WHY PBD HAS REMAINED A DIAGNOSIS OF THE USA
An article in The Lancet, described the paradigm shift towards biomedical reductionism of the past 20 years as a “A Psychiatric Revolution” [ http://download.thelancet.com/pdfs/journals/lancet/PIIS0140673610605326.pdf?id=3d35b1b5aa0ec416:-4350490:1370b8496b4:532a1335933787530 ]. The eminent American child psychiatrist Leon Eisenberg coined the term “brainless psychiatry” to refer to mid 20th century over-emphasis on psychoanalysis to explain everything, and “mindless psychiatry” for the current era of biomedical reductionism and it’s “pill for every ill” approach. PBD has arisen in this era [ http://www.tandfonline.com/doi/full/10.1080/15299732.2011.597826 ].
Several factors seem to have contributed towards biomedical reductionism affecting child psychiatry in the USA more than its counterparts in the rest of the world.
Influence of the pharmaceutical industry
The USA has the world’s largest psychotropic market [ http://current.com/community/93594937_the-united-states-is-the-worlds-biggest-users-of-psychotropic-drugs.htm ] and direct to consumer advertising by the pharmaceutical industry is only legal in the USA and New Zealand (but NZ has a miniscule psychotropic market). Pharmaceutical companies like to make drugs that are beneficial, but their foremost goal is to survive as businesses. Recent court cases, mainly by US state and federal attorneys against pharmaceutical companies have led to the release of internal industry documents [ http://www.healthyskepticism.org/global/news/int/hsin2009-12 ] that reveal some companies saw maximizing the diagnosis of bipolar disorder [ http://www.healthyskepticism.org/files/docs/lilly/olanzapine/Zypr... documents ppt 1. ] as a way of increasing markets for antipsychotics. Some documents mention PBD [ http://psychrights.org/research/Digest/NLPs/Risperdal/081112Opp2BiedermanQuash-Seal.pdf ] and a retired psychiatrist has investigated this issue on his blog [ http://1boringoldman.com/index.php/2012/01/28/a-mess/ ] including observations from attending a court case.
The Grassley inquiry into the relationship of the pharmaceutical industry and the medical profession found issues pertaining to PBD. These are summarized in an article in Adolescent Psychiatry [ http://www.benthamscience.com/aps/pdf%201-1/11-Levin_APS.pdf ] where we observed that the AACAP leadership is responding to public concerns about conflict of interest.
The pharmaceutical industry is a major source of research funding. The biggest research centers in psychiatry are in the USA. Academic psychiatrists whose views converge with industry goals receive more funding and can conduct more studies and produce more published articles than researchers or clinicians with opposing views.
At the 2009 AACAP conference a presentation on neuroimaging research in PBD children [ http://www.ncbi.nlm.nih.gov/pubmed/19242292 ] had findings identical to research from the attachment and developmental trauma literature – that does not see such children as having PBD but as having “affect dysregulation”. These include an overactive right-side amygdale (the brain’s alarm/warning center) and underactive right-sided frontal lobe (the brain’s center for social reasoning). I and others asked the presenter why not call the children “affect dysregulated” rather than PBD. She stated publicly that she would prefer to call them affect dysregulated but “if we don’t call them bipolar we won’t get research funding.” This way of deciding the outcome at the start turns science upside down.
“Diagnostic upcoding” in the American health care system
The USA has a predominantly private health insurance system that often favors brief consultations and medication instead of time-consuming individual and family psychotherapy and parent training programs. When presenting a poster at the 2009 AACAP conference about the ANZ survey on PBD, I was privileged to speak with many US colleagues. A major problem was insurance reimbursement. This was summed up by a child psychiatrist who said if she is seeing a boy with emotional and behavioral problems embedded in difficult family dynamics, with some insurers she has to phone the insurer in the first session and is asked to give a diagnosis. If she says she has no diagnosis at that early stage, the insurance clerk says no reimbursement. If she says the diagnosis is a “parent-child relational problem” (which is a non Axis I DSM diagnosis) she may also be told no reimbursement. If she says it is an “adjustment disorder” (an Axis I DSM diagnosis) then she may be allowed 1 or 2 sessions to fix the complex problems. But if she says it is “bipolar disorder” then ongoing sessions are likely to be reimbursed.
