Bipolar diagnosis controversy

A recent article in The Boston Globe (see below) highlights the controversy surrounding the explosion of bipolar diagnoses in children and adolescents. In my own experience, I have only seen very few patients who actually meet the traditional criteria for bipolar disorder. And in children and adolescents, I am even more cautious in diagnosing bipolar mood disorder. Some of the hallmark symptoms of bipolar disorder, such as impulsiveness, grandiosity, mood fluctuations in so-called rapid cyclers, risk-taking, and hypersexuality, to name a few, are quite normative in adolescent development.

Now there may be even more buzz about the possible addition of disruptive mood dysregulation disorder, DMDD for short, to the new DSM addition, DSM-5. I was part of the team that field-tested this new diagnosis and initially thought that many of the children who had a previous diagnosis of Bipolar Mood Disorder would now be labeled DMDD. However, my experience was very different. I am not sure that I have diagnosed this once in all the children I evaluated as part of the field trials. In fact, most of the children with mood problems did not meet the criteria for bipolarity or DMDD. Many of the diagnoses ended up being parent-child relationship problems, PTSD, NOS mood disorder, subsyndromal mood disorder, anxiety disorders, etc.

One thing that gets overlooked in the coverage of psychiatric diagnoses is how strict the diagnostic criteria really are and the reality that the way criteria are written leaves much to subjectivity on the part of the patient, parents, teachers and the doctor. For example, looking at the criteria for DMDD (see below), it should be obvious that this is a very high bar to cross to get this diagnosis. A child must have recurrent and severe outbursts of anger disproportionate in intensity or duration, more than 3 times per week, with persistently angry or irritable mood between outbursts most of the day, nearly every day.

These symptoms or behaviors must be present for 12 months and there cannot be a period of time during that year in which the child has not had the symptoms for 3 or more months. The diagnosis does not apply to children younger than 6 years or older than 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. Of all the children I have seen practicing psychiatry, I am not sure that any of them meet this strict criteria. And if they did, the biggest question for me is always how to help her child and her family.

I believe that diagnosis is vitally important as it guides treatment, however, I am very thorough and sensitive when it comes to evaluation. Also, I strongly believe that what is more important than diagnosis is understanding the reasons for symptoms and behaviors. If a child is displaying symptoms that have recently been considered “bipolar” symptoms, but in reality the child is using drugs, being bullied, reacting to current or being triggered by past trauma, all the mood-stabilizing medications in the world are not they will solve the problem or make the child feel better.

http://www.bostonglobe.com/metro/2012/05/09/proposed-new-diagnosis-for-bipolar-disorder-children-divides-psychiatrists/An4RHSU5uVZ6l6AiyTy9eP/story.html?camp=pm

http://www.dsm5.org/proposedrevisions/pages/proposedrevision.aspx?rid=397