ corrections as needed. E.S: Effect Size (Cramer’s V).

The parents in the control group reported their socioeconomic status as middle significantly more frequently than the parents of youth with DMDD and BD, although this difference did not reach significance. Peer relations of youth with DMDD and those with BD were significantly worse, and their academic achievements were significantly lower compared to controls, with both differences having a small effect size. Other sociodemographic variables were similar across the groups.

Stroop Color and Word Test (SCWT)

A MANOVA was conducted to evaluate the SCWT performance of youth with DMDD, BD, and controls. Covariance matrices (Box’s M = 147.4, p < 0.001) as well as error variances in SCWT (Levene’s test, except number of errors and spontaneous corrections, both p > 0.05) were not equal therefore Pillai’s trace was used in analysis. SCWT performance differed significantly between groups (F [12.0, 104.0] = 5.9, p < 0.001, partial η 2 = 0.40). The results of univariate ANOVAs are listed in Table 2.

Table 2.

Stroop Color Word Test (SCWT) Performance of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

Mean (S.D)	DMDD (n = 21)	BD (n = 21)	Controls (n = 21)	F/p	Partial η 2
SCWT-1 duration (sec)	56.4 (15.4)	42.1 (10.8)	28.8 (5.0)	31.3/< 0.001	0.53
SCWT-2 duration (sec)	44.1 (12.1)	28.7 (4.5)	25.3 (2.6)	34.5/< 0.001	0.55
SCWT-3 duration (sec)	100.9 (27.8)	72.3 (17.2)	51.0 (7.2)	34.8/< 0.001	0.55
SCWT-4 duration (sec)	56.6 (19.7)	44.1 (18.5)	25.1 (7.4)	20.2/< 0.001	0.42
Spontaneous corrections	1.9 (0.9)	1.8 (1.0)	1.5 (0.8)	1.2/0.313	0.04
Errors	1.1 (1.0)	1.2 (1.0)	1.1 (1.0)	0.4/0.689	0.13

SD: Standard Deviation, sec: seconds.

Post-hoc comparisons with the Tamhane T2 test revealed that the DMDD, BD, and control groups differed significantly in terms of SCWT duration, with the DMDD group being the slowest, while controls were the fastest performers (all p < 0.05).

Wisconsin Card Sorting Test (WCST)

WCST performance (i.e., failures to maintain set, correct responses, total errors, perseverative error rates, and categories completed) was compared between the groups using MANOVA. Covariance matrices (Box’s M = 140.0, p < 0.001) as well as error variances (except failures to maintain set and categories completed, Levene’s test, both p > 0.05) were not equal and Pillai’s trace was used in analysis. The WCST performance differed significantly between the groups (F [10.0, 110.0] = 7.6, p < 0.001, partial η 2 = 0.41). The results of univariate ANOVAs are listed in Table 3.

Table 3.

Wisconsin Card Sorting Test (WCST) Performance of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

Mean (S.D)	DMDD (n = 21)	BD (n = 21)	Controls (n = 21)	F/p	Partial η 2
Failures to maintain set	1.3 (1.0)	1.3 (1.3)	1.4 (0.9)	0.1/0.936	0.00
Number of correct responses	39.9 (7.3)	42.4 (8.1)	51.9 (3.0)	20.1/0.000	0.41
Total errors	24.1 (7.3)	21.6 (8.1)	12.1 (3.0)	20.1/0.000	0.41
Perseverative error rate (%)	13.4 (5.4)	9.8 (4.0)	3.3 (1.5)	34.4/0.000	0.54
Categories completed	12.1 (7.9)	19.2 (11.9)	40.0 (6.0)	55.6/0.000	0.66

SD: Standard Deviation.

Post-hoc comparisons with the Tamhane T2 test revealed that for the number of correct responses, total errors, rate of perseverative errors, and number of categories completed, the BD was similar to the DMDD, and both groups performed at significantly lower levels compared to controls (all p < 0.05). For the perseverative error rates, youths with BD tended to perform at better levels than those with DMDD, albeit not reaching significance (p = 0.063).

