A Matter of Personality

From borderline to narcissism

None Dare Call It Acting Out, Part I

Drugging children for fun and profit.

She knows what acting out is

A recent headline (November 11, 2010) in the Memphis Commercial Appeal newspaper shouted: "Survey: 1 in 10 U.S. children has ADHD." One in ten. Imagine that! "Biological" psychiatrists believe that ADHD is a genetic and/or neurodevelopmental disorder. I can not think of any other such disorder that affects 10% of the entire population.

The survey was performed by the U.S. Government. According to the newspaper article, this represents a "sizable increase from a few years earlier that might be explained by growing awareness and better screening." Specifically, the number represents an increase of 22% from 2003 to 2007. The actual numbers of affected kids would be 5.4 million children - an increase of about one million in that period of time. Two thirds of the children were on medication.

Of course, the study seemed to just assume that the diagnoses were all valid. Surely there are more parents aware of ADHD than ever before, so the "increased awareness" part of the story is undoubtedly true.

The statistics for the "incidence" of childhood bipolar disorder (also called pediatric bipolar) are even more striking. Prescriptions for powerful psychiatric drugs to young children for this disorder quintupled in less than four years. The graph below shows the amazing increase in private office visits for allegedly bipolar disorder in children under twenty.

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In fact, true bipolar disorder often first manifests in a sufferer's late teens, and we used to think it rarely occured in children - as reflected in the number of office visits shown in '94-95, before pediatric bipolar diagnosis became a fad.

For decades, the incidence of bipolar disorder was pegged at about 1%, but now suddenly it is almost 5%. However, this figure includes many who are diagnosed as with highly suspect and ambiguous "disorders" sometimes called "bipolar NOS" (not otherwise specified),"  "soft bipolar disorder," or "bipolar spectrum disorder" (or as I like to call it, BS).

The dramatic increase in diagnosis of both ADHD and pediatric bipolar - without any corresponding change in the gene pool - could be construed as evidence for an unspoken and unholy alliance between pharmaceutical companies, biological psychiatrists, and overwhelmed and guilty parents that has led to the disappearance in many mental health circles of the use of the term acting out in children in favor of a brain disease model for out-of-control children.

As defined by Psychcentral.com, acting out is performing an extreme behavior in order to express thoughts or feelings the person feels incapable of otherwise expressing. Instead of saying, "I'm angry with you," a person who acts out may instead throw a book at the person, or punch a hole through a wall. When a person acts out, it can act as a pressure release, and often helps the individual feel calmer and peaceful once again. For instance, a child's temper tantrum is a form of acting out when he or she doesn't get his or her way with a parent. Self-injury may also be a form of acting-out, expressing in physical pain that which one cannot stand to feel emotionally.

Acting out is a construct that has been observed in children and their families for decades by family therapists and psychodynamic psychotherapists, and can be observed weekly on the television show Supernanny.  Oh, I know; that's only a TV show. Repeat after me:  "It's only a TV show! It's only a TV show...."

When it comes to the causes of unruly behavior in children, heaven forbid we should look at the widespread problematic parenting trends described in detail by parenting advice columnist extraordinaire John Rosemond, or the staggering incidence of child abuse and neglect.  How much more comforting for parents to think that they bear absolutely no responsibility for how their children turn out.

John Rosemond, co-author, "The Diseasing of America's Children"

Indirect evidence that kids from bad environments are being mislabeled with biogenetic disorders is the fact that children in foster care in Texas are given heavy psychiatric medicines at a rate far greater than that seen for children not in foster care. (Barlas, S. [2008]  "Concern about psychotropic drugs and foster care". Psychiatric Times, July).  Does being placed in foster care also stem from having brain pathology? Are headaches caused by a deficiency in the body of aspirin?

So what on earth is going on here?

To quote fellow blogger The Last Psychiatrist, "If a psychiatrist looked a single parent a joint away from a nap right in the eye and said, 'Nope, he's acting out because of X, Y, Z, and medications aren't going to fix this,' that doctor will get his head handed to him by parent or by lawyer.'"

Let's first take a look pediatric bipolar disorder; I'll discuss some interesting developments in ADHD research in Part II of this post.

The alleged symptoms of mania in children look suspiciously similar to acting out, so one must wonder how a psychiatrist who does not even look at family behavior can really tell the difference.  The symptoms also look a lot like the symptoms of ADHD.   In fact, many children have been diagnosed with both bipolar disorder and ADHD. They are then prescribed both a stimulant and a central nervous system depressant, many of whose effects cancel each other out from a pharmacological point of view.   The same children often carry still other, additional diagnoses that all smack of acting out behavior: oppositional defiant disorder and conduct disorder.

