Mood Swings

A psychiatrist surveys the mind and the wider world

Depression in Children: Proof of Bipolar Disorder

Some say bipolar disorder NEVER happens in children. What about depression? Does that never happen either? If so, then bipolar disorder happens too. Read More

The emotionally blind

My daughter is in seventh grade, and what some kids say,think,do, qualifies as psychosis.

Something far Beyond just Depression or Mania.

We know that Bipolars also create (a genetic emotional de-evolution) ''Psychopathic brains''.

''Psychotic'' and ''psychopathic'' children, actually makes the clueless psychiatrists at least 2 steps behind.

You're being very kind Mr. Ghaemi.

Discussion Over the past

Over the past decade, EBM has become a major driving force world wide, impacting medical education, policymaking, and research. The teaching of evidence-based medicine has been increasingly integrated into curricula at all levels of medical education as advocated by the Medical School Objectives Program developed by the Association of American Medical Colleges (AAMC) [8]. Like most medical schools, (name deleted) has integrated EBM into its curriculum and our data indicates that students who are soon to graduate can demonstrate proficiency at critically appraising an article about diagnostic testing. But in a simulated clinical encounter, few students are able take the last step of using EBM in diagnosing medical illness. We found almost uniform failure of our students to correctly revise a pretest probability of disease given a test result despite their earlier demonstration of competency with Bayes' Theorem on their Laboratory Medicine clerkship. This finding raises questions about whether our students can fully utilize their EBM training in the clinical setting.

Not sure about the bipolar part but...

I can promise you I was depressed my entire childhood due to abusive and neglectful family. I don't think I have ever been bipolar though. After I grew up and got away from my parents the depression lifted. So its obviously possible some kids are depressed. Considering how bad violence and bullying has gotten in school wouldn't surprise me a bit that some kids have diagnosable depression.

What You See is What You Get

I appreciate Dr. Ghaemi’s reply to a post on my blog, Your Child Does Not Have Bipolar Disorder. Dr. Ghaemi is a distinguished psychiatrist and scholar of mood disorders. His bewilderment about my position on the absence of bipolar disorder in children is a testament to the complexity of the problem.
Dr. Ghaemi queries whether children with a diagnosis of major depressive disorder who go on to develop bipolar disorder in adolescence or adulthood should be considered to have had bipolar disorder during their childhoods. The answer is no. Children who are depressed receive their diagnoses of depression based on DSM IV criteria. Children, adolescents, and adults who meet DSM IV criteria for bipolar disorder receive bipolar disorder diagnoses.
It has long been accepted in child psychiatry that a proportion of those with a given childhood psychiatric diagnosis may develop other diagnoses over time. For example, a proportion of children with attention deficit hyperactivity disorder may develop conduct disorder during adolescence. Similarly, a proportion of children with major depressive disorder may ultimately develop bipolar disorder in late adolescence or adulthood. The longitudinal outcome of a diagnosis is not identical to the diagnosis that preceded it.
Stuart L. Kaplan, M.D.

What is "MDD"

I appreciate Dr. Kaplan's collegial response to my commentary. I think the issue is whether one can say that the disease changes when we change what we call it. We call it "MDD" because we don't know (although God and Nature do) that the patient will have manic episodes and thus really has bipolar disorder. Changing the name later doesn't mean the disease was different earlier. It makes no biological sense to say that the disease initially was MDD, really, and then it became bipolar disorder, something completely different later. In fact, the original view of manic-depressive illness was all about the fact that this distinction, between "MDD" and bipolar disorder, has no biological or scientific reality. Cases of people who "change" from one to the other is consistent with this concern. The very frequent occurrence of this evolution in children demonstrates the danger of making simplistic claims, such as the notion that manic-depressive illness does not happen in children.

I agree that children can experience true clinical depression

For my whole life (I'm 60) I had the sense that my own mother didn't actually like me. Her declarations of love didn't match the way she treated me, as though I was repulsive to her and disappointingly inferior. She was unpredictably physically violent with me, often emotionally abusive, and perfectionistic. I grew up jittery, anxious, severely lacking in self-esteem and self-confidence, with several symptoms of ptsd as well. I was actually trauma-bonded to my mother; until about my mid-thirties: she and dad were virtually my only social outlet.

Although I've never been diagnosed, I believe that I have had depression off and on throughout my life. I also have traits of avoidant pd and traits of schizoid pd. (I've never had a long-term adult relationship, never married or had children, aka I rarely date due to anxiety regarding intimacy, trust, and sexuality.) However, I am well regarded and successful in my line of work and I've been self-supporting for most of my life.