Evaluation of the Social Cognition

MANOVA was used to evaluate SC among the groups. Covariance matrices (Box’s M = 13.7, p = 0.392) and error variances were equal (Levene’s test, all p > 0.05), and Wilk’s lambda was used. The groups differed significantly in terms of SC (F [6.0, 116.0] = 10.1, p < 0.001, partial η 2 = 0.34). Univariate ANOVAs are listed in Table 4.

Table 4.

Social Cognition Performance of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

Mean (S.D)	DMDD (n = 21)	BD (n = 21)	Controls (n = 21)	F/p	Partial η 2
RMET	20.8 (1.1)	21.9 (1.4)	22.5 (1.2)	10.3/0.000	0.26
Faces test	15.1 (0.8)	16.1 (1.1)	16.5 (1.0)	11.5/0.000	0.28
Faux-pas test	6.9 (0.8)	7.1 (0.9)	8.1 (0.8)	11.6/0.000	0.28

SD: Standard Deviation, RMET: Reading the Mind in the Eyes Test.

Post-hoc Scheffe tests revealed that RMET and FT performance of groups differed, with DMDD performing significantly worse than BD (p = 0.028 and 0.005, respectively), which was similar to controls (p = 0.223 and 0.380, respectively). The FPT performances of the DMDD and BD groups were similar (p = 0.546) and significantly worse than those of the controls (p < 0.001).

Emotion Regulation Skills and Irritability Tests

The DERS subscales, total DERS scores, and ARI-P were compared among the groups using MANOVA. Covariance matrices (Box’s M = 191.8, p = 0.000) and error variances except ARI-P and DERS- awareness (Levene’s test, all p < 0.05) were not equal therefore Pillai’s trace was used. The groups differed significantly in terms of ER skills measured by the DERS and ARI-P (F [14.0, 110.0] = 1.2, p = 0.000, partial η 2 = 0.59, Table 5).

Table 5.

Emotion Regulation Skills and Parent-Rated Irritability of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

Mean (S.D)	DMDD (n = 21)	BPSD (n = 21)	Controls (n = 21)	F/p	Partial η 2
DERS-goals	13.7 (4.7)	13.3 (4.5)	9.5 (1.7)	7.4/0.001	0.20
DERS- strategies	18.1 (7.5)	19.2 (6.0)	9.5 (1.3)	18.8/0.000	0.39
DERS- impulsivity	17.9 (6.1)	18.8 (5.6)	8.6 (1.4)	28.8/0.000	0.49
DERS- awareness	15.0 (4.0)	14.2 (2.9)	12.7 (2.3)	2.9/0.062	0.09
DERS- clarity	11.3 (4.5)	11.8 (4.9)	10.1 (1.7)	0.9/0.396	0.03
DERS-non-acceptance	15.0 (5.4)	15.4 (5.0)	9.4 (1.1)	12.6/0.000	0.30
ARI-P	9.6 (0.9)	7.5 (1.1)	2.4 (1.1)	285.9/0.000	0.91

SD: Standard Deviation, DERS: Difficulties in Emotion Regulation Scale, ARI-P: Affective Reactivity Index- Parent Form.

Post-hoc Tamhane T2 and Scheffe (for DERS awareness and ARI-P) tests revealed that for goals, strategies, impulsivity, and non-acceptance, BD and DMDD were similar and scored significantly higher than controls. All three groups differed significantly from each other for ARI-P, with scores ranking as DMDD > BD > control.