The criteria for oppositional defiant disorder are particularly instructive and revealing:

        (1) often loses temper 
        (2) often argues with adults 
        (3) often actively defies or refuses to comply with adults' requests or rules 
        (4) often deliberately annoys people 
        (5) often blames others for his or her mistakes or misbehavior 
        (6) is often touchy or easily annoyed by others 
        (7) is often angry and resentful 
        (8) is often spiteful or vindictive 

We used to have another term that was applied to children with this sort of behavior:  spoiled brat. There is also an outmoded term for conduct disorder: juvenile delinquency.

The insanity of today's "diagnostic process" for pediatric bipolar disorder was illustrated in an outlandish article in a psychiatric newspaper, Clinical Psychiatry News (July, 2011) that I happened to read while in the process of writing this very blog post.  The article was touting a study that allegedly showed how effective the antipsychotic medication Rispiridone is in treating pediatric bipolar disorder.

As skeptical of these studies as I am, I was still shocked by what I was reading.  According to the article, in the study the vast majority of the children who were subjects had multiple diagnoses, just as I described above.  The rate of these additional "disorders" in the subjects?  ADHD: 92%.  Oppositional Defiant Disorder: 90%.  70% also had an anxiety disorder.  32% were also given the diagnosis of a sleep disorder - when disordered sleep should already be one of the most prominent symptoms of mania!

Since a lot of the symptoms of these disorders are similar to each other and to acting out as I mentioned, and there are no lab tests for any of them, they were able to make these distinctions exactly how?  Oh, and the average subject in the study was carrying the bipolar diagnosis since the age of five.

Any journal article about "pediatric bipolar disorder" (or ADHD) that does not describe the methodology used to evaluate for and exclude acting-out or anxious children in the research subjects is automatically suspect in my mind. This would have to include observing the kids and parents interact for a considerable amount of time in their home environments, which is rarely if ever done.

The docs who make these diagnoses are looking at extremely common behavior of children that might easily be accounted for by family or other issues rather than by a biogenetic disorder, yet are automatically jumping to the conclusion that a disease state exists.

Now let us look at how this explosion of pediatric bipolar disorder diagnoses got started.

Joseph Biederman is a Harvard psychiatrist who almost single-handedly started the current craze. By now it is well known that drug companies paid Dr. Biederman at least $1.6 million in consulting fees from 2000 to 2007, but for years he did not report much of this income to university officials, according to information given Congressional investigators.  In fact, according to a New York Times article from March 19, 2009, Biederman told drug giant Johnson and Johnson that his studies using its brand named antipsychotic agent, Rispiridone, would be positive before he even did the studies:

"The psychiatrist, Dr. Joseph Biederman, outlined plans to test Johnson & Johnson's drugs in presentations to company executives. One slide referred to a proposed trial in preschool children of risperidone, an antipsychotic drug made by the drug company. The trial, the slide stated, 'will support the safety and effectiveness of risperidone in this age group.'

Dr. Biederman was the lead author of a trial published last year concluding that treatment with risperidone improved symptoms of attention deficit and hyperactivity disorder in bipolar children."

Very recently, Harvard "punished" Biederman and colleagues for these transgressions by administering a very firm slap on the wrist

Of course, taking money from drug companies does not prove that the studies themselves were done dishonestly.  A better way to examine their validity is to examine Dr. Biederman's theories and the evidence for them.

Dr. Biederman argued that the symptoms of bipolar disorder in children are very different from those of adult bipolar disorder. In particular, he said that manic or depressed mood episodes, required by the DSM-IV (psychiatry's diagnostic manual) to last for a minimum of four to seven days for mania and two weeks for bipolar depression, could last for mere minutes in children.

Of course, the DSM duration requirements are somewhat arbitrary, but they were put in to make certain that normal mood reactions to challenging environments were not misdiagnosed as episodes of bipolar disorder.

Whenever the topic of diagnosing bipolar disorder in young children arise in throwaway journals (journals financed by big Pharma and widely distributed free of charge to doctors), I see this mantra that bipolar symptoms do not have to meet the duration criteria.  In fact, bipolar kids are said to have several mood swings in one day. This is usually said as if it is an established fact whose validity has been accepted by the entire profession. 

