Manuel Mota-castillo, MD

A few years ago, the eminent professor of psychiatry, Dr Ronald Pies, wrote a commentary for 

 titled, “Are We Misreading the Signs in Psychiatry?”

 In that article, Dr Pies discussed the need for the comprehensive evaluation of patients in order to arrive at the correct diagnosis. We want to take from his premise that this concept should be expanded to include that among patients presenting with substance abuse as a primary diagnosis, other co-existing Axis I diagnoses should be considered. 

The recent passing of the famous British singer Amy Winehouse highlights once again the question: Is substance abuse a form of self-medication in some of the most well-known cases of public self-destruction? A 

 reads:“Amy Winehouse Died from Alcohol Withdrawal, Says Family.” Several London newspapers previously speculated about a heroin overdose. Whatever the cause of death, the demise of Amy Winehouse again sparks the debate about public figures who die from “yet another addiction,” leaving open the possibility that other co-existing Axis I diagnoses are being ignored and untreated.

As psychiatrists, we are well aware of the co-morbidity of substance abuse with major mental illness. Long before Mickey Mantle declared that he always needed several shots of liquor to face the press (social anxiety?), we have been aware that Vincent Van Gogh, Charles Dickens, Lord Byron, Salvador Dali, Sylvia Plath, and many other famous artists have struggled with mental illness and co-existing substance abuse disorders.

We have also seen the other side of the coin, for example, when clear cut alcohol or opiate abusers present with racing thoughts and irritable mood upon interrupting the abuse of their substance of choice and a diagnosis of bipolar disorder is made, only to discover later that such presentation was part of the withdrawal syndrome.

We venture to speculate that we, as psychiatrists, are not the ones misreading the signs, but that it is the media who miss the signs and misinform the public. It is our responsibility as psychiatrists to educate the media and the public in general about the danger of oversimplification and of the possibility that behind egregious and self-destructive substance abuse, there is often a co-existing psychiatric diagnosis.

1. Pies R. Are we misreading the signs in psychiatry? 

 2006;23(2):15-16.
2. Nudd T. Amy Winehouse died from alcohol withdrawal, says family. 

 Available at: http://www.people.com/people/article/0,,20513558,00.html. Accessed August 15, 2011.

Articles

It is our responsibility as psychiatrists to educate the media and the public in general.

Are the Media and the Public Still Missing the Clues?

This commentary arises from my concern about the superficiality that characterizes the process of diagnosing attention-deficit/hyperactivity disorder (ADHD) in children-usually followed by the prescription of one of the most powerful drugs on earth, methylphenidate. The years pass and I see an even more frightening picture-one in which disorders in children are often given inaccurate and punitive psychiatric diagnoses and treated with inappropriate medication. And yet, the 2 organizations that represent the majority of American psychiatrists, the American Psychiatric Association (APA) and the American Academy of Child and Adolescent Psychiatry (AACAP) show no sign of worry, despite the terrible consequences that often follow when a disorder is incorrectly diagnosed and treated in emotionally disturbed young people.

Consider the case of María (not her real name), a Hispanic teenager I have been treating for several years. In 2003, María and her mother came to me because the girl had been experiencing hallucinations, racing thoughts, insomnia, elevated mood, and grandiose ideation. She had been taking mixed amphetamine salts prescribed by another psychiatrist who had diagnosed ADHD. No doubt, the psychiatrist had based this diagnosis on features such as increased energy and arousal as well as disruptive behavior and distractibility in the classroom. But the patient's symptoms and family history made me suspicious of a psychotic or affective disorder, especially in light of what María's mother told me: "María is acting exactly like her father, and you know that I have a bad temper and my mother is schizophrenic."

I decided to discontinue the mixed amphetamine salts and started giving María quetiapine. Unfortunately, the psychotic process that had been under way for some time could not simply be stopped in its tracks. A week later, the girl's mother called me in desperation because María had just run into oncoming traffic, apparently in response to the ongoing command auditory hallucinations she was experiencing. I advised her mother to take her to the hospital immediately and talked with the doctor on call to discuss my impression that María's symptoms were a common side effect of amphetamines when they are prescribed to individuals with bipolar spectrum disorders.

Despite the obvious red flags for a serious mental illness,

 María was hospitalized with a primary diagnosis of oppositional defiant disorder (ODD)

 and ADHD as a secondary diagnosis. In her mental status examination report, the admitting psychiatrist quoted the girl as saying that she was "hearing voices." Yet this doctor wrote, "I am not clear if the patient is really psychotic, or [whether] she is just trying to get what she wants and using the symptoms to her advantage."

In a discharge summary, the physician noted ADHD as the final diagnosis but sent the girl home on a regimen of 200 mg of quetiapine at bedtime. I suspect this doctor was deferring to my judgment while maintaining his belief that ADHD was the correct diagnosis.

This sort of disposition is all too familiar to me in my practice, which raises the following question: how can competent and caring psychiatrists miss the diagnostic target when assessing patients like María? There may be a few important contributing factors:

Failure to obtain a complete family history. 

Family history was reported as "negative" by both the inpatient psychiatrist and the outpatient psychiatrist who had preceded me. In reality, the family history was strongly positive, based on my evaluation and treatment of several of the patient's relatives. Specifically, bipolar disorder had been diagnosed in the patient's parents, sister, and maternal cousin; her maternal grandmother had schizophrenia; the paternal grandfather had a history of extreme violence; and her maternal uncle had a history of depression.

