Ellen Frank, Ph.D., a distinguished psychologist and member of the DSM 5 workgroup on bipolar disorders, recently lamented that the DSM IV criteria for bipolar disorder mixed type were too stringent. Although the diagnosis was often made, she argued that the disorder as defined by DSM IV did not exist. For a diagnosis of DSM IV bipolar disorder mixed type, the patient had to meet both the criteria for a manic episode and the criteria for major depressive episode simultaneously for one week. Dr. Frank said,”…it’s a lovely idea, but just like I have never seen a unicorn, I don’t think I have ever seen a patient ….who simultaneously met all of these criteria” http://www.medscape.com/viewarticle/744816
. What will be the fate of the small unicorns of child bipolar disorder? Will they return to their natural home in children’s books and mythology or will they wander DSM 5? There are forces in the more recent versions of DSM 5 that support the banishment of the small unicorns of child bipolar disorder to their mythological homes, but stronger forces seem to compel them to continue to roam DSM 5.
Among the forces for eviction of the small unicorns of child bipolar disorder from DSM 5 is the proposed diagnosis of Disruptive Mood Dysregulation Disorder (DMDD). The DSM 5 criteria for this diagnosis include age six to twelve, a minimum of three temper tantrums per week, and a sullen depressed mood between tantrums http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201207/occam-s-razor-and-childhood-behavior-disorders. This new entity was expected to greatly reduce the frequency of the diagnosis of bipolar disorder in children. Part of the process of development of DSM diagnoses is to test the developed criteria with actual patients in clinical settings. Although the criteria for DMDD seem clear and clinicians expected to see many cases, in the clinical field trials of DSM 5 few cases were found. The small number of cases identified in the field trials, raises the possibility that DMDD might not be included in the final version of DSM 5.
The DSM IV diagnosis of Intermittent Explosive Disorder (IED) offers a pathway for the return of some child bipolar disorder unicorns to the land of imagination. IED is characterized by episodes of severe aggression leading to physical violence and destruction of property. In practice, this diagnosis was often restricted to adults and adolescents. DSM 5 may offer encouragement to extend this diagnosis to elementary school aged children and serve as a useful alternative to a diagnosis of child bipolar disorder.
The widest pathway for the return of the small unicorns to the land of the imagination was the refusal of the DSM 5 bipolar disorders group to develop special diagnostic criteria for the diagnosis of bipolar disorder in children. As was true in DSM IV, children will have to meet the same diagnostic criteria as adolescents and adults.
Some forces may serve to keep small unicorns in DSM 5. A series of bipolar diagnoses were proposed that reflect a relaxing of DSM IV criteria. These looser standards for the bipolar disorder diagnosis were intended to reflect more accurately the clinical appearance of patients and assist clinicians to make diagnoses of the patients seen. An unintended consequence would seem to be that the diagnosis of bipolar disorder would be made more frequently.
One important example of loosening criteria is accepting an increase in energy level as an alternative to the currently required increase in activity level in the A. criterion for the diagnosis of bipolar I disorder. A second example of loosening criteria is shortening the minimal length of a hypomanic episode from four days to two days. A third example is the loosening of the diagnostic criteria for the diagnosis of mixed bipolar disorder alluded to in the opening paragraph of this post. Seven additional bipolar diagnoses are proposed that lower the requirements for making a bipolar disorder diagnosis. Two of these diagnoses will be mentioned to exemplify the ambiguous quality of the diagnostic criteria: (1) “Major Depressive Episode and Hypomanic Episodes Characterized by Insufficient Symptoms,” and (2) “Uncertain Bipolar Condition Observed in a Clinical Examination.”
Many of these DSM 5 initiatives threaten to increase the diagnosis of bipolar disorder in children, an imaginary diagnosis with the scientific status of unicorns.
Much of the material for this post was gathered at a multi-authored, day-long symposium on DSM 5 titled “DSM-5 Criteria Changes Important to Child and Adolescent Psychiatrists” at the 2012 Annual Meeting of the American Academy of Child and Adolescent Psychiatry, San Francisco. For an additional report about this symposium see https://my.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201211/drama-october-2012-child-psychiatry-meeting.
Copyright, 2012, Stuart L. Kaplan, M.D.
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, available at Amazon.com.