Mark Twain observed that "the past may not repeat itself, but it sure does rhyme." An unfortunate rhyme in psychiatric history is the recurrence of fad diagnoses. Childhood Bipolar Disorder is the most dangerous current bubble, with a remarkable forty-fold inflation in just one decade.
Painful experience has taught me a lot about diagnostic fads. As Chair of the DSM-IV Task Force (which prepared the official manual of psychiatric diagnosis), I bear partial responsibility for 2 other false "epidemics"--of attention deficit and autistic disorders. But the childhood bipolar fad did not arise from anything we wrote into DSM-IV.
Instead, it started because clinicians ignored the DSM-IV definition in favor of a new and largely untested idea that Bipolar Disorder presents very differently in children. Most kids who now get the diagnosis have non-episodic temper outbursts and irritability--not the classic mood swings between mania and depression. The boundaries of childhood Bipolar Disorder have pushed far into unfamiliar territory, to label kids who previously received other diagnoses (eg, Attention Deficit, Conduct, Oppositional, or Anxiety Disorder) or no diagnosis at all ("temperamental" but normal kids).
When I began psychiatric training 40 years ago, we were not taught anything about childhood Bipolar Disorder. There was no point--it was so rare that no one had seen any cases. I once evaluated a 9-year-old boy whose symptoms seemed vaguely bipolar, but my supervisor told me to stop searching for the exotic. In the old days, we were undoubtedly missing many cases and withholding helpful treatment. But the pendulum has now swung wildly in the other direction.
To become a fad, a psychiatric diagnosis requires 3 preconditions: a pressing need, an engaging story, and influential prophets. The pressing need arises from the fact that disturbed and disturbing kids are very often encountered in clinical, school, and correctional settings. They suffer and cause suffering to those around them--making themselves noticeable to families, doctors, and teachers. Everyone feels enormous pressure to do something. Previous diagnoses (especially conduct or oppositional disorder) provided little hope and no call to action. In contrast, a diagnosis of childhood Bipolar Disorder creates a justification for medication and for expanded school services. The medications have broad and nonspecific effects that are often helpful in reducing anger, even if the diagnosis is inaccurate.
The "epidemic" of childhood Bipolar Disorder fed off the engaging storyline that it:
1. Is extremely common
2. Was previously greatly under-diagnosed
3, Presents differently in children because of developmental factors
4. Can explain the variety of childhood emotional dysregulation
5. Has diverse presenting symptoms (eg, irritability, anger, agitation, aggression, distractibility, hyperactivity, and conduct problems)
The prophets were "thought leading" researchers who encouraged child psychiatrists to ignore the standard bipolar criteria and instead to make the diagnosis in a free-form, over-inclusive way. Then enter the pharmaceutical industry-- not very good at discovering new drugs, but extremely adept at finding new markets for existing ones. The expanded reach of childhood Bipolar Disorder created an inviting target. The bandwagon was further advanced by advocacy groups, the media, the internet, and numerous books aimed at suffering parents.
The massive over-diagnosis of childhood bipolar disorder comes with large costs. Inappropriately diagnosed children are often treated with medications that are unnecessary and potentially quite harmful (especially those that cause rapid and substantial weight gain, increasing the risk of diabetes, and possibly reducing life span). Other more specific causes of irritability may be missed. For example, Attention Deficit Disorder often presents with an irritability that responds best to stimulants, but these may be withheld in the face of an incorrect bipolar diagnosis. Substance abuse should always be the first thought for irritable teenagers.
The label Bipolar Disorder also carries considerable stigma, implying that the child will have a lifelong illness requiring lifetime treatment. Many causes of temper outbursts are much shorter lived and amenable to time-limited treatment. The diagnosis can distort a person’s life narrative, cutting off hopes of otherwise achievable ambitions. People worry about getting married, having children, or taking on stressful ambitions, jobs, or work challenges. It may become more difficult to get insurance. An incorrect diagnosis of bipolar disorder may reduce one's sense of personal responsibility for, and control over, undesirable behavior. People sometimes use the diagnosis as an excuse for interpersonal or legal problems.
The editors of the recently posted first draft of DSM5 should be commended for recognizing that Bipolar Disorder is being diagnosed much too frequently in children. Their proposed solution is well intentioned, but inadequate, and would create its own set of serious problems. They propose a new diagnosis-- "Temper Dysregulation Disorder with Dysphoria"-- to create a less harmful home for explosive kids now mislabeled as having childhood Bipolar Disorder.
Temper Dysregulation is itself too risky to be included in DSM5 because, once in general use, it would undoubtedly be misapplied to many kids with normal temper tantrums--who don't require any diagnosis and should be kept away from potentially harmful medications. It would also blur the boundaries with all of the other causes of temper outbursts. A far better solution for DSM5 would be to add a specifier, "With Explosive Outbursts” whenever this is a prominent part of the presentation of all of the many possible differential diagnoses (eg, Major Depressive, Bipolar, Attention Deficit, Substance, Conduct, Oppositional, Post traumatic Stress, Schizophrenic, Autistic, and Borderline Personality Disorders). This would make the point that temper outbursts are (like fever) nonspecific symptoms of many disorders, not a specific and separate disease.
The “epidemic” of childhood Bipolar Disorder has created a public health dilemma. Based on much hype and very little scientific evidence, a huge and heterogeneous cohort of explosive kids has received powerful treatments that can sometimes do much good, but sometimes do much harm. How do we tame the fad? Merely rewriting DSM5 cannot cure what has become the deeply ingrained habit of over-diagnosing and over-treating childhood Bipolar Disorder
I suggest that the National Institute of Mental Health is best positioned to restore order. It should convene a consensus conference to:
o Determine the current best practice for diagnosing and treating childhood irritability and temper problems
o Reeducate the public and professionals to the risks of this false “epidemic”
o Plan the next steps in a badly needed research program.