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Bipolar diagnosis controversy
A recent article in The Boston Globe (see below) highlights the controversy surrounding the explosion of bipolar diagnoses among children and adolescents. In my own experience, I have seen very few patients who actually meet the traditional criteria for bipolar disorder. And I am even more cautious about diagnosing bipolar affective disorder in children and adolescents. Some of the characteristic symptoms of bipolar disorder, including impulsivity, grandiosity, rapid cycler mood swings, risk-taking, and hypersexuality, to name a few, are quite normative in developing adolescents. There could be even more turmoil now with the possible...
Bipolar diagnosis controversy
A recent article in The Boston Globe (see below) highlights the controversy surrounding the explosion of bipolar diagnoses among children and adolescents. In my own experience, I have seen very few patients who actually meet the traditional criteria for bipolar disorder. And I am even more cautious about diagnosing bipolar affective disorder in children and adolescents. Some of the characteristic symptoms of bipolar disorder, including impulsivity, grandiosity, rapid cycler mood swings, risk-taking, and hypersexuality, to name a few, are quite normative in developing adolescents.
There may be even more turmoil now with the possible addition of Disruptive Mood Dysregulation Disorder, or DMDD, to the DSM's new addition, DSM-5. I was part of the team conducting field trials for this new diagnosis, and I initially thought that many of the children who had previously been diagnosed with bipolar affective disorder would now receive the DMDD label. However, my experience was very different. I'm not sure I even diagnosed this in all of the children I examined in the field trials. In fact, most children with mood problems did not meet criteria for bipolar or DMDD. Many of the diagnoses were parent-child relationship problems, PTSD, mood disorders NOS, subsyndromal mood disorders, anxiety disorders, etc.
One thing that is overlooked when recording psychiatric diagnoses is how strict the diagnostic criteria really are, and that the way the criteria are written leaves much to subjectivity on the part of the patient, parent, teacher, and clinician. For example, looking at the criteria for DMDD (see below), it should be obvious that this is a very high bar to clear in order to actually get this diagnosis. A child must have severe recurrent outbursts of anger more than 3 times per week, completely disproportionate in intensity or duration, with a mood between outbursts that is persistently angry or irritable, occurring almost every day for most of the day.
These symptoms or behaviors must be present for 12 months, and there cannot be a period during that year when the child did not have the symptoms for 3 or more months. The diagnosis does not apply to children under 6 or over 18, but the diagnosis must be made before the age of 10. Finally, the behaviors and symptoms cannot be better explained by depression, anxiety, or other psychiatric disorders. I'm not sure all the children I saw practicing in psychiatry would meet these strict criteria. And if so, the bigger question for me is always how I can help the child and his family.
I believe that diagnosis is crucial as it guides treatment, but I am very thorough and sensible when it comes to assessment. Additionally, I strongly believe that understanding the reasons for symptoms and behavior is more important than the diagnosis. If a child is exhibiting symptoms that were recently thought to be "bipolar" symptoms, but in reality the child is using drugs, being bullied, reacting to electricity, or triggered by a past trauma, all the mood stabilizing medications in the world will not solve the problem, resolve the problem, or make the child feel better.
http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=397
Inspired by Asa Marokus