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My DSM-5 Report Card - Grading Child Bipolar



Is the new DMD diagnosis an "anything but child bipolar diagnosis"?

by John McManamy


The DSM-5 and child bipolar. Ten years ago, virtually everyone thought you had to be of voting age to qualify for a bipolar diagnosis. Thankfully that has changed. In a blog post on Knowledge is Necessity, I placed recognition of child bipolar at the top of my list of mental health stories over the past decade. The draft DSM-5, unfortunately, is poised to reverse a decade of progress.

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Child Bipolar - Some Background

Back in the 1990s, Joseph Biederman and his colleagues at Harvard separated out a population of troubled kids whose behavior could not be entirely accounted for by ADHD or various conduct disorders. To Dr Biederman, plus investigators at other centers, the behavior looked a lot more like bipolar disorder.

Mood swings proved a key separator from ADHD, with grandiosity a major giveaway, but the manias these kids experienced were rarely euphoric, more like mixed raging states that literally held entire families hostage. Because these kids tended to cycle in and out of these states at least once a day (rather than the one-week minimum) technically they did not meet the DSM criteria for bipolar.

This was not a case of kids merely acting out, nor of bad parenting. Parents reported horror stories of their very young kids wanting to die and impulsively jumping out of moving cars and a lot more.

Although there was no precise agreement among researchers on the fine points of what a child bipolar diagnosis would look like, there was a strong general consensus that the phenomenon of raging kids with out-of-control moods was indeed real and needed to be included in the next DSM.

As awareness grew, so did the rates of kids being diagnosed with bipolar. This resulted in an inevitable backlash, not only among the general public, but among psychiatrists and other professionals. The issue was further complicated by turf wars involving ADHD specialists and child therapists.

In the meantime, the tragic death in 2007 of four-year-old Rebecca Riley on a medications overdose set off a feeding frenzy of hysterical and uninformed commentary. Soon after, it was discovered that Dr Biederman had neglected to disclose his financial ties to Johnson&Johnson, makers of Risperdal, a drug used for treating bipolar. This resulted in yet another feeding frenzy.

The unenviable task for those working on the DSM-5 was to sort out competing scientific claims, rise above petty professional turf issues, pay no attention to the crazy talk inside and outside psychiatry, and arrive at a diagnosis (perhaps more than one) wide enough to identify kids in need but sufficiently narrow to avoid pathologizing normal child behavior.

On with the grading ...

Narrow, Intermediate, and Broad Views

In 2003, Ellen Leibenluft of the NIMH proposed three “phenotypes” of “juvenile mania.” The “narrow phenotype” would strictly adhere to adult criteria. Two “intermediate phenotypes” would lower the criteria (to shorter episodes featuring tantrums and rages), while the “broad phenotype” would recognize a raging and aroused population without classic mood episodes.

As long as “narrow” and “intermediate” accompanied “broad,” these classifications showed promise. Unfortunately, the draft DSM-5 picked just one. Think of “The One Musketeer” or an eskimo with just one word for snow.

Grade: F-minus.

Pediatric (or Early Onset) Bipolar Disorder

Despite the claims of naysayers, the case for DSM pediatric bipolar is well-established. Dr Leibenluft’s “narrow” view (with identical pediatric and adult versions) would work, provided that first the criteria for the adult version is slightly widened. (This would account for clinical realities occurring within the adult population, as well.)

The draft DSM-5 for adult bipolar is arguably half-way there with a widened view of mixed states, but appears incapable of making a decision concerning extreme rapid-cycling.

An “intermediate” view would acknowledge that kids may present somewhat differently than adults, but that their behavior can nonetheless be attributed to bipolar. The tip-off is episodic states. The pediatric version would stress the mixed state rages and extreme rapid cycling.

The DSM need not include both views (though it would be helpful), provided one of them employs a name that acknowledges both the illness and the population it preys upon. Thus: “Pediatric Bipolar Disorder,” “Child and Adolescent Bipolar Disorder,” “Juvenile Bipolar Disorder,” or “Early Onset Bipolar Disorder.”

In a pinch, something like “early onset” could be employed as a specifier under the standard bipolar diagnosis. The point is the DSM-5 needs to send a clear signal to clinicians and the general public that bipolar in kids is very real.

Suffice to say, the draft DSM-5 chose not to send that signal. Why are we not surprised?

Grade: No grade. This is unforgivable.