A heatmap of correlations between SCWT-1, 2, 3, and 4 durations; WCST: correct responses, total errors, perseverative error rates, categories completed, RMET, FT, FPT, DERS goals, strategies, impulsivity, non-acceptance, and ARI-P for the whole sample and for youths with DMDD and BD are illustrated in Figure 2(A) and (B)

In the whole sample slower information processing speed as measured by SCWT durations correlated significantly and negatively with SC (rhos between −0.26- - 0.44) and positively with DERS strategies, impulsivity and non-acceptance (rhos between 0.25-0.45) as well as ARI-P (ehos between 0.67- 0.78, all p < 0.05). Executive functions and cognitive flexibility as reflected by WCST scores correlated positively with SC (rhos between 0.36- 0.48) and negatively with DERS strategies, impulsivity, and non-acceptance (rhos between −0.28- 0.52) as well as ARI-P (rhos between −0.64- - 0.73, all p < 0.05). SC domains were negatively and significantly correlated with ARI-P (RMET = −0.45, FT = −0.39, FPT = −0.50, Figure 2 (A)).

Among youth with DMDD and BD, most of these correlations lost significance while slower information processing speed as reflected in SCWT durations correlated positively and significantly with ARI-P (rhos between 0.44- 0.57) and only WCST categories completed correlated positively with DERS-impulsivity (rho = 0.36) and negatively with ARI-P (rho = −0.34) none of the SC tests correlated with ARI-P (Figure 2 (B)).

Finally, a mediation analysis was conducted to evaluate the effects of information processing speed (standardized z-scores of SCWT durations) and ED (DERS-total Z scores) on parent-rated irritability (ARI-P z scores) in the whole sample and in youths with DMDD and BD (Table 6 and Figure 3 A and B).

Table 6.

Effects of Information Processing Speed and Emotion Dysregulation on Parent Rated Irritability of Adolescents With Disruptive Mood Dysregulation Disorder (DMDD), Bipolar Disorder (BD) and Controls

Whole sample
Direct effects
Path	Estimate	Standard error	Z value	p	95 %CI
Z-SCWT → Z-ARI-P	0.163	0.041	4.0	<0.001	0.084-0.242
Indirect effects
Z- SCWT → Z-DERS-Total→Z-ARI-P	−0.024	0.017	−1.4	0.157	−0.058-0.009
Total effects
Z- SCWT → Z-ARI-P	0.139	0.041	3.4	<0.001	0.058- 0.219
Path coefficients
Z-DERS-total → Z-ARI- P	0.292	0.135	2.2	0.031	0.027- 0.557
Z- SCWT → Z-ARI- P	0.163	0.041	4.0	<0.001	0.084- 0.242
Z- SCWT → Z-DERS- total	−0.083	0.044	−1.9	0.062	−0.170- 0.004
Youth with DMDD and BD
Direct effects
Z- SCWT → Z-ARI- P	0.073	0.018	4.0	<0.001	0.037- 0.108
Indirect effects
Z- SCWT → Z-DERS-Total→Z-ARI-P	−0.011	0.008	−1.4	0.157	−0.026- 0.004
Total effects
Z- SCWT → Z-ARI- P	0.062	0.018	3.4	<0.001	0.026- 0.098
Path coefficients
Z-DERS-total → Z-ARI- P	0.133	0.062	2.2	0.031	0.013- 0.254
Z- SCWT → Z-ARI- P	0.073	0.018	4.0	<0.001	0.037- 0.108
Z- SCWT → Z-DERS- total	−0.081	0.043	−1.9	0.062	−0.166- 0.004

CI: Confidence Interval, SCWT: Stroop Color Word Test, ARI-P: Affective Reactivity Index- Parent Form, DERS: Difficulties in Emotion Regulation Scale, Delta method for SE, Normal theory for CI, Maximum likelihood estimator.

In both the whole sample and in youth with DMDD and BD, information processing speed and DERS total scores had significant direct effects on parent-rated irritability. Information processing speed explained 29.3 % of the variation in parent-rated irritability in both analyses (R² = 0.293), while DERS total scores had an effect of less than 8.0% (R² = 0.077).

