Ellen Leibenluft, M.D, a leading NIMH investigator of bipolar disorder in childhood, and colleagues have published an article in the leading child psychiatry journal in the USA, The Journal of the American Academy of Child and Adolescent Psychiatry, in May, 2013, that encourages child psychiatrists to diagnose a vague form of bipolar disorder in children called Bipolar Disorder NOS (not otherwise specified) and to consider treating it with agents used to treat adult Bipolar Disorder. See Differentiating Bipolar Disorder–Not Otherwise Specified and Severe Mood Dysregulation. The American Academy of Child and Adolescent Psychiatry e-mailed a copy of the article to all of its members to insure that the article would have the widest possible influence on the practice of child psychiatric clinicians.
The article was published the same month that DSM-5 was published; criteria for diagnosing Bipolar Disorder NOS in the article were absent from DSM-5.
On the one hand, Dr. Leibenluft and colleagues in the article performed a great service by attempting to minimize the overdiagnosis of bipolar disorder in children by advocating for the diagnosis of Severe Mood Dysregulation (SMD). This diagnosis requires severe irritability and temper outbursts of four hours per day for one year in children between the ages of seven and seventeen. The disorder must begin below the age of 12. Children with any symptoms of elation, grandiosity, or episodically decreased need for sleep are excluded from the diagnosis. Severely irritable children had been incorrectly diagnosed with Bipolar Disorder in the past, and it is hoped that the SMD diagnosis would reduce the overdiagnosis of Bipolar Disorder in this group of children.
On the other hand, the widely distributed review article lent credence to the belief that more vague sub-threshold forms of Bipolar Disorder in children can be identified and treated in clinical practice. The diagnosis of Bipolar Disorder NOS in this article specifies the criteria used by the NIMH-funded COBY study conducted by the child psychiatry department at the University of Pittsburgh. One criterion is that the child must not meet criteria for the diagnosis of Bipolar I Disorder or Bipolar II Disorder. Although there are many other criteria for the diagnosis, the most important criterion for this diagnosis is that mania, elation, or irritability must last at least four hours per day for four days. The four hours per day do not have to be continuous and the four days do not have to be consecutive. Irritability alone without elation can serve as a diagnostic criterion.
While the study of the COBY criteria in Bipolar Disorder NOS is an interesting research initiative, the effort to translate the findings of the study into clinical work is premature. The dangers of the premature translation of research efforts into clinical care become more clear in the article’s discussion of the pharmacological treatment of Bipolar Disorder NOS. It lends support to a variety of agents with no demonstrated efficacy in child bipolar disorder, such as lithium and valproic acid, for use in an ill-defined form of the disorder that has largely been rejected by the DSM-5. The predictable, discredited assertion that stimulants are contraindicated in bipolar disorder is repeated, giving this false belief new credence.
In 2001 NIMH published a roundtable in the Journal of the American Academy of Child and Adolescent Psychiatry that served as a rationale for clinicians to make the diagnosis of Bipolar Disorder in children. http://www.jaacap.com/article/S0890-8567(09)60333-6/fulltext This article was a “how to“ manual for the overdiagnosis of Bipolar Disorder in children, with all of its catastrophic consequences. NIMH seems to be at it again.
Copyright Stuart L. Kaplan, M.D., 2013.
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 www.amazon.com.