You Say Potato, I Say. . .Disruptive Mood Dysregulation Disorder

Posted on April 30, 2012 by

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Paediatric bipolar disorder is notoriously controversial with the epicentre of the debate being whether the condition can be diagnosed in pre-pubertal children at all ~ Ghaemi & Martin

Do you remember I wrote a while back that the Diagnostic and Statistical Manual of Mental Disorders (DSM)-5, the psychiatric ‘Bible,’ was mucking about with personality disorders, cutting 4 out of 10 (see ‘Perish the Paranoid’)?

And it seemed like one day you went to sleep with a paranoid personality disorder, and the next day you wake up. . .well, just plain nutty, I guess?

If big clinical thinkers and researchers have their way, it will be pretty much similar with pediatric bipolar disorder.

One day you put your kid to bed with bipolar disorder, and the next day he’ll wake up with (and here’s a mouthful): Disruptive Mood Dysregulation Disorder.

It’s a brand-spanking new diagnosis, so the site provides no history, but you can get a run-down of the illness’ symptomatology at the American Psychiatric Association’s website on the DSM-5.

Yesterday’s post was a rundown of the highlights of why researchers and clinicians want to put a stop to what’s become a near epidemic of diagnosing children with pediatric bipolar disorder (PBD).

But the questions becomes–what to do with an estimated 1 million children who would have received a very serious diagnosis? Send them to bed with a spanking and without supper? It’s their very mood lability and out-of-control outbursts or rages that earned them admission to the PBD club to begin with, as that became the new ‘children’s definition of mania.

But some very interesting things have been observed in the years that we’ve worked with this diagnosis.

Gabrielle Carlson, Professor of Psychiatry and Pediatrics, Director, Child and Adolescent Psychiatry at Stony Brook University School of Medicine, with an expertise in pediatric bipolar–often concentrating on rages–and her colleagues studied 71 5–12 year olds hospitalized for ‘rages,’ or “agitated/angry behaviors requiring seclusion or medication because the child could not be verbally redirected to ‘time out.’”

Rages such as these, under the definition of mania for children, would be the hallmark of a manic episode, and, as such, would define the child as bipolar, as the authors note that “rages have become synonymous with bipolar disorder in some views.”

But, found Carlson et al, half of those children hospitalized with rages do not have them at all in the hospital. It begs the question of whether the illness is, in fact, chemically based–or rather is some interaction between child and environment that is yielding dysfunction.

This is not to say that no children have bipolar disorder. There are a few, very very few children, who present with the classic symptomatology. To step outside of America, which is like stepping back in time to before pediatric bipolar became almost a fad, a survey of Australian and New Zealand doctors found that

The majority of participants said they had never seen a case of pre-pubertal bipolar disorder… Most participants were of the opinion that bipolar disorder in pre-pubertal children was either “very rare (less than 0.01%)”. . .[or] “rare (less than 0.1%).”

But the very existence of this disorder asserts that children who don’t meet the classic criteria of bipolar disorder are not, in fact, bipolar.

Doesn’t really sound all that novel if you put it that way, does it?

We might ask this new DSM creation , “what have you done for me lately?” Why diagnose children with these out of control behaviors and tendency to rages with DMDD, untested and untried, if children and parents aren’t kicking up a fuss with the bipolar designation–which, by and large, they haven’t?

Well, there are several reasons:

1. Children with pediatric bipolar disorder (PBD) don’t go on to have bipolar disorder as adults. If PBD were, in fact, just bipolar in children, then these children would go on to develop the classic adult symptoms of bipolar disorder as they grew up. But overwhelmingly they don’t. Hence they’re being saddled with a diagnosis that doesn’t fit them in the long-term.

2. As I addressed in my lost post (see the graph there), the gender breakdown of the illness is all wrong. Adult bipolar is fairly gender neutral, breaking down evenly among women and men. What’s being called PBD is largely an illness of boys.

3. Non-responsiveness to lithium. Despite issues with lithium tolerance, and a certain percentage of patients who will need to either switch or add to an anticonvulsant, lithium remains, after all, the gold standard in bipolar treatment. But, in unexpected results, researchers studying 11 children diagnosed with bipolar disorder that only 3, a paltry 27%, improved enough on lithium to be discharged after 8 weeks. It’s no proof, but an indication that the illness being treated simply isn’t bipolar.

Look, if you ask me, the whole megilla in yesterday’s post plus the point about lithium non-responsiveness seem pretty good reasons to move on from diagnosing so many children with bipolar disorder.

Dr. Frances, who smiles when he’s not discussing the DSM-5

But we’re jumping without a parachute. DMDD is a new diagnosis, cut from whole cloth. Dr. Allen Frances was foaming at the mouth in yesterday’s post about the dangers of over-diagnosing PBD. So you’d think he’d be happy with this. But seems like the editor of the last DSM isn’t going to cut any slack to the editors of the fifth one.

Calling the creation of the disorder one of “worst ideas dreamed up by the DSM-5 work groups” [I love this guy] he writes that:

Everyone must have known that DMDD is a made up and unstudied diagnosis with no real scientific support. The review group probably bought the child group’s argument that DMDD is a lesser evil replacement for childhood bipolar disorder. .. But their proposed fix is a disaster in the making that will most likely make an already bad situation much worse. DMDD will capture a wildly heterogeneous and diagnostically meaningless grab bag of difficult to handle kids.

I like nothing better than a little positive thinking.

But love it or lump it, when that new DSM-5 comes out, we’ll be moving the kids off the rolls of PBD (don’t you love a psychiatric alphabet soup?) and onto those of DMDD.

Unhappy on behalf of those losing a diagnosis? Talk to those who once had paranoid personality disorders. They were in the complaint line first.

References

Allen F. DSM-5 Approves New Fad Diagnosis For Child Psychiatry: Antipsychotic Use Likely to Rise. Psychiatric Times, July 22, 2011.

Carlson GA, Rapport MD, Pataki CS, Kelly KL. Lithium in hospitalized children at 4 and 8 weeks: mood, behavior and cognitive effects. Journal of Child Psychology and Psychiatry 1992; 33(2):411-25.

Carlson GA, et al. Rages—What are they and who has them? Journal of Child and Adolescent Psychopharmacology 2009; 19(3):281-8.

Ghaemi SN, Martin A. Defining the boundaries of childhood bipolar disorder. American Journal of Psychiatry 2007; 164:185-188.

Lopex-Duran N. Childhood Bipolar Disorder is not Bipolar? DSM-V and the new Temper Dysregulation Disorder with Dysphoria.

Parry P, Allison S. Pre-pubertal paediatric bipolar disorder: A controversy from America. Australasian Psychiatry 2008; 16(2):80-84.

Parry P, Furbe G, Allison S. The paediatric bipolar hypothesis: The view from Australia and New Zealand. Child and Adolescent Mental Health 2009; 14(3):140-147.