Lastly, and as a hypothesis generating analysis, we evaluated the performance of machine learning (with support vector machine, SVM) using z scores of YMRS, CDRS, processing speed (as reflected in SCWT duration), DERS-Total, ARI-P and WCST-categories completed, total errors, perseverative error rate and number of correct responses. The SVM model was trained on 51 jack-knife samples and tests on 12 with an accuracy of 0.92 (Figure 4). Area Under Curve (AUC) for BD and controls were 1.0 for both while it was 0.83 for DMDD. Variable importance plot for groups is illustrated in Figure 5. According to this plot standardized YMRS, CDRS and SC scores were more important for BD while SC and processing speed were more important for DMDD and controls.

Discussion

This single-center, cross-sectional, case-control study aimed to evaluate the neurocognitive, SC, and ER processes of youths with DMDD and BD using neuropsychological tests along with self- and parent-report scales and compare them with healthy controls. To achieve this, 21 youths matched in terms of sex and age were enrolled in each of the three groups. Peer relations of youth with DMDD and BD were significantly worse, and their academic achievements were lower than those of controls. Information processing speed, as reflected in SCWT performance, was lowest in DMDD and highest in controls, with BD in between. However, the groups performed similarly in terms of resistance to interference. WCST performance in terms of correct and erroneous responses, perseverative errors, and completed categories was similar in DMDD and BD and lower than in controls. In tests of SC, there were conflicting results; in the RMET and FT, the DMDD group performed lower than BD, which was similar to controls, while in FPT, youth with DMDD and BD performed at similar levels, and their performances were lower than controls. In the DERS, DMDD, and BD groups, scores were similar and elevated in the goals, strategies, impulsivity, and non-acceptance domains compared to controls. ARI-P scores were ranked as DMDD > BD > Controls, with each group differing significantly from the others. Among youth with DMDD and BD, slower information processing speed correlated positively and significantly with ARI-P, and WCST categories correlated positively with DERS impulsivity and negatively with ARI-P. In both the whole sample and in youth with DMDD and BD, slower information processing speed and DERS total scores had significant direct effects on parent-rated irritability, with no mediation by DERS scores.

Executive function problems may play important roles in the development of mood disorders (Kaiser et al., 2024). Youths with MDD may have impairments in attention, memory, verbal reasoning, and global IQ scores, although the importance of these results is controversial (Goodall et al., 2018; Urbańska-Grosz et al., 2024). Similarly, youth at risk for BD may have impaired processing speed and executive functioning, including attention (Bora et al., 2024; Guglielmo et al., 2021). Studies on the cognitive profiles of youth with DMDD are limited in number and suggest that these youths may have lower IQ, inhibitory control, and set shifting (Apicella et al., 2023; Brænden et al., 2023a; Sharifi et al., 2021). The results of our evaluations with SCWT support and enrich those of previous studies and suggest that processing speed impairment may be greater among youth with DMDD compared to those with BD and that both may be impaired compared to controls. The lack of differences between groups in terms of resistance to interference and set shifting in SCWT may reflect task demands, the effects of treatment, partial remission of depressive and full remission of manic symptoms, or a combination of all these factors. The similarity in performance of youth with DMDD and BD in the WCST suggests that task demands may be important and support the role of executive dysfunction and set shifting in both groups. Future studies on neurocognitive functioning among youth with DMDD and BD may employ more ecologically valid tests of executive functioning (Soto et al., 2020) and evaluate the role of symptom status as well as dose of treatments on EF.

