Childhood Bipolar Boom: More Cases or Misdiagnoses?

Dr. Avram H. Mack, a child and adolescent psychiatrist in Washington, D.C., wonders if an explosion in childhood bipolar disorder reflects a true increase in the condition, or the inappropriate labeling of some youngsters that potentially could hold them back the rest of their lives.

"I often encounter kids who have been called bipolar where I suspect that bipolar is not the accurate diagnosis," said Mack, an associate professor of psychiatry at Georgetown University School of Medicine.

Bipolar disorder, sometimes called manic depressive illness, is classically characterized by mood swings between depression and mania, and notoriously tricky to diagnose in children. That's partly because symptoms frequently overlap with those of such disorders as ADHD, anxiety, depression, obsessive compulsive disorder (OCD), and oppositional defiant disorder (ODD).

Children tend to have more angry outbursts or tantrums than adults, and those episodes of poorly controlled behavior have led to a school of thought that irritability and tantrums are key components of bipolar disorder in children and teens. Diagnoses in children began to take off in the late 1990s.

Although there have been scant studies quantifying the increase in diagnoses, a 2007 study in the Archives of General Psychiatry led by Columbia University researchers found a 40-fold rise in office visits among youth diagnosed with bipolar disorder between 1994-95 and 2002-3. The estimated annual number of office visits for people 19 and below skyrocketed from 25 per 100,000 to 1,003 per 100,000 during the period.

Telling children and teens that they suffer from bipolar disorder – especially if that's not firmly established -- can lessen their self-esteem, expose them to side effects of powerful antipsychotic and mood-altering drugs and land them in special education classes or even a residential setting "that may do more harm than good," Mack said. Some say some of these children might be better served with a proposed diagnosis of "disruptive mood dysregulation disorder."

"Bipolar disorder is real, and I have seen it among toddlers," said Mack. "The number of youth diagnosed with bipolar clearly has risen, but should "bipolar" have been diagnosed in all of those additional cases? Many psychiatrists feel the answer is 'no.'"

"I'm not denying there is bipolar disorder, and there are some whose severe temper tantrums and outbursts are deserving of care," he said. Mack said the key question is what you call those outbursts, "because what we call it influences how we treat it and the patient's expectations for the future."

Many psychiatrists aren't yet ready to embrace DMDD, although the condition, which is more likely to be limited in duration than bipolar disorder--a lifetime affliction--could reduce a patient's sense of being disabled and increase "their hope for the future."

Mack's caution reflects some of the concerns currently being aired as the American Psychiatric Association continues reviewing criteria for diagnoses to be included in the upcoming revision of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) due out in May 2013. That book, often referred to as the Bible of psychiatry, defines mental health disorders for diagnosis, treatment and research. Its diagnostic codes are the basis of health insurance reimbursements for treatment.

The proposed new diagnosis of "disruptive mood dysregulation disorder" follows studies led by Dr. Ellen Leibenluft, at the National Institute of Mental Health in which she and colleagues have made physiologic distinctions between youngsters with strictly defined bipolar disorder and those with what they call "severe mood dysregulation" (a term that isn't yet officially part of the manual). Her work has found, for example, that few youngsters diagnosed with severe mood dysregulation subsequently are diagnosed with bipolar disorder.

No Data Yet For So-Called Disruptive Mood Dysregulation Disorder

Although some people say that giving a youngster a diagnosis of "disruptive mood dysregulation disorder" might be less stigmatizing than bipolar disorder, Mack said there's no data yet to show if that might be the case.

"It is unknown what would be the medical or social effect of a new diagnosis like DMDD," he said. "It certainly needs to be vetted as to its utility in psychiatry's classification of disorders. We don't want to miss kids who have true bipolar disorder, and we don't want to ignore kids with severe mood problems… We just want to know what is the right diagnosis."

Revising the DSM is a years-long project that includes comment periods and intermediate changes in proposed diagnostic criteria for psychiatric disorders. APA announced earlier this month that results of field trials at 11 medical centers for two proposed diagnoses, "attenuated psychosis syndrome," which was meant to identify people at risk of psychosis, and "mixed anxiety depression disorder," which combines anxiety and depression, weren't reliable enough to put them into broader use. As a result, they will be included in a special section of the manual for conditions requiring further research before APA determines whether they should be recognized as formal disorders.

Among other conditions to be further studied are "Internet use disorder," "caffeine use disorder," and "hypersexual disorder."

The committee also recently changed some language within criteria for major depressive disorder to acknowledge that sadness, insomnia and other symptoms while grieving a significant personal loss don't in themselves constitute a mental disorder.

Field trials at pediatric medical centers demonstrated that the proposed disruptive mood dysregulation disorder diagnosis worked in clinical settings, APA said. Similarly, field trials with 322 youngsters support a controversial proposal to narrow the definition of autism spectrum disorder and excluded very few children who meet the current definition. Critics and parents, however, fear that the new definition, which eliminates Asperger's syndrome and "pervasive developmental disorder" as related conditions, would shrink the number of children eligible for medical, social and school-based services for autism spectrum disorders.

The process of revising the manual for the first time since the DSM-4 came out in 1994 "is about compromise," said Dr. Liza Gold, a clinical and forensic psychiatrist in Arlington, Va. "The question is: how do you do science by consensus?"