This is more or less diagnosis by medically untrained insurance clerk. The phenomenon is known as “diagnostic upcoding” and was cited as a reason for overdiagnosis of PBD in US psychiatric inpatient units [ http://www.ncbi.nlm.nih.gov/pubmed/17306773 ]. A US child psychiatrist published an Op-Ed [ http://articles.latimes.com/2008/dec/14/opinion/oe-williams14 ] that expands on these issues.
Diagnostic upcoding, at least for most disorders, is a minor issue in countries with universal health insurance. Therapy is commonly provided on the basis of severity of problems as judged by clinicians. Although some public health services require diagnostic coding for funding, there is usually not a direct link of funding to individual cases. Thus a child with emotional and behavioral problems associated with parenting and family dynamic stress, learning difficulties and academic stress, bullying etc – may not be given a clear diagnostic label but rather a biopsychosocial formulation of his/her problems and treated accordingly with individual, parenting, family and school based interventions and possibly adjunctive medication.
Nearly all developed countries have universal cover [ http://www.oecd.org/dataoecd/24/8/49084488.pdf ] and spend on average 8% to 11% of GDP on health care. The USA spends 17% of its massive GDP on health care [ http://www.oecd.org/dataoecd/24/8/49084488.pdf ], much going to the health insurance company profits and bureaucracies, for example to pay medically untrained clerks.
“Diagnostic upcoding” for ASD in Australia and Canada
Diagnostic upcoding does occur for autistic spectrum disorders (ASD) in Australia [ http://www.dailytelegraph.com.au/news/faking-autism-to-get-help-for-kids-according-to-claims-made-by-autism-spectrum-australia/story-e6freuy9-1226097806649 ] and Canada [ http://www.thenadd.org/cgi-bin/checkmember.pl?page=pages/membership/bulletins/v11n1a2 ]. The Australian government provides education authorities with funding for extra tuition to children with ASD and parents and teachers seek this diagnosis for students with problems. Also Australian parents receive extra welfare payments if their child has an ASD diagnosis and special funding goes to non-psychiatrists to make ASD diagnoses – thus fueling an ASD epidemic, similar to the PBD epidemic in the USA. Some parents want the ASD diagnosis as it suggests there are no parenting or family dynamic problems.
Simplistic symptom checklist approach of the DSM
The DSM (Diagnostic and Statistical Manual of Mental Disorders) is produced by the American Psychiatric Association. It has come under intense criticism [ http://www.ipetitions.com/petition/dsm5/ ]. Elsewhere I argued how brief DSM diagnostic labels can lead to insufficient attention to biopsychosocial contextual factors [ http://www.clinicalpsychiatrynews.com/views/commentaries/single-article/diagnostic-labels-and-kids-a-call-for-context/5783d363fe823984bafbef98b0ffaa75.html ]. The DSM allows more scope for PBD diagnoses under the PBD-NOS category than the ICD-10 (International Classification of Diseases of the World Health Organisation) system, used for coding outside the USA. Researchers on DSM committees may promote their areas of research interest and Dr Allen Frances, chair of the former DSM-IV committee, has criticized this focus on “pet theories” [ http://www.nytimes.com/2012/05/12/opinion/break-up-the-psychiatric-monopoly.html ] as leading to overdiagnosis of diagnoses like PBD.
The DSM tends to overlook the role of developmental trauma and attachment disruption in childhood disorders. This is the case in PBD [ http://cdn.intechopen.com/pdfs/29393/InTech-Paediatric_bipolar_disorder_are_attachment_and_trauma_factors_considered_.pdf ]. Generally when attachment and developmental trauma factors are addressed, the diagnosis of PBD can be dispensed with and much medication ceased [ http://www.ncbi.nlm.nih.gov/pubmed/19764849 ; http://furiousseasons.com/documents/levinpaper.pdf ]. This was also the case on a unit that diagnosed high rates of PBD [ http://ps.psychiatryonline.org/data/Journals/PSS/3642/529.pdf ].
The DSM includes “culture-bound syndromes”, generally exotic disorders [ http://rjg42.tripod.com/culturebound_syndromes.htm ] in indigenous communities and developing countries due to cultural factors. But in the case of PBD, the question has to be asked: are the above described factors in the USA specific enough to qualify PBD as a culture-bound syndrome of this great first world nation?