SC is important for understanding the self and others and for the formation/maintenance of social relationships (Barnby et al., 2023; Schurz et al., 2021). This is also important in various psychopathologies. Patients with BD may have impaired SC regardless of remission status (Halac et al., 2021), and these impairments were also noted among patients with MDD (Pagnoni et al., 2022). SC in DMDD may also be impaired, although whether this importance is seen among all patients or limited to those with comorbid ADHD or with significant depressive symptoms is still debated (Brænden et al., 2023b; Özyurt et al., 2024). In our study, the DMDD group performed lower than BD, which was similar to controls in RMET and FT, while in FPT, both DMDD and BD groups performed at similarly lower levels compared to controls. This discrepancy may reflect task demands in that both the RMET and FT involve static images of eye regions and faces, which necessitate understanding mental states/emotions and facial emotion displays (Ekman & Friesen, 1976; Greenberg et al., 2023). These tasks may be more demanding for youths with DMDD than for those with BD. On the other hand, performance in the FPT requires advanced levels of mentalizing with working knowledge of social rules (Ekman & Friesen, 1976), and these processes may be equally impaired among youth with DMDD and BD. It is important to note that the SC tests in our study were static and required basic visual and verbal processing of information. Similar to neurocognitive tests, future studies may employ dynamic social stimuli to evaluate SC among youth with DMDD and BD (e.g., Movie for the Assessment of Social Cognition) (Soto et al., 2020; Tsui et al., 2024).

ER is another transdiagnostic construct that may play an important role in psychopathology (Gross, 2015). Specifically, habitual, rigid use of rumination and suppression may lead to psychopathology, whereas cognitive reappraisal may be a more beneficial ER strategy (Gross, 2015). In terms of impaired emotion recognition, ED may be observed in both MDD and BD. Emotion appraisal and regulation may be more impaired in patients with MDD, while emotion perception may be more impaired in patients with BD (Wu et al., 2024). Youths with DMDD may have impaired emotion recognition abilities and hostile attribution bias (Brænden et al., 2023a; Özyurt et al., 2024). Limited awareness of ER strategies/goals, elevated impulsivity, and rumination have been associated with adolescent irritability (Bos, 2024; Brænden et al., 2023a; Elvin et al., 2024; Paulus et al., 2021). Our results are partially in accordance with these views; youth with DMDD and BD were similarly impaired in ER goals, strategies, impulsivity, and non-acceptance compared to the controls. Parents rated youths with DMDD as significantly more irritable than those with BD and controls. In both the DMDD and BD groups, slower information processing speed correlated positively with parent-rated irritability, while the WCST categories correlated negatively with parent-rated irritability and positively with youth-reported impulsivity. This discrepancy may be due to recall and reporting bias inherent in self-report scales, as well as the effects of depressive symptoms in youth that were in partial remission. Parents may be better informants for irritability and angry outbursts, which may be outwardly observable compared to their adolescent offspring, whose internal experiences may still be colored by mood symptoms. Supporting this view, mediation analyses revealed that information-processing speed and total DERS scores had significant, direct, and positive effects on parent-rated irritability. Taken as a whole, our results suggest that adolescent irritability may be a function of reduced processing speed in the context of rapidly evolving, dynamic, and emotionally/socially salient stimuli along with limited awareness or acceptance of the need for ER along with its strategies and goals, and is behaviorally expressed in moments of frustrative non-reward (Barnby et al., 2023; Bora et al., 2024; Guglielmo et al., 2021; Kaiser et al., 2024; Schweizer et al., 2020). EF problems, including reduced set-shifting and increased perseverative responses, further augment this problem. These hypotheses should be evaluated with further studies using dynamic, socially salient, and ecologically valid paradigms (e.g., ecological momentary assessment, interactive aggression paradigm etc.) (Koch et al., 2024; Soto et al., 2020; Tsui et al., 2024).

Lastly, we evaluated whether machine learning with SVM may differentiate the groups. SVM model was trained on 51 jack-knife samples and tests on 12 with an accuracy of 0.92. AUC for BD and controls were 1.0 for both while it was 0.83 for DMDD. Variable importance plot revealed that standardized YMRS, CDRS and SC scores were more important for BD while SC and processing speed were more important for DMDD and controls.

