On October 22, The New York Times ran a front-page article about a 10-year-old girl named Haley, suffering with a probable bipolar disorder. Because Haley was extremely anxious and distractible, had obsessional thoughts and fears, exhibited rapid mood swings, was often aggressive, and was experiencing psychotic symptoms, her psychiatrist could not point to one, specific diagnosis. “Her screening,” he said, “showed that she met criteria for every mental disorder listed.”
He went on to tell journalist Pam Belluck, that “Her symptoms suggested anxiety, morbid thoughts, obsessions of a possibly sexual nature, frequent fluctuations in mood, periods of euphoria, giddiness, irritability, rapid speech, auditory and visual hallucinations, thought disorganization, vocal tics, distractibility, poor socialization in school, sensory integration issues, attention impulse disorder, manic behavior, sleep disturbance.”
After the article appeared, people called and emailed us and expressed their confusion about Haley’s diagnosis. Did she have a mood disorder plus obsessive-compulsive disorder, attention-deficit disorder with hyperactivity, anxiety disorder, sensory integration disorder, a sleep disorder, and a psychotic disorder? Could this ten-year-old actually have six or seven disorders that were co-occurring at the same time?; Why was the diagnosis of bipolar disorder so tentative? They pointed to her rapid mood swings, hypersexuality, periods of elation and giddiness, grandiosity, and sleep disturbances–all hallmarks of a bipolar disorder. Many seemed extremely frustrated with the lack of knowledge about Haley’s condition.
So we thought that perhaps the time had come to write a newsletter focusing on the diagnostic conundrums and controversies of the psychiatric conditions in childhood, with a specific emphasis on the diagnosis of pediatric bipolar disorder.
Diagnosing Non-Psychiatric Illnesses
Anyone who has seen the medical-mystery show, House, knows that there is an opening scene in which a man, woman, or child collapses from some mystifying illness. Just after the titles and the first commercial, viewers get to see the brilliant and misanthropic, Dr. Gregory House, assemble his team of specialists (whom he proceeds to abuse). House scrawls the patient’s symptoms on an easel and asks his young hotshots to suggest candidate diagnoses that would account for all the symptoms. (The short list of candidates is called the differential diagnosis.)
House scrawls their suggestions on the easel as well, and then abruptly orders MRIs, other scans, sophisticated lab work to test for what he considers the most likely diagnosis. Never right the first time, however, House and his team go back to the drawing board, cross out the initially-proposed illness, and home in on another (more abuse). At show’s end, we see the patient walk out–cured–from a difficult to discern, but ultimately named, single, medical condition.
Not So in Psychiatry
The human brain is the most complex structure on earth. Packed into three-and-a-half pounds of grey and white matter, compressed into a structure no larger than a grapefruit are perhaps 100 billion brain cells, each linked to as many as 10,000 others. It is said that the number of possible interconnections between the cells is greater than the number of stars in the universe.
The brain is very plastic by design–it develops and changes and is impacted by environment. In addition, each person experiencing a psychiatric illness expresses it through the unique filter of mind and temperament.
Diagnosis in psychiatry is a problem. After all, there are no lab tests in psychiatry that conclusively pinpoint a diagnosis, and there are a host of overlapping symptoms (especially in children’s disorders).
The psychiatrist’s main diagnostic instruments are the patient’s report of symptoms (tough to get in young children), observable behavior, the parents’ report, family history, and the clinical course of the disorder.
Distinguishing between normal behaviors and pathological ones in a young child is even more challenging for a number of reasons: The span of time in a young life is insufficient to establish a course of illness; developmental factors are in full play; and a child’s often nonstop motion, lack of impulse control, difficulty tolerating frustration, and vivid imagination are part of a typical, everyday picture.
So How Does a Psychiatrist Make a Diagnosis?
The most recent criteria established by the American Psychiatric Association (APA) are delineated in the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders. With some interim changes, it is officially called the DSM-IV-TR, Text-revision), but for our purposes we will refer to it simply as the DSM-IV.
Today, the DSM-IV holds great sway over psychiatrists and their ability to diagnose and select treatment modalities. Should a doctor seek reimbursement for a clinical evaluation or an office visit, a DSM-IV diagnosis must appear on the patient’s insurance form.
Yet it bears knowing that the DSM is based on a paucity of scientific research, has never been validated, and is the product of 25 committees and multiple voices. Its final conclusions and criteria were sometimes pushed by the winds of politics and personalities. Shouting matches were not uncommon as the manual took shape.
