Bipolar Diagnosis Controversy

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

There may now be even more uproar with the potential addition of Disruptive Mood Dysregulation Disorder, DMDD for short, to the new addition of the DSM, DSM-5. I was part of the team who conducted field trials for this new diagnosis and I was initially thinking many of the kids who had a prior diagnosis of bipolar mood disorder would now receive the DMDD label. My experience was very different however. I am not sure if I even diagnosed this once in all the kids I evaluated as part of the field trials. In fact, most kids with mood issues did not meet criteria for bipolar or DMDD. Many of the diagnoses ended up being parent-child relational problem, PTSD, mood disorder NOS, 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 the criteria are written leaves a lot up to subjectivity on the part of the patient, parents, teachers, and doctor. For example, in looking at the criteria for DMDD (see below), it should be obvious that this is a very high bar to clear to actually get this diagnosis. A kid has to have severe recurrent temper outbursts grossly out of proportion in intensity or duration, 3+ times per week, with a mood between outbursts that is persistently angry or irritable occurring most of the day nearly every day.

These symptoms or behaviors have to be present for 12 months and there can be no period of time during that year when the kid has not had the symptoms for 3 or more months. Diagnosis does not apply to kids under 6 or older than 18 but diagnosis must be made before age 10. Finally, the behaviors and symptoms cannot be better accounted for by depression, anxiety or other psychiatric disorders. In all of the kids I have seen practicing psychiatry, I am not sure any of them would meet this strict criteria. And, if they did, the bigger question for me is always how to help the kid and his family.

I do believe diagnosis is crucially important as it guides treatment, however I am very thorough and sensible when it comes to assessment. Furthermore, I feel strongly that what is more important than diagnosis is understanding the reasons for the symptoms and behaviors. If a child showing symptoms that have recently been considered “bipolar” symptoms, but in reality the kid is using drugs, being bullied, reacting to current or being triggered by past trauma, all the mood stabilizing medication in the world is not going to solve the problem or make the kid feel better.

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