At the 2012 annual meeting of the American Academy of Child and Adolescent held in San Francisco, on Thursday afternoon, October 25, the conference ballroom was packed with excited child psychiatrists and other mental health specialists. Every seat was taken, standing room behind the seats was jammed, and many sat crowded together on the floor of the central aisle. The attendees were eager to hear the members of the American Psychiatric Association’s DSM 5 Children’s Committee present the latest DSM 5 child diagnostic recommendations.
The meeting’s discussant was Gabrielle Carlson, M.D., an authority on the diagnosis of bipolar disorder in children and adolescents, who would play a major role in the event by presenting several clinical cases to the committee and asking the committee members to make a diagnosis based on the latest DSM 5 criteria. There were four exceptionally distinguished child psychiatrists each one representing a different diagnosis work group from the DSM 5 Children’s Committee. Representing bipolar disorders in children and adolescents, and chairing the symposium, was Daniel Pine, M.D., Chief, Section on Development and Affective Neuroscience of the National Institute of Mental Health, Intramural Research Program.
Dr. Pine presented the criteria for bipolar disorder; as is true in DSM-IV, in DSM 5 these criteria will be the same for children and adults. As with DSM-IV, to meet the criteria for a bipolar disorder diagnosis, the patient must first meet the criteria for mania. The most important criteria for the diagnosis of a DSM disorder are the “A” criteria. To oversimplify, the “A” criteria for mania include a period of expansive/euphoric mood or irritable mood that lasts for seven days. For a diagnosis of hypomania, a less severe form of mania, the euphoric or irritable mood must last for four days. The mood must be distinctly different from the patient’s usual self. The “B” criteria detail a number of additional requirements for the diagnosis.
A third and new form of Bipolar Disorder was introduced by Dr. Pine as one that will be included in DSM 5. This form is called Bipolar Disorder Not Elsewhere Classified (NEC). NEC replaces the DSM-IV term Not Otherwise Specified (NOS). Unlike the NOS classification, the NEC classification will require specific criteria. The form of mania for the NEC diagnosis is similar to that of DSM-IV hypomania, but will only require two days’ duration.
After the brief introduction of the DSM 5 revisions of several diagnoses, Dr. Carlson presented clinical case vignettes to the DSM 5 committee members so that the committee members could demonstrate to the audience how the criteria were to be used. For the bipolar disorder case, Dr. Carlson presented an adolescent female who had been having manic episodes lasting one to two hours per day for several years. Dr. Pine and other members of the committee believed the patient did not have any form of bipolar disorder because she did not have manic episodes that lasted at least two days. Dr Carlson was insistent but the committee refused to award the patient the diagnosis of bipolar disorder.
Although the child presented at the conference did not merit the DSM 5 diagnosis of Bipolar Disorder, undoubtedly reducing the required time for mania will promote the continued overdiagnosis of Bipolar Disorder.
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 on Amazon.com.