The people who say this are in fact making up their own absurd criteria out of thin air because they do not like the ones in the DSM.  No widely accepted science of any sort supports this idea - at least not any studies that do not resort to circular reasoning by assuming that the duration criteria in adults with bipolar disorder are also not essential to the diagnosis. Typically, researchers circumvent the duration criteria by diagnosing people with bipolar disorder "NOS" (not otherwise specified).

In addition to making up his own duration criteria, Biederman opines that symptoms of bipolar disorder seen in children but not in adults include temper tantrums and "explosive irritability." Not that he had any clear scientific evidence connecting those symptoms to adult bipolar disorder either. The rules of this blog preclude me from saying from where I suspect he pulled these ideas.

In adults, tantrums, rage, emotional instability, low frustration tolerance and the like are all symptoms of a personality disturbance known as borderline personality disorder (BPD). These types of symptoms fall under the rubric of affective instability or mood dysregulation, and also called neuroticism by personality theorists.

Individuals with BPD get depressed, anxious, or angry quite easily and take much longer to calm down than average person. According to a well-done study, adult patients with BPD are frequently misdiagnosed as bipolar in the world of today's psychiatry. This study, in the Journal of Clinical Psychiatry by Reggero, Zimmerman et. al. (71:1, January 2010, pp.26-31), showed that 40% of patients in their sample who met clear DSM criteria for borderline personality and clearly not for bipolar and who had been seen by a prior psychiatrist had been misdiagnosed as bipolar - as well as 10% of all of the other patients.

Is similar diagnostic bungling being seen today with out-of-control children who exhibit affective instability? Well, according to a new review of all of the existing studies in the February 2011 edition of the American

Ellen Leibenluft, M.D.

Journal of Psychiatry by Ellen Leibenluft, the answer is quite clearly yes.

From the abstract: "An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood.

Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups."

In the absence of any validated biological laboratory tests for a psychiatric disorder, the time course of symptoms, clustering of the symptoms in close family members, and differences in brain physiology and mental abilities on various mental tasks are the most important indirect ways of assessing whether two similar-appearing psychiatric syndromes have something important in common. In each of these ways, comparing short-term affective instability to the longer term symptoms seen in bipolar disorder shows that the phenomena are not the same thing.

It is also important to note that irritability is a criterion for at least six different psychiatric diagnoses in children (manic episode, oppositional defiant disorder, generalized anxiety disorder, dysthymic disorder, posttraumatic stress disorder, and major depressive episode).

Of interest is the frequent report by those who advocate for diagnosing bipolar disorder in young children that the illness in kids does not generally respond to Lithium treatment.  Lithium is still the gold standard in the treatment of genuine adult bipolar disorder. The usual explanation is, once again, that pediatric bipolar disorder is "different" that it is in adults. 

Could it be that the reason that pediatric bipolar disorder does not respond to lithium is that these children are not bipolar in the first place?  So which drugs do these experts usually recommend?  Those expensive brand-named atypical antipsychotic drugs. Few of these drugs have ever been tested in pediatric populations.  

So what might Biederman's answer be to this new data? Amazingly, according to Leibenluft, Biederman's research group and some other groups maintain that it is "nonetheless reasonable to apply a bipolar diagnosis to children with such a clinical presentation. One important argument for this position is that children with severe non-episodic irritability manifest severe mood symptoms and are as severely impaired as those with classic bipolar disorder, but without a diagnosis of bipolar disorder their access to the mental health services they need might be limited." (p.129-130).

Wow. In other words, we should label kids who actually have behavior problems as having bipolar disorder, so instead of doing family therapy, we can treat them with sedating drugs that have not been approved as safe or efficacious in children, and which have a lot of potentially extremely serious toxic side effects.

An amazing display of twisted phony logic worthy of (insert your most hated Fox News or MSNBC political commentator here).

Of course, not even Leibenluft discusses the possibility that - just maybe - affective instability in children is reactive to a chaotic family environment. Interestingly, in an interview in the January 21, 2011 Psychiatric News, she was quoted as saying, "The phrase we commonly hear from parents is that they have to 'walk on eggshells.'"

Translation: the kids in these families are determining what the adults do or say, not the other way around. A situation in which parents seem to be afraid of their own children is very bad for children, who tend to desperately need to be taken care of and given limits by their adult caretakers - despite the kids' protestations to the contrary. There is very strong evidence from the attachment literature that such situations actually create affective instability in children.

David M. Allen, M.D., is a Professor of Psychiatry at the University of Tennessee and author of the book How Dysfunctional Families Spur Mental Disorders.

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