Posted on February 12, 2010 - by David

The Children Formerly Known as Bipolar

According to an article I read on Wednesday, a new diagnostic category is expected to be included in the upcoming DSM-V which may provide psychiatrists with an alternative to diagnosing the most troubled kids they see with bipolar disorder. The creation of the new diagnosis, called temper dysregulation disorder with dysphoria, seems aimed at dealing with concerns over the growing prevalence of the lifelong, stigmatizing bipolar label among children.

Back in the 90’s, thanks largely to the work of one Dr. Janet Wozniak, an assistant professor of psychiatry at Harvard, the bipolar diagnosis was stripped of one of its most defining characteristics as professionals puzzled over what to do with children with ADHD who were prone to particularly persistent and disruptive outbursts. The traditional definition of bipolar was closely tied to the presence of alternating periods of mania and depression, but these kids rarely if ever experienced the typical episodic fluctuations. In order to make the new use of the diagnosis stick, some argued that in children, the episodes might be very brief and occur many times throughout the day. Critics of the extended application complained that “there wasn’t good evidence that these kids grew up to be bipolar, and that if you looked backward at bipolar adults, they didn’t necessarily have these uncontrolled anger issues when they were young.” Nevertheless, the pediatric bipolar diagnosis quickly spread, and Wozniak maintains this is “because it made clinical sense.”

The article suggests that part of the shift to childhood bipolar diagnoses may have been related to a desire to treat this kind of behavior as a disease which could be dealt with via medicine. The only other diagnostic option seemed to be conduct disorder, which usually wasn’t treated with medication and seemed to imply a parental failure. Now, with TDD, the behavioral and mood problems can still considered a medical illness, but those diagnosed aren’t necessarily lumped into a category of people required to take drugs for the rest of their lives.

What really struck me when reading this article was how the language used to talk about this stuff makes it so plainly obvious that these psychiatrists and researchers really don’t know what it is they are dealing with. First of all, the shift in diagnosis in the 90’s had nothing to do with any breakthrough discovery about how the brains of children with behavior problems function. Basically, the symptom-based definition of a particular mental illness was revised or expanded to fit the troubling phenomenon that psychiatrists were observing. That is not how science is supposed to be done. To quote the article: “research psychiatrists worried that the children were being given a label that wasn’t right for them, and saddled with the sentence of a serious mental illness for the rest of their lives.” A label? Is it an illness, or just a label? Does the naming of the thing determine its nature? And if people have a serious illness of any kind, doesn’t it exist independently of any “sentence”?

I find it strange that the word ‘label’ is used over and over again and there’s all this talk about categories or diagnoses being created and changed in order to deal with stigma and avoid offending parents, and yet these psychiatrists believe that whatever it is they are talking about is unquestionably a problem with the brain. I mean, isn’t the reason they can’t decide what to call it that they can’t pin down what is actually happening with these kids? I can’t help but shake my head when I read that “it will be seen as a brain or biological dysfunction, but not as a necessarily lifelong condition like bipolar?” How exactly did they determine that this is a biological dysfunction? Is it just the assumption that if symptoms are severe and difficult to manage, it must be a brain malfunction?

The article ends with the following two paragraphs:

Of course there is no way to predict what practical effects creating the TDD category might have. For instance, Carlson points out that even if they are successful at changing the label that clinicians use, it could be that the kids all get the same medications as before. “They may get many of the same. Absolutely,” she says. “But the difference is going to be that you won’t have to take this for the rest of your life.”

Carlson doesn’t necessarily see this as a bad thing. She emphasizes that these children have very serious problems, and though there’s been trouble naming it, there’s clearly some sort of dysfunction in their brain. Shaffer agrees. “I don’t think anyone is arguing that these are perfectly normal children that get the label [bipolar] — far from it,” he says. “We’re saying these kids are very sick. But they probably don’t have bipolar disorder. And they probably do deserve a name that adequately describes what they’re doing.”

I’m not arguing that these kids are “perfectly normal,” but I do take issue with the idea that a team of psychiatrists can create a new category and say without any evidence that the problem they are attempting to describe has its root causes in biological dysfunction. Am I the only one who finds this approach both arbitrary and dogmatic? I believe these kids deserve more than a name that fits their symptoms. They deserve an approach directed at understanding the nature and cause of whatever it is they are suffering from.

We still have another 3 years to go before the DSM-V is published. It will be interesting to see if this the unofficial diagnosis comes into common use before then.