Mother died last year; my younger sister and I recently discovered mother's therapy journal, in which she confessed in writing that she did not really like me and never had. Mother had been formally diagnosed with borderline pd, twice (two different therapists) but I personally think she also had narcissistic pd. With rare insight, mother speculated in her journal that there must be something wrong with her because mothers are supposed to like/love their own children, but she felt that even as an infant I, her first-born, was cold, rejecting, and unloving toward her. That admission explained a lot of things, like puzzle pieces falling into place. My instincts, my gut feeling was accurate: I was merely tolerated, not loved, and it had a devastatingly negative and long-term impact on me.

I hope that researchers can utilize such information in understanding more about the Cluster B pds and understanding how vital, how crucial it is for a child to have a mentally healthy parent who is capable of empathy, compassion, patience, and able to bond closely with her child. Being unloved, unwanted, or actively resented by one's mother/primary caregiver can warp the life-trajectory of a child.

Its that vital for a child to have a close, warm, trusting, genuinely loving and reciprocal maternal bond; not having that can cripple a child emotionally as surely as amputating a baby's limbs would. Its that level of vital. In my opinion.

You are not alone

Annie wrote:

I hope that researchers can utilize such information in understanding more about the Cluster B pds and understanding how vital, how crucial it is for a child to have a mentally healthy parent who is capable of empathy, compassion, patience, and able to bond closely with her child. Being unloved, unwanted, or actively resented by one's mother/primary caregiver can warp the life-trajectory of a child.

Its that vital for a child to have a close, warm, trusting, genuinely loving and reciprocal maternal bond; not having that can cripple a child emotionally as surely as amputating a baby's limbs would. Its that level of vital. In my opinion.

I'm really sorry you experienced that in your childhood. Just wanted to let you know you are not alone in your experience. I think it helps sometimes for others to know they were not the only person in the world that experienced something. I suspect my mom has borderline PD and possibly schizophrenia. I feel certain my father has Aspergers or some other form of high functioning autism like maybe Rhetts Syndrome. I suspect my mom might have it as well. A couple doctors tried to diagnose me with it till one said she believed I had socialization problems because of the way I was raised and not how I was born. I grew up completely isolated and was punished whenever my mother found out I talked to other kids at school. During summer vacations I was forced to stay in my room and was never allowed to associate with other kids not even as a late teen. I never dated or went to movies with friends or anything normal other kids took for granted. I ended up a caregiver for my divorced father in my 20's and was again not permitted to have friends and would have to endure verbal abuse for driving outside an approved area. I finally moved out of state and had my own life. I feel my mother never wanted me because she complained about having to care for me despite fact I was a very quiet and well behaved child. My dad at least brags on me for being an easy child as he calls it. I was an only child after my twin brother died. The way my mom talked to me when I was younger she seemed to blame me for my brother being miscarried. The doctors did suggest that I absorbed part of my twin, so I guess that is why my mom blames me. Thing is its pretty obvious she never wanted me. We no longer communicate with each other at all.

Thing is early childhood experiences can damage people for life. I've yet to have a successful romantic relationship as I seem to attract disturbed people. I have multiple stalkers, both male and female, on top of that, so I feel like I have a neon sign over my head that attracts weirdos. I finally just gave up on dating and have very limited socializing with others. I mainly keep to myself and am fairly content though I do miss not having children. I've done a lot of work on myself and had several years of counseling so I think I would make a great parent now as I know how to treat people correctly.

Dr. Kaplan, A diagnosis is a

Dr. Kaplan,
A diagnosis is a human creation a disease is a disease. If depressed children who develop bipolar later in life are not to be thought of as having had bipolar when they were children we have nosology problem. The poor kids have a medical problem.

Annie; I had a somewhat turbulent childhood also. There was a lot of screaming but no hitting. This affected me in serious ways---because I was biologically constructed for it to affect me.

I have no doubt that your mother's behavior shaped your brain. This is an important part of your story but your brain was vulnerable to being shaped. You have some of your parent's genes.

Many men survived a year or more living as psychopaths in the War in the Pacific. A lot came home, married slept well and had kids after killing and experiencing killing in ways that no human can imagine.

This is not either/or but it is why we must, must see biology first, and at the same time avoid the reductionist evil of naive drug giving.

the whole picture is important

I agree that its important to properly diagnose an individual so they can get the right treatment.

