5 April 10, 2011 DSM-V, HAWMC

HAWMC – Day Ten: My Postsecret

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.  


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  • lynn April 11, 2011 at 2:11 am

    I read "The Center Cannot Hold", it was an amazing book.This is interesting information about bi-polar. It makes a lot of sense.

  • TwisterB April 11, 2011 at 5:19 pm

    There are a lot of people out there who hate the institution of psychiatry on principle. I wouldn't call them completely wrong on all fronts, but what they often fail to take into consideration is how psychiatry is very much a work in progress. The idea of psychology was really only discovered in the late 19th century, and psychiatric medications (such as they were) weren't created until the late 50s.

    So yeah, psychiatrists used to lobotomize people, they still give people potentially lethal or brain damaging drugs, and yes, they are often prescribed based on vague guidelines of diseases we barely understand at all.

    BUT surgery used to kill you 100% of the time. Doctors used to think some pretty abstract stuff about the human body that we know now to be completely untrue. Chemotherapy is a poison that can do incredible damage to your body, statistically doesn't work very well, and when it DOES work can actually CAUSE cancer later on in life.

    I believe mental healthcare will (much more slowly) follow the path of regular medicine. When a person got cancer, they used to think it was evil spirits, then they knew it was cancer but when they tried cutting it out they would kill the patient, they try poison and hope it goes away…but they are also developing new cutting edge cancer treatments which could someday greatly reduce cancer related death.

    Such is psychiatry.

  • Chrisa April 11, 2011 at 5:20 pm

    B – you are spot on, IMHO. We violently agree.

  • lynn April 11, 2011 at 7:03 pm

    That was a very good post. And a very good view point.

  • Adrienne April 15, 2011 at 7:11 pm

    I agree. Absolutely. And I think Carter is in that group.

    Does he have bipolar disorder? I don't know. I think it's reasonably likely, and it's plenty clear that he has significant mental health issues of some kind. But I consider his official diagnosis – bipolar with psychotic features – to be something that's helpful in getting the insurance to pay for treatment more than an accurate description of Carter's illness. A mental health diagnosis for a pre-adolescent child is provisional, at best (excepting a very few extremely obvious cases).

    At 8, Carter is just too young for an accurate diagnosis. Psychiatric diagnosing isn't an exact science even in adults, but in children, it's even more difficult.

    Before Carter had his first psychotic symptoms, I would fantasize that he would grow up and have his diagnoses "downgraded" to acute anxiety disorder and depression. Since delusions and hallucinations started showing up at the party, I've had to learn to stop fantasizing and just deal with what's in front of me and let questions about future diagnoses stay in the future (bipolar? schizophrenia? schizoaffective disorder? very crabby person who was parented by really lousy people? (kidding, mostly)).

    Too bad insurance companies can't do that. Too bad they won't pay based on a psychiatrist saying, "This kid has some serious issues that require a multi-faceted treatment approach. We'll work on a diagnosis after puberty." It would be better for all of us – parents, kids, the medical system and a culture that's so busy putting people in diagnostic boxes that we don't have enough time to really listen to people who are suffering. I don't need Carter to have a diagnosis as much as I need people and programs to help him create the best possible life for himself.

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