The publication of the DSM-5, due out in May, has presented an excuse for us to cast a critical eye on how the experts choose to define our illness (see eg Duration Criteria). With the one exception of widening the criteria for mixed episodes, DSM-5 bipolar will look very much like the current DSM-IV bipolar.
The situation for early-onset bipolar, however, is a lot different. Let’s take a look:
The DSM-IV came out in 1994. At the time, there was virtually no literature on early-onset bipolar. That began to change a year or two later when various academic researchers - most notably Joseph Biederman of Harvard - began questioning whether ADD/ADHD or various forms of conduct disorder fully explained the behavior of a substantial number of the very young kids they were seeing in their clinics.
What Biederman and others investigated was extremely complex, but they did come up with a number of distinguishing features that everyone could more or less agree on, namely: grandiosity (high in bipolar kids, low in ADHD kids), sustained rages (as opposed to explosive and other behaviors in kids with conduct disorders), plus evidence of cycling (typically from one extreme to another over the course of a day, with accompanying disturbances in sleep).
What separated the presentation of child bipolar from adult bipolar was these kids cycled a lot more rapidly than adults.
At around the same time, parents were sharing their stories. To those who contend that child bipolar is some kind of Pharma plot to keep kids on meds for life, it pays to keep in mind that the major impetus for getting the word out came from parents. In 1999, Papolos and Papolos gave these parents a voice in the publication of their surprise best-seller, The Bipolar Child.
It is very important to note that the Papolos’ and Biederman and others weren’t distinguishing between bipolar and normal. These were kids in extreme distress. Listen to the parents and you will hear stories of their kids jumping out of moving cars, engaging in suicidal behavior, and holding their families hostage. At the 2001 International Conference on Bipolar Disorder, I heard Barbara Geller of the University of Washington (St Louis) tell her audience: "A seven-year-old manic child is sicker than a 20-year-old manic adult."
The question, then, isn’t whether one should treat these kids or not, but how one should treat them.
There is a major catch to this. If bipolar meds worked as well for bipolar kids as ADD meds for ADD kids, the inevitable controversies about putting kids on meds would probably be manageable. Putting a young child on an antipsychotic, however, comes across as a crime against humanity. Severely clouding the issue were back-to-back stories, in 2007 and 2008, of the death of a four-year-old (the parents were convicted of murder) and of Biederman not disclosing to Harvard his ties to Johnson&Johnson (makers of Risperdal).
But to do nothing? To not help these kids? Do you see a major dilemma, here?
The picture grows more complicated. Over at the NIMH, Ellen Leibenluft was looking at a different population of kids that she classified as having “severe mood dysregulation disorder.” To vastly oversimplify, Leibenluft was assigning a new disease to kids on the softer end of the mood spectrum, kids whose behavior might be considered close to normal on one end and close to bipolar on the other. But how do you tell them all apart?
Alas, the DSM-5 drops the ball. Although there will be a new diagnosis for severe mood dysregulation disorder (which will now be called “disruptive mood dysregulation disorder”), there will not be a new diagnosis for “early onset bipolar disorder.”
What is going on? Who knows?
More to come ...
Published On: March 02, 2013
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