DMD - Credibility

In light of the failure of the draft DSM-5 to include a diagnosis along the lines of pediatric bipolar, everything else its two relevant workgroups may come up with is highly suspect. This is unfortunate, as the new diagnosis of “disruptive mood dysregulation disorder” (DMD) deserves a fair hearing. But in the present context, DMD comes across as “anything but bipolar.”

Grade: F-minus.

DMD, Scare Tactics

The DSM-5 Child and Adolescent Disorders Workgroup (which collaborated with the Mood Disorders Workgroup) served up a background paper detailing its reasons for this new diagnosis. The first paragraph cites a study that “found a 40-fold increase between 1994 and 2003 in the number of outpatient pediatric psychiatry visits associated with the diagnosis of BD.”

But, when starting from a baseline of zero, any increase cited in percentages is highly suspect. A 2007 study found that youth released from the hospital with a primary diagnosis of bipolar amounted to less than one in a thousand.

True, misdiagnosis and overdiagnosis is always a danger. But clinicians finally waking up to reality can be regarded as a cautiously encouraging sign. Meanwhile, arguments employing selective science in pursuit of an agenda are best suited to talk radio.

Grade: F-minus.

DMD - Justification

An earlier version of DMD was "temper dysregulation disorder with dysthymia" and before that “severe mood dysregulation” (SMD), a term coined by Dr Leibenluft to define her “broad phenotype.” These are kids who experience down moods and rage in a manner similar to those with bipolar, but not in episodes. This may be the tip-off that TDD is a separate phenomenon entirely from child bipolar, or, if related, nonetheless needs to be separated out.

The background paper cited an NIMH study which found that, unlike kids with narrow bipolar symptoms, minors with SMD failed to develop classic mania/hypomanic episodes when followed over time. Less reliable data suggest that kids with SMD are more likely to be at risk for unipolar than bipolar as young adults.

What’s missing from the analysis is the fact that the current DSM does not recognize a wide variety of depressions and hypomanias as part of bipolar (namely mixed states and very rapid cycling). So SMD kids may very well experience mania/hypomania episodes and grow into adults whose moods more resemble bipolar than unipolar.

Again, SMD/TDD/DMD may be valid (the background paper also cited preliminary brain scan studies), but when the yardstick is crooked so are any measures and conclusions based on those measures.

In any other context, the inclusion of an entirely new diagnosis based on the best knowledge we have at the time may have been justified. But not when the Mood Disorders Workgroup deliberately and obstinately shunned the “best knowledge” criterion for all the rest of mood disorders, even when clinical reality screamed for such changes.

Another way of putting it: Extreme double standards are in force here.

Grade: F-minus.

DMD - A Catch-all Diagnosis?

At least the term bipolar was sufficiently frightening to make clinicians think twice before diagnosing kids. But a diagnosis that comes across as a euphemism? And one sufficiently broad to embrace normal kids going through bad phases?

Yes, the background paper cautions that kids with DMD are as bad off as those with bipolar, but who (besides me) reads background papers?

What is going on here? Has the draft DSM-5 come up with a new diagnosis to make it safe for clinicians to diagnose problem kids with bipolar without calling it bipolar? In which case, we may find overdiagnosis in abundance, along with inappropriate treatments.

We wouldn’t be asking these questions if those working on the draft DSM-5 possessed the common sense to issue a clear and unambiguous “pediatric bipolar” diagnosis. Then there would have been an acceptable context for DMD. This would have accorded with the original intention of Dr Leibenluft when she came up with SMD as one of three child bipolar phenotypes.

Leave it to the DSM-5 people to mess it up entirely.

Grade: F-minus.

Child Bipolar, Summing Up

Coming up with criteria for child bipolar was supposed to be a collaborative effort between two of the DSM-5’s workgroups. Judging by how the Mood Disorders Workgroup passed on all but one opportunity to make substantial changes to the rest of mood disorders, it is fairly apparent that they caved into the demands of the Child and Adolescent Workgroup.

No recognition of some form of child bipolar at all? No attempt to provide the necessary context for a new DMD diagnosis? Clearly, the child psych people, with an agenda of their own, ran roughshod over the mood disorders people, a fight that never should have been allowed to break out.

The result is an unmitigated disaster, one that shames psychiatry and performs a considerable disservice to the public, whose interest is supposed to come first.

Published as a blogs April 2010, reworked into an article Jan 3, 2011.

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