The other doctors involved in María's care did not speak Spanish, and the patient's mother does not speak English. This sort of communication barrier is known to create diagnostic confusion and may interfere with culturally competent treatment.

Failure to communicate with clinicians who know the patient well.

 Neither the clinician who performed the initial intake nor the evaluating psychiatrist on call that weekend called to speak with me.

Misconstruing behaviors as causative explanations.

 "Hyperactivity," "oppositional behavior," and "defiance" may be seen in a variety of neuropsychiatric disorders. This does not mean that we should ignore better-defined disorders such as bipolar disorder and reflexively diagnose ADHD or ODD.

María's case illustrates not only the trend toward overdiagnosing ADHD but also the dangers inherent in 

 Both diagnoses may open the door to blaming the victim for behavior that he or she cannot control and denying medical services to patients in desperate need of psychiatric services.

To dissipate any doubt as to how much confusion the ODD diagnosis has brought to the mental health community, suffice it to say that in a note written by the social worker who held a family session with María and her mother, this professional implied that there was a secondary gain in the girl's auditory hallucinations and display of anger, that is, to manipulate her mother. The social worker also noted that the treating psychiatrist labeled María's symptoms as "behavioral" and, therefore, not suitable for inpatient treatment.

Obviously, 2 experienced professionals forgot that behavior is determined by the patient's psychological functioning (mood, needs, and dynamics).

 The patient's supposed manipulation of her mother, in my judgment, was an expression of her anger and represented a sign of mental illness-not a conscious decision to be bad just for the fun of it. Indeed, the whole concept of the manipulative patient has been carefully deconstructed by Bowers.

Like the social worker and the psychiatrist in this case, thousands of experienced professionals and psychiatric residents at training centers follow the guidelines set forth in 

 This is why I postulate that a real change in the current child-blaming stance has to start from the top: the APA and the AACAP need to make the first move if we are to influence the writers of the guiding principles in 

I think that our profession has been in the grips of a kind of post-Freudian denial when it comes to recognizing psychiatric disorders in children. I believe this denial has indirectly contributed to high rates of school dropouts and unnecessary commitments to juvenile detention centers. For example, by the time of her hospitalization, María had already been sent by the school district to a school for the behaviorally disturbed because of her aggression toward teachers and peers as well as her defiance of adult authorities.

In the past 10 years, I have been the medical director at a juvenile detention center and several residential treatment centers. I have reviewed hundreds of cases that started with placement of a youngster in foster care, owing to parental abuse and neglect; and ended up with the child being transferred to a detention facility because of aggressive behavior or sexual acting out, often exacerbated by the ADHD medications wrongly prescribed on the basis of an incorrect diagnosis.

Having seen all too many cases like that of María, I have joined the voices of a few colleagues, such as Charles Huffine

 who have called for a more logical approach to diagnosing mental illnesses in children. The current 

 classification of childhood diseases resembles a collection of recipes in which several "dishes" look very similar, even though they originate from exceedingly different ingredients. That is, 

 classification fails to distinguish among conditions presenting with similar symptoms (including, hyperactivity, agitation, increased energy) but arising from vastly different disorders. This problem is exacerbated by diagnostic conclusions based on the clinician's best recollection of 

 wording and arrived at after 10- to-15-minute evaluations.

For the sake of children like María, I believe it is time for a change in perspective.

 We need to open our ears when a mother says, "Doctor, I am bipolar, and I think that my son has what I have."

Mota-Castillo M. Schizophrenia + bipolar disorder = ADHD? 

 Dilsaver SC, Akiskal H. Preschool-onset mania: incidence, phenomenology and family history. 

 Mota-Castillo M, Steiner H. Childhood conduct disorder and oppositional-defiant disorder are common manifestations of bipolar disorder, pro and con. 

 Lasseter JH, Baldwin JH. Health care barriers: Latino children and provision of culturally competent care. 

 Pumariega AJ. Cultural competence in systems of care for children's mental health. In: Pumariega AJ, Winters NC, eds. 

Handbook of Community Systems of Care: The New Child & Adolescent Community Psychiatry

. San Francisco: Jossey-Bass Publishers; 2003:82-106.


 Mota-Castillo M. Eliminate conduct disorders and ODD . . . this is the right time! 

 Bowers L. Manipulation: searching for an understanding. 

 Huffine C. Conduct disorder should be eliminated from the 

Adolescent Psychiatry: The Annals of the American Society for Adolescent Psychiatry

 (Volume 26, Developmental and Clinical Studies). Hillsdale, NJ: The Analytic Press; 2002.


 Kilgus MD, Pumariega AJ, Cuffe S. Race and diagnosis in adolescent psychiatric inpatients. 

This commentary arises from my concern about the superficiality that characterizes the process of diagnosing attention-deficit/hyperactivity disorder (ADHD) in children--usually followed by the prescription of one of the most powerful drugs on earth, methylphenidate.

Author | Manuel Mota-castillo, MD

Articles

Are the Media and the Public Still Missing the Clues?

The Crisis of Overdiagnosed ADHD in Children