Most people are familiar with Postsecret, the long time art and social experiment where strangers send anonymous secrets on postcards to a guy named Frank. Today’s Health Advocates Writing Monthly Challenge is to create my own Postsecret here – not anonymous, obviously – and explain why. So, here it goes.
I absolutely believe that Childhood Onset Bipolar Disorder is over diagnosed.
Is that hard to believe? I think in many cases, children diagnosed with Bipolar Disorder are diagnosed as such because there’s nothing else to diagnose them with. That’s why I feel this way. Don’t get me wrong – I do believe that some children do have “classic” Bipolar Disorder. I’ve met them. But there are just as many children that have some type of mood condition that have manic or hypomanic components, severe agitation, anxiety and rage, but aren’t necessarily Bipolar. I’m not alone in feeling this way. The American Psychiatric Association is working on the DSM-V, a new revision of the Diagnostic and Statistical Manual of Psychiatric Disorders right now, and part of the debate in revising it is whether there is another diagnosis that fits children that are currently diagnosed with (or suspected of having) Bipolar Disorder. The proposed new diagnosis is currently called Temper Dysregulation Disorder with Dysphoria, and is described this way:
A. The disorder is characterized by severe recurrent temper outbursts in response to common stressors.
1. The temper outbursts are manifest verbally and/or behaviorally, such as in the form of verbal rages, or physical aggression towards people or property.
2. The reaction is grossly out of proportion in intensity or duration to the situation or provocation.
3. The responses are inconsistent with developmental level.
B. Frequency: The temper outbursts occur, on average, three or more times per week.
C. Mood between temper outbursts:
1. Nearly every day, the mood between temper outbursts is persistently negative (irritable, angry, and/or sad).
2. The negative mood is observable by others (e.g., parents, teachers, peers).
D. Duration: Criteria A-C have been present for at least 12 months. Throughout that time, the person has never been without the symptoms of Criteria A-C for more than 3 months at a time.
E. The temper outbursts and/or negative mood are present in at least two settings (at home, at school, or with peers) and must be severe in at least in one setting.
F. Chronological age is at least 6 years (or equivalent developmental level).
G. The onset is before age 10 years.
H. In the past year, there has never been a distinct period lasting more than one day during which abnormally elevated or expansive mood was present most of the day for most days, and the abnormally elevated or expansive mood was accompanied by the onset, or worsening, of three of the “B” criteria of mania (i.e., grandiosity or inflated self esteem, decreased need for sleep, pressured speech, flight of ideas, distractibility, increase in goal directed activity, or excessive involvement in activities with a high potential for painful consequences; see pp. XX). Abnormally elevated mood should be differentiated from developmentally appropriate mood elevation, such as occurs in the context of a highly positive event or its anticipation.
I. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder (e.g., Major Depressive Disorder, Dysthymic Disorder, Bipolar Disorder) and are not better accounted for by another mental disorder (e.g., Pervasive Developmental Disorder, post-traumatic stress disorder, separation anxiety disorder). (Note: This diagnosis can co-exist with Oppositional Defiant Disorder, ADHD, Conduct Disorder, and Substance Use Disorders.) The symptoms are not due to the direct physiological effects of a drug of abuse, or to a general medical or neurological condition.
Can this condition eventually develop in to, or be a precursor to true Bipolar Disorder? The discussion seems to be, yes. But where this proposed new diagnosis differs from Bipolar Disorder is the complete absence of mania – long-lasting, elevated mood. My completely unqualified opinion is that many children with these symptoms have an underlying and severe anxiety issue, and their anxiety is what causes them to rage uncontrollably. Think about the terrible twos – when typically developing children hit this stage, what is a common reaction to anxiety or frustration? A meltdown. It’s not inconceivable that this same behavioral reaction can persist longer into the child’s development if that anxiety still persists.
On the flip side, there is more and more evidence that the symptoms of adult onset mental health conditions have their roots in childhood, where symptoms first start appearing. Elyn Saks writes about this in her memoir, The Center Cannot Hold
, her memoir of growing up and into a diagnosis of Schizophrenia. So maybe what looks like Temper Dysregulation Disorder in childhood is the precursor to Bipolar Disorder in an adult. Without a childhood disorder to diagnose and then study as the patients such diagnosed grow into adulthood, we won’t know. Without this new diagnosis and the patients to follow in a long-term study, we will never be able to know with scientific definitiveness.