Personality disorder is considered unresponsive to either talk therapy or drug therapy; their "ego syntonic" state of mind (as in, "I'm just fine, its everyone else who is crazy and/or causing me problems, so why should I seek therapy when there's nothing wrong with me?") keeps them from seeking therapy or remaining in therapy. My bpd/npd mother stopped therapy once her therapist suggested that she needed to take personal responsibility for her own negative, destructive behaviors and words, instead of blaming others. Her ego-syntonic state remained intact and she remained intransigently bpd/npd until her death. My sister reported to me that the one time that our mother took a mood-stabilizing med, the resulting improvement was like a small miracle. Mother refused to keep taking the med, though, because she said it made her feel "weird." Perhaps "normal" or "emotionally stable" felt "weird" to mother because she was used to the wild, extreme emotional roller-coaster ride that is bpd, I guess.

I on the other hand had a great result from what turned out to be a short-term course of anti-anxiety meds at one point in my life, when I was in a horribly stressful job working for a boss who hated me. But when I managed to get myself transferred to another department, I found I didn't need the anti-anxiety med anymore. (Blood pressure and heart rate were back to normal.) I thought of that med as a kind of leg-cast or a wheelchair, giving me temporary support while I extricated myself from the horribly stressful situation.

When I travel long distance, I use sleeping pills for a couple of nights to help me sync up with the 12 hour (or more) time differences more efficiently, both coming and going. I find they really help me a lot with readjusting my body clock aka jet lag.

So, I'm for the judicious and selective use of drug therapy, under such conditions.


What You See Is What You Get, Part 2

I am grateful for Dr. Ghaemi’s interest in my comment. I am pleased to have the pleasure and honor of engaging him in this dispute.
The terms must be defined. Dr. Ghaemi seems to use the term “children” to define all individuals under the age of 20. To clarify the meaning of the term “children,” the distinction must be made between prepubertal children (generally aged 12 or under) and adolescents (aged 13-18). There is no controversy about the development of bipolar disorder in adolescents. The controversy centers around the existence of bipolar disorder in prepubertal children.
The Strober, et al reference cited by Dr. Ghaemi is not germane; the article is limited exclusively to adolescents. The Geller reference, on the other hand, is directly relevant to Dr. Ghaemi’s argument and is supportive of it. There are reasons for misgivings about the article. It is old (1994) and comes from a center that was an original advocate for many questionable ideas about the diagnosis of bipolar disorder in children. Geller’s center regularly reports unusual findings about bipolar disorder in children such as its occurrence in pre-school children and its routine manifestation of 365 bipolar cycles per year in prepubertal children. The unusual qualities of this purported diagnosis raise questions about the credibility of the work.
More dispassionate investigators of bipolar disorder in pre-pubertal children describe a very different picture of the childhood of adult psychiatric patients with bipolar disorder. In the elegant New Zealand longitudinal study, which followed subjects from earliest childhood to adulthood, Kim-Cohen found the childhood of adult bipolar patients to be free of bipolar disorder below the age of eighteen years. (Archives of General Psychiatry, July, 2003). Instead, conduct disorder, oppositional defiant disorder, and depression were diagnosed below the age of 18 in those who developed bipolar disorder as adults. Duffy (2012) in a recent longitudinal study from early childhood to adulthood found current adult bipolar disordered subjects to have had childhoods marked by intense anxiety and an absence of bipolar disorder (Am J. Psychiatry 169:12, December 2012). In both the New Zealand study and the Duffy study, the children’s diagnosis changed dramatically from childhood to adulthood. Neither Duffy nor Kim-Cohen revised the childhood diagnoses of the subjects who became bipolar disordered during late adolescence or adulthood. Their subjects had one diagnosis as children and another as adults.
I agree with Dr. Ghaemi that there are pre-pubertal children who are depressed in childhood who do develop bipolar disorder in adolescence and adulthood. As Dr. Duffy indicates, we may be beginning to understand prodromal states in childhood leading to the subsequent development of bipolar disorder. We do not have a biological test for psychiatric disorders; we must rely on the DSM system which demands that we diagnose (and treat) what is before us. There is no warrant in the DSM for revising prepubertal diagnoses based on adult outcomes.

Stuart L. Kaplan, M.D. is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis.

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Nassir Ghaemi, M.D., M.P.H.,

is Professor of Psychiatry at Tufts University School of Medicine, and Director of the Mood Disorders Program at Tufts Medical Center in Boston. more...

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