Moreover, the decision was made to diagnose according to a categorical system, a sort of Chinese menu of symptoms and observed behaviors. For instance, the diagnostic criteria for attention-deficit disorder with hyperactivity (ADHD) requires six out of nine symptoms describing inattention; as well as six out of nine describing hyperactivity-impulsivity.
In addition, the categorical design of the Diagnostic and Statistical Manual sequesters individual symptoms into arbitrarily-divided disease categories that, in effect, dismisses the concept of overlapping symptoms. Each cluster of symptoms is walled off in its own airtight box.
So, unlike the other specialties in medicine, a psychiatric patient may receive multiple diagnoses. For instance, if a child with bipolar disorder also meets criteria for ADHD (and a majority of them do), then he or she is diagnosed as having both bipolar disorder and ADHD. If the child is experiencing manic symptoms, is fidgety and distractible, appears oppositional, is extremely anxious about being separated from his or her mother and has panic attacks as well as germ phobias, the child is plastered with an alphabet soup of diagnoses: bipolar, ADHD, Oppositional-Defiant Disorder (ODD), and multiple anxiety disorders (obsessive-compulsive disorder is considered an anxiety disorder).
What Does the DSM-IV Say About Children and Mood Disorders?
Children are mentioned in the DSM-IV, but they are to be diagnosed according to adult criteria. And this is where huge problems develop. Clinical investigators are beginning to realize that bipolar disorder in childhood presents in a very different pattern–one that bears little resemblance to classical cycles of mania and depression as they are expressed in adulthood. For instance, children have more irritable moods with explosive outbursts, and their cycles of mania, hypomania, and depression are far more rapid than the typical adult presentation. Yet the DSM-IV specifies that a mood episode must last for a specified period of time.
For instance, duration criteria for the diagnosis of a hypomanic episode requires a “period of persistently elevated, expansive, or irritable mood lasting throughout at least four days.” (Italics ours.) Yet a significant proportion of early-onset bipolar children have a form of the condition that is marked by frequent mood and energy shifts that occur multiple times throughout the day.
For a depressive episode, the DSM-IV duration criteria is even more demanding: The manual requires at least a two-week period with five or more depressive symptoms. Therefore, by definition, an individual who has rapidly shifting mood states of less than the required duration cannot be formally diagnosed as having bipolar disorder.
A separate and distinct category–Bipolar Disorder Not Otherwise Specified (NOS)–was established to include disorders with bipolar features that do not meet full duration criteria. While most children with bipolar disorder fit into this category, still it is not an accurate description of the condition as it presents in childhood.
So, Haley’s doctor and other clinicians and researchers are in an extremely difficult position: When they attempt to diagnose children with bipolar disorder, either they cannot use DSM-IV criteria and must describe these children as having “mania-like symptoms,” or they must modify other diagnostic instruments in order to treat the primary problem. Alternatively, they can diagnose BP-NOS.
How Does Bipolar Disorder Actually Present in Childhood?
Children with bipolar disorder veer from irritable, easily annoyed, angry mood states to silly, goofy, giddy elation, and then just as easily descend into low energy periods of intense boredom, depression and social withdrawal, fraught with self-recriminations and suicidal thoughts. These abrupt swings of mood and energy can occur multiple times within a day, and intense outbursts of temper (rages that can go on for hours), poor frustration tolerance, and oppositional defiant behaviors are commonplace. The children frequently suffer severe anxiety–separation anxiety, generalized anxiety, and panic disorders–as well as obsessive-compulsive symptoms, particularly aggressive obsessions, hoarding, the need for symmetry and ritual requests for reassurance.
Moreover, many of the children have sleep disturbances, often accompanied by night terrors, nightmares filled with blood and gore and themes of pursuit and abandonment, as well as other arousal disorders of sleep.
Accompanying elevated periods of mood may be an increased sexuality (hypersexuality). It is an accepted fact that hypersexuality is a symptom of hypomania or mania in an adult who has bipolar disorder. In young children, the symptom may manifest as a fascination with private parts and an increase in self-stimulatory behaviors, a precocious interest in things of a sexual nature, and language laced with highly sexual words or phrases.
Psychotic symptoms, such as delusions (fixed irrational beliefs), and hallucinations (hearing voices, seeing things that others don’t see) are not uncommon. Sometimes the voices and visions are compelling; often they are threatening, critical, or instruct the child to act on aggressive impulses towards others or self.
The Problematic DSM-IV
When we take into account a diagnostic system that demands that moods of depression and mania last for two weeks or four days, respectively, and combine that with the historical bias against diagnosing bipolar disorder before puberty, we don’t need to search very much further for reasons why this condition is so poorly recognized, and why a psychiatrist may be on shaky ground trying to conform to the diagnostic dictates of the DSM-IV.
