Disorder in Children and Adolescents: a Caution
(Added 6/2005; updated 9/2007)
Dr. Simon Sobo has written many cautions about the "group think"
which is common in psychiatry. One current trend in psychiatry is to look
closely for bipolar-like conditions in children. He is very concerned about that
trend. At my encouragement, he has prepared the following comments to keep
everyone thinking critically about diagnosis and treatment in children.
great difficulty with your connecting people to that "wonderful"
2005 APA [American
Psychiatric Association -- the big annual psychiatry convention] meetings'
hottest controversy was about bipolar disorder in children. As you know
I am not a great fan of spectrum disorders. They make sense in the
abstract but when put into practice they can lead to extremely loose
criteria for making an unwarranted diagnosis.
I would prefer that people who do not meet criteria for the illness be
labeled as atypical (for now). If
later solid evidence is found to support the inclusion of patients not meeting
the criteria, or if solid reasons are found for redefining the criteria so be
it. But for now I think the group pushing for very loose criteria are out of
let me remind you of the sequence that has led to their descriptions of
bipolar children. There were a
number of huge leaps of faith not justified by any new findings
and Post (1996) described clear-cut bipolar (bipolar I) patients who were
followed on a ward and rated for mood every two hours during the course of a
day. They found a group of five patients(I believe out of 13 patients) who
went up and down throughout the day and wondered whether these represented
"ultra-ultra rapid cycles" or as they called it "ultradian
cycling". Their observation was not all that startling.
Such patients have long been know to exist and were categorized as
having the mixed form of bipolar disorder.
Speculating that their mood lability was ultrarapid cycling was
interesting and cannot be dismissed out of hand.
But that was not what happened. The
concept was embraced by many psychiatrists with very little discussion as
if it were an established fact. This
totally changed what is meant by “mood swings”.
Previously rapid cycling in bipolar disorder meant 4 changes in a year!
Suddenly we were talking about cycling going on many times in a day. And
people were being diagnosed as bipolar on the basis of this kind of mood
lability. How we went from
the observation that some bipolar I patients are labile and are having
extremely rapid cycling (controversial to begin with)
to using these “mood swings” as the basis for
making the diagnosis is completely beyond me.
It is possible but the burden of proof is on those making such claims.
added 9/11/07: Consistent with the above observations, a 40 fold ! increase
has been found nationally by Dr. Moreno from Columbia University (National
Trends in the Outpatient Diagnosis and Treatment of Bipolar Disorder in
Youth). The article is in the Sept 07 issue of Archives of General
Psychiatry, page 1032.
The criteria for bipolar was loosened with bipolar II. Mania was no
longer needed. In my article
on bipolar disorder “Mood
Stabilizers and Mood Swings: In Search of a Definition”
I agree that there are undoubtedly some patients with a gene for
bipolar disorder who have a milder form of the disease.
However, the looser definition of what constitutes the illness has led
to many patients being told they have bipolar II when I believe they don’t,
particularly when the basis of that diagnosis is “mood swings” as outlined
the two together, add moody kids and now you have a new definition of the
disorder and it isn't even being presented as a spectrum disorder.
Add to that “experts” (for a
discussion of “experts” see my “Can Prozac Make You Into a
Murderer?”) from some of
our best universities signing off on the new concept for kids, then
send out pamphlets to doctors, stating that patients are going undiagnosed for
an unacceptably long period of time. Warn
of malpractice if these kids aren't treated with meds and we have the current
situation. That plus spread the word through well meaning sites like the
"wonderful" site you alluded to who still have faith in the experts.
you have it. A new disease born with speculations built upon
speculations upon speculations
you. I am not saying that they must be absolutely wrong. Or that I am
against progress or "new thinking.” Who knows at this point
what percentage of children diagnosed by their very loose criteria will
actually have adult bipolar when they grow up,
thereby confirming they do indeed have a disease that will be with them
for a lifetime. They do not have to be wrong.
the fact that there are no decent longitudinal studies about whether chronic
good treatment affects the long term course of the disease in known
bipolar I disorder patients; and all the questions I raised above
about the basis of their diagnosis should make the burden of proof
fall on those insisting they can identify childhood bipolar disorder and the
children must be treated NOW.
others words supporters of the wildly expanded new definitions of bipolar in
children should do some research before they make proclamations for others.
It is astonishing that this minimum requirement of scientific inquiry is not
only being ignored but allowed even a hint of respectability. Before
they try to intimidate everyone else they should be held to the hot fires of
scientific scrutiny. If they want to do research in these area (over the
several years it will take to establish their position) that is wonderful, but
until then their proclamations should be modest ones, that of inquiring minds
with several hypotheses to clarify, not experts ridiculing everyone else
for "missing" the diagnosis.
Sobo concluded his note about this as follows:
they were challenged at the APA convention so that the issue is not yet
completely out of control, but I don't think the site you are describing as
"excellent" sufficiently addresses the controversy. We are talking
about young children with problems which may not be bipolar disorder. And
drugs with plenty of known side effects. While I appreciate that a well
meaning educational site should not burden patients with uncertainties and
controversies, especially since the idea of the illness is frightening enough, I
am quite concerned that bipolar disorder in children will turn into the
next ADHD, a run-away freight train if ever there was one. Once again for
those interested in a skeptical view of current thinking about ADHD here is
another article "ADHD and Other Sins of our Children" : long
version and book chapter in Rethinking