Limitations

Our results should be evaluated within their limitations. First, the results are valid for patients evaluated at the study center within the study time frame and may not be valid for patients evaluated at other study centers and those living in the community. The relatively small sample size, limited variability especially for tests of SC and lack of intellectual assessment with valid psychometric measures may also be listed among limitations. Second, the depressive symptoms of youth with DMDD and BD were only partially remitted, which may have affected our results. Future studies may evaluate neurocognition, SC, and ER in DMDD and BD in syndromic, partially and fully remitted status, and under conditions of recovery to evaluate state- and trait-related changes. Third, more than half of the youth with DMDD and approximately one-third with BD had comorbid diagnoses. Although the groups did not differ significantly in the rate of comorbidity, this may be associated with confounding factors, and future studies should control for the presence of comorbidities. Fourth, all of the patients with DMDD and BD in our study were under treatment, with most receiving atypical antipsychotics and/or mood stabilizers, which may have affected our results. Future studies may calculate the daily dose equivalents of treatments and evaluate the effects of these treatments on EF, SC, and ER. Fifth, both the EF and SC tests in our study employed static stimuli with relatively limited ecological validity, and future studies may employ more ecologically valid tasks for EF and SC, especially focusing on “hot” EFs. Sixth, we depended on youths’ reports on ER problems and parents’ (specifically mothers’) reports on irritability, and future studies may use multi-method, multi-informant designs to reduce bias. Seventh, EF, SC, and ER display complex, dynamic, and multidirectional relationships, which may be better addressed by socially salient, dynamic, and ecologically valid tasks. Future studies may use ecological momentary assessments, dynamic visual stimuli, and interactive aggression paradigms to address this limitation. Lastly, human development is dynamic, nonlinear, and complex, which may limit the generalizability of the results from cross-sectional studies. Accelerated longitudinal designs and analyses of cross-lagged reciprocal effects may be more informative in this regard (Galbraith et al., 2017).

Conclusions

Regardless of its limitations, our study adds to the growing evidence base for DMDD and BD and suggests that youth with DMDD may have more impaired processing speed than those with BD, while EF problems seem to be similar between the two groups. Therefore, dialectical behavioral therapy sessions for youth with DMDD may be modified to address this issue compared to those with BD (Kalvin et al., 2025). In SC tests with relatively basic task demands, such as RMET and FT, DMDD may be more impaired, whereas in FPT, which requires advanced mentalizing and knowledge of social rules, both groups of youth may be similarly impaired. Youths with DMDD and BD seem to have limited knowledge of goals and strategies for ER along with elevated impulsivity and non-acceptance. These results suggest that therapies for irritability in youth with DMDD and BD may include components on mentalizing/social rules, impulsivity and possibly features of acceptance and commitment therapy to improve ER skills (Byrne & Cullen, 2024).

Slower information processing speed and EF problems were correlated with parent-rated irritability in both DMDD and BD in our study. Slower information-processing speed and greater ED have significant direct effects on parent-rated irritability. Future studies may evaluate the effects of interventions addressing processing speed and ER skills on parent rated irritability among youths with DMDD and BD. Also, further studies with larger samples using machine learning algorithms are needed to evaluate the commonalities as well as the distinctions between DMDD, BD and other psychopathologies (Pettersson et al., 2020).

Keypoints

Changes in neurocognitive functions, especially executive functions and reward sensitivity, may be important for the development of mood disorders.

Youths at risk of BPSD were found to display impaired processing speed, executive functions, and sustained attention however, the cognitive profiles of youth with DMDD are less clear.

Emotion dysregulation in BPSD may be especially prominent during mood alterations and in presence of depressive symptoms and may also affect emotion recognition.

Studies on the cognitive profiles of youth with DMDD are limited in number and suggest that these youths may have lower IQ, inhibitory control, and set shifting.

The similarity in performance of youth with DMDD and BPSD in the WCST suggests that task demands may be important and support the role of executive dysfunction and set shifting in both groups.