Moreover, the strict division of symptoms into arbitrary diagnoses in a categorical system is a particular problem in early-onset bipolar disorder as so many symptoms manifest concurrently.
Some would say that these basic and arbitrary principles around which the field has organized diagnostic categories are flawed and need to be rethought and overhauled.
Dr. C. Robert Cloninger of Washington University School of Medicine makes no bones about this view when he says that “There is no empirical evidence for natural boundaries between major syndromes. No one has ever found a set of symptoms, signs or tests that separate psychiatric disorders fully into non-overlapping categories.”
In simpler terms, Dr. Cloninger is making the case that there is no scientific evidence to support placing diagnostic categories into separate, airtight boxes. There is no good reason to construct artificial walls between diagnostic categories.
What Are the Questions Researchers Are Attempting to Resolve?
Three come to mind:
- Does bipolar disorder occur simultaneously with other psychiatric disorders making it possible for a child actually to have three, four, or more diagnoses?
- Are these clusters of symptoms that suggest distinct disorders merely early precursors on a developmental continuum that eventually expresses itself as full-blown bipolar?
- Is there a set of symptoms shared from DSM-IV categories that more fully describe the full syndrome, and that are actually part of a spectrum of conditions that share a common biological substrate?
The truth is no one knows for certain. And until research can provide clarification, parents are going to have to tolerate a great deal of diagnostic ambiguity. Yet a correct diagnosis is vital to a child’s well-being, for it is the proper diagnosis that guides the treatment and–equally important–prevents the child from being placed on medications such as antidepressants or stimulants that may considerably worsen the course of a bipolar disorder.
A Closer Look at Problematic Boundary Issues: ADHD and Bipolar Disorder
At least seven of the DSM-IV criteria used to diagnose ADHD are commonly shared with bipolar disorder as it presents in childhood. A study of 1200 cases diagnosed with pediatric bipolar disorder performed by researchers of the Juvenile Bipolar Research Foundation found exceedingly high rates of endorsement of these “ADHD” symptoms:
- Easily distracted by extraneous stimuli 96%
- Difficulty sustaining attention in tasks or play 96%
- Restlessness as if driven by a motor 71%
- Often talks excessively 80%
- Difficulty waiting turn 96%
- Blurts thoughts out 96%
- Often has difficulty organizing tasks 91%
Many of the most commonly used diagnostic inventories employed by mental health professionals to diagnose ADHD include symptoms that would be indistinguishable from the most common symptomatic profiles observed in children with bipolar disorder. Therefore, since attentional problems, motor disinhibition, and organizational deficits are part and parcel of both conditions, it is difficult to make a clear diagnosis. If a clinician diagnoses according to strict DSM-IV criteria, and there are symptoms of mania present also, than, as we mentioned earlier, both bipolar disorder and ADHD must be diagnosed as co-occurring disorders.
What Is Another Way To Classify Psychiatric Diagnoses?
A considerable amount of recent research has focused specifically on whether psychiatric disorders are best classified dimensionally. Some clinical investigators believe that a dimensional approach (which calls upon new statistical methods to examine patterns of symptom co-occurrence) could help take into account biological relationships as well as a common underlying genetic predispositions yet to be discovered among research subjects.
Co-occurring diagnoses might best be explained by the presence of common, shared symptoms that are linked and exist along a continuum.
What Are The Advantages of a Dimensional Diagnostic System?
Data derived from these models of patterns of co-occurrence among bipolar spectrum conditions in childhood (e.g. ADHD, OCD, separation anxiety disorder, oppositional defiant disorder, and others) may help determine whether they are, in fact, indicators of a coherent underlying domain, rather than separate conditions with little or no relationship.
The promise of a dimensional model of classification is that it could provide a more specific and individualized profile description of a patient’s illness that may in turn offer better treatment strategies.
Has a Dimensional Approach Been Studied?
Research studies that use a dimensional approach to diagnostic classification and that have the potential to clarify the current diagnostic confusion in juvenile-onset bipolar disorder are already underway. Early reports suggest that the condition may indeed be better described along a continuum with specific features of other disorders, in addition to features included in the present DSM-IV criteria for mania and depression.
A unique screening inventory called the Child Bipolar Questionnaire is used frequently by the Juvenile Bipolar Research Foundation and has revealed some interesting findings.
