Although the DSM-V Child and Adolescent Disorders Work Group has rendered an invaluable service to the public by taking a critical stand against Pediatric Bipolar Disorder, disturbing signs of endorsement of the diagnosis are creeping back into the Work Group's deliberations. Like a horror movie, just when we've been lulled into thinking our heroes have killed the monster, the monster comes back to life. In this post and several more to follow, I want to slay the monster completely. If good evidence for its existence cannot be found, pediatric bipolar disorder should be consigned to a museum of psychiatric fads rather than a place in DSM-V.
In a recent paper from this DSM-V Work Group (Justification for Temper Dysregulation Disorder with Dysphoria), it is noted in passing that, "In its deliberations, the Childhood Disorders Work Group was keenly aware that research demonstrates the ‘classic' adult [bipolar disorder] clearly does present in pre-pubertal children as well as in adolescents, although it may be rare [italics added] in the younger age group. Unambiguous agreement about this fact [italics added] weighed heavily in the Work Group's deliberations."
The use of the wording "unambiguous agreement about this fact" [italics added] is a coercive rhetorical device that has held sway for more than 15 years in the pediatric bipolar scientific literature. Instead of providing evidence, the Work Group attempts to persuade the reader that everyone who is smart and important knows this to be true. In truth the assertion is unfounded and has no place in sophisticated scientific discussions of bipolar disorder in children. The clause "although it may be rare in the younger age group" suggests some hesitation on the part of the Work Group in endorsing the existence of Bipolar Disorder in pre-pubertal children.
That the committee accepted as fact that bipolar disorder exists in children raises the issue of the use of the word fact in psychiatry as contrasted with its use in other sciences and in everyday conversation. The use of word "fact" in scientific papers in psychiatry is highly unusual. The use of the word in this context by the DSM-V Work Group is jarring to regular readers of the scholarly literature in psychiatry. In this scientific literature, papers end with conclusions preceded by discussions that are expected to point out the limitations of the scientific work. Conclusions are usually modest, tentative and limited. The word fact is almost never used.
Are there "facts" in psychiatry comparable to the physical constant of the speed of light in physics, the periodic table in chemistry, the function of the adrenal gland in biology, or the boiling point of water on the earth at sea level in everyday life? There may be some (e.g., need for an adequate environment for infants and children for psychological growth and development) but most so called facts in psychiatry are brief stand-ins or proxies for many inferences and theories that shift and change abruptly. For example, the diagnosis of bipolar disorder in adults is based to some degree on the diagnosis of Manic Depressive Insanity first developed by Kraepelin. The veracity of his observations and theories about psychosis are part of the brew of the current diagnosis of Bipolar Disorder. The diagnosis is based to limited degree on Kraepelin's theories and a large number of other hypotheses many of which are disputable. Fact as the acceptance of some immutable truth does not enter into the discussion.
When the DSM-V Work Group refers to the unambiguous fact that the disorder exists in prepubertal children, does the Work Group have any specific age range in mind? Preschoolers? Children ages 10 years to 12 years? Children ages 6 years to 12 years? Each of these age groups has been the subject of controversy related to bipolar disorder in children, but they are lumped together without any discrimination between them. Similarly, the use of the word "rare" by the DSM-V Work Group remains inexplicably undefined. The expression "rare" has a specific meaning in medicine, referring to a prevalence of 1 or less cases per 1500. Is this what the DSM-V Work Group means? There is a startling lack of precision in the discussion of the existence of pediatric bipolar disorder in childhood by the DSM- V Work Group. Many people, myself included, believe it is closer to the truth to assume, until proven otherwise, that this prepubertal "disorder" does not exist at all.
The misdiagnosis monster lives: the stake must still be driven in to the heart of the beast. Stay tuned for the next post.
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. For more information, and to order the book, go to www.notchildbipolardisorder.com
Copyright: Stuart L. Kaplan, M.D., 2011
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