In social cognition tests with relatively basic task demands, such as Reading the Mind in the Eyes Test and Faces Test, DMDD may be more impaired, whereas in The Faux-Pas Test, which requires advanced mentalizing and knowledge of social rules, both groups of youth may be similarly impaired.

Supplemental Material

Supplemental material - Comparing Neurocognition, Social Cognition and Emotion Regulation in Youth With Disruptive Mood Dysregulation Disorder (DMDD) vs. Bipolar Disorder (BD)

Supplemental material for Comparing Neurocognition, Social Cognition and Emotion Regulation in Youth With Disruptive Mood Dysregulation Disorder (DMDD) vs. Bipolar Disorder (BD) by Gonca Özyurt, Burak Baykara, Ali Evren Tufan, Yusuf Öztürk, İmge Mercanoğlu, Ezgi Karagöz Tanıgör, Sevay Alşen Güney, Aynur Akay, Neslihan İnal, Rasim Somer Diler in Clinical Child Psychology and Psychiatry.

Footnotes

Acknowledgements

We would like to thank Dr. Ellen Leibenluft for her critical reviews and contributions to the study.

ORCID iDs

Gonca Özyurt

Ezgi Karagöz Tanıgör

Ethical Considerations

Author Contributions

GÖ: Conceptualization Data curation Formal analysis Investigation Methodology Resources Supervision Validation Writing – original draft Writing – review & editing. BB: Conceptualization Methodology Supervision Writing – review & editing.AET: Conceptualization Formal analysis Methodology Supervision Writing – original draft Writing – review & editing.YÖ: Formal analysis Methodology Writing – original draft Writing – review & editing. İM: Data curation Methodology Writing – review & editing. EKT: Formal analysis Methodology Writing – original draft Writing – review &editing. SAG: Methodology Supervision Writing – review & editing. AA: Conceptualization Methodology Supervision Writing – review & editing. Nİ: Conceptualization Methodology Supervision Writing – original draft Writing – review& editing. RSD: Methodology Supervision Writing – review & editing

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Declaration of Conflicting Interests

The authors declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Authors are requested to disclose interests that are directly or indirectly related to the work submitted for publication.

Data Availability Statement

The data is not available to public but can be obtained from the corresponding author at a reasonable request. The data from study is not publicly available but can be obtained from the corresponding author at a reasonable request.

Supplemental Material

Supplemental material for this article is available online.

Author Biographies

Gonca Özyurt, Associate Professor of Child and Adolescent Psychiatry at İzmir Katip Çelebi University Medical School, İzmir, Turkey.

Burak Baykara, Professor of Child and Adolescent Psychiatry at Dokuz Eylul University Medical School, İzmir, Turkey.

Ali Evren Tufan, Professor of Child and Adolescent Psychiatry at Abant İzzet Baysal University Medical School, Bolu, Turkey.

Yusuf Öztürk, Associate Professor of Child and Adolescent Psychiatry at Health Sciences University Medical School, Ankara, Turkey.

İmge Mercanoğlu, Psychologist and has completed a Master's degree in Neuroscience in the Health Sciences Institute of Dokuz Eylul University, İzmir, Turkey.

Ezgi Karagöz Tanıgör, Specialist in Child and Adolescent Psychiatry at İzmir Katip Çelebi University Atatürk Education and Research Hospital,İzmir, Turkey.

Sevay Alşen Güney, Professor of Child and Adolescent Psychiatry at Dokuz Eylul University Medical School, İzmir, Turkey.

Aynur Akay, Professor of Child and Adolescent Psychiatry at Dokuz Eylul University Medical School, İzmir, Turkey.

Neslihan İnal, Professor of Child and Adolescent Psychiatry at Dokuz Eylul University Medical School, İzmir, Turkey.

Rasim Somer Diler, Professor of Psychiatry at the Western Psychiatric Institute and Clinic, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA.

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