The Child Bipolar Questionnaire
Until very recently, newly-proposed diagnostic criteria for juvenile-onset bipolar disorder have been based on information from very small clinical samples, or from expert consensus. Diagnostic rating scales used in clinical studies have all been modified from adult versions that are derived from DSM-IV diagnostic concepts, and focus almost exclusively on symptoms of mania and/or depression.
This focus limits the capacity to encompass a broader view afforded by a dimensional analysis of the primary features of the illness.
In order to avoid imposing such artificial distinctions that carve out symptoms into pre-established diagnostic categories, and to address the fact that psychiatric rating scale instruments do not represent a finer grained dimensional view of the condition, the Child Bipolar Parent Questionnaire (CBQ) was developed.
This is a 65-item questionnaire completed by a parent or parent surrogate that is based upon a Likert Scale. The questionnaire requires a rating for frequency of occurrence for each of the 65 symptoms or behaviors. For instance, a rating of 1 signifies that a symptom or behavior never occurs, or occurs only rarely; a rating of 4 signifies that a symptom or behavior occurs very frequently, or almost constantly. It was developed to serve as a rapid screening inventory of common behavioral symptoms and temperamental features associated with pediatric bipolar disorder. (To read about the development of the CBQ, or to complete the screening inventory, visit http://www.jbrf.org/cbq/index.html).
The ability of CBQ screening diagnoses and of the CBQ Core Index subscale to effectively predict diagnostic classification by structured interview was assessed using the well-validated Kiddie-SADS P/L. The validation study of the CBQ is published in the Journal of Affective Disorders (see bibliography below).
What Did a Dimensional Analysis of the CBQ Reveal in a Large Sample of Children Diagnosed With, or at Risk For, Bipolar Disorder?
In a sample of over 2,000 children, researchers originally identified 11 factors that represent dimensions of impairment associated with juvenile-onset bipolar disorder. These factors are best described as:
- Poor frustration tolerance
- Dysregulation of attention/executive function deficit
- Depression/poor self esteem regulation
- Low threshold for arousal/sensory sensitivity
- Poor regulation of aggressive impulses
- Sleep/wake cycle disturbances
- Poor regulation of sexual impulses
- Fear of harm (to self or others)
- Low threshold for anxiety.
On subsequent analysis of these eleven factors in a sample of sibling pairs both affected with the illness, four of these factors were found to have the highest concordance rates: anxiety, attention deficit, fear of harm, and aggressive behavior, in addition to the traditional categorical symptoms of mania embedded in the DSM-IV.
So, rather than characterizing the condition as a potpourri of different diagnostic entities, these findings support the existence of a distinct behavioral phenotype that includes primary symptoms from overlapping DSM-IV categories such as anxiety disorders and disruptive behavior disorders, as well as primary symptoms of juvenile mania.
Back to Haley
So if we go back now and look at many of the symptoms that Haley exhibited as described in The New York Times article: manic behavior, frequent fluctuations in mood, periods of euphoria, giddiness, irritability, rapid speech, hypersexuality, auditiory and visual hallucinations, anxiety, morbid thoughts, sleep disturbance, distractibility, poor impulse control, and aggressive behavior, we can see that the predominant symptoms that Haley displays are in the realm of bipolar disorder.
Adhering to DSM-IV criteria, however, may confuse the clinical picture by imposing arbitrary duration criteria on mood swings that are almost always rapid and abrupt, and dividing the panoply of symptoms into a handful of categorical diagnoses.
By incorporating a dimensional view as we’ve suggested above, many of the observed symptoms would round out a complete picture of bipolar disorder as it more typically presents in childhood.
Allen Frances, the chairperson of the task force that produced DSM-IV wrote that “We are at the epicycle stage of psychiatry where astronomy was before Copernicus, and biology before Darwin. Our inelegant and complex current descriptive system will undoubtedly be replaced by simpler, more elegant models.”
From many vantage points, we appear to be approaching a paradigm shift in psychiatric diagnosis, and, as we all well know, these tectonic shifts don’t occur without great upheaval. Childhood-onset bipolar disorder may very well be at the epicenter of such a shift in psychiatry.
For the sake of the children and the families and the doctors who are forced to grapple with the diagnostic dilemmas, may the shift come soon and with greater validity.
We’ll write again soon, but before we sign off, we’d like to tell you how pleased we are that the third edition of The Bipolar Child has recently been published by Broadway Books. This new edition is significantly expanded and revised with over 22,000 words added to the text.
It is our hope The Bipolar Child, Third Edition will be extremely helpful to you and your children, and to their educators and treatment teams.
As always, we look forward to hearing from you. May the holidays usher in a new year of hope and peace.
We send you our best,
Janice Papolos and Demitri Papolos, M.D.
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