The pediatric bipolar disorder (PBD) diagnosis is almost never used in Australia where I work as a child and adolescent psychiatrist. In previous articles on Professor Kaplan’s blog [ http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201205/the-geography-pediatric-bipolar-disorder and http://www.psychologytoday.com/blog/your-child-does-not-have-bipolar-disorder/201206/the-geography-pediatric-bipolar-disorder-part- ] I explained how PBD has remained mostly confined to the USA.
Nonetheless PBD intrigued and concerned me – initially I wondered whether child psychiatrists outside the USA were missing something. Later, as I believed we were not, I was concerned the diagnostic fad might spread beyond the USA.
In 2008 I started to correspond with a young American man in an online mental health forum on the topic of PBD. His account of the diagnosis and accompanying cocktails of psychotropic medications throughout his adolescent years – read like a horror story. In 2013 I and an Australian child psychiatrist friend met and dined with the young man whilst we were on a study tour of the USA.
The young man, “Adam” (not his real name), is now in his mid-20’s and completing university. He is highly intelligent and articulate with a warm personality and astute comprehension of issues. He carried the PBD diagnosis from age 12 to 19 when he left home. A year later another psychiatrist informed him he had never had bipolar disorder. He has had no psychotropic medication since he left home 7 years ago.
Recently I had “Adam’s” story published in the Journal of Clinical Medicine. The article is open access - http://www.mdpi.com/2077-0383/3/2/334 To give you a sense of what he went through for the duration of his teenage years, I quote from his account:
…it goes without saying there was a lot the psychiatrist I was referred to should have asked about if he was ever so inclined.
…Within about three months I was on 8 different medications at one time. Very scientific treatment. All the best – several anticonvulsants, several antipsychotics, a couple antidepressants, and Lithium too.
…My mother fed into my ‘being sick’ and gained a lot of collateral from it. But worse still, it caused complete neglect of any other possible causes of my problems. And my parents in many ways tended to over-interpret every solitary behavior as part of the ‘disease’.
…Everything in my life was screened through the filter of this immaterial ‘disease’.
…a few years after the diagnosis at 12 I started to put some odd pieces of the puzzle together, like: I have this ‘disease’ and it only manifests itself at home and only in the presence of 2-3 people that happen to be a part of my life.
…I always had terrible sedation from the anticonvulsants and atypical antipsychotics. The sedation from divalproex was unmanageable and had a deadening effect on me. When I was initially on 7 or 8 drugs, I had terrible tremors and could not literally think. My head was about as functional as a block of lead and I had severe memory problems. One very embarrassing problem, which at this point I might imagine divalproex is involved with and which my psychiatrist certainly never imagined asking about, was my pubic hair had begun to fall out.
…I also had severe weight gain. From my first contact with these psychotropics, after only 4 months I had gained over 50 lbs. I would subsequently lose it when I would stop the medication myself and then gain it back when I was forced to go back on the medications. This cycle repeated itself 5 times over 8 years.
… I read your papers and letters published in the journals, and I have to tell you it gave me a lot of hope and sort of made me feel like the world is a little less crazy.
The USA’s PBD epidemic and “Adam’s” experience reminded me of an article in the Australian and New Zealand Journal of Psychiatry that had stuck in my memory since my psychiatry training in 1990. Sydney-based Prof Derek Silove reported on his study trip to the USA, where he said there had been “a recent ideological shift in the USA to an extreme biological model of mental disorders. …this monotheistic biologism rejects …the roles of social, cultural and psychological factors in the genesis and treatment of psychiatric disorders.”
In the rest of my article in the Journal of Clinical Medicine [ http://www.mdpi.com/2077-0383/3/2/334/htm ] I analyse how two decades of rampant “biologism” had led to what happened to “Adam”. He suffered over-medicating and horrible side-effects and the corrosive effects of carrying an erroneous pathological label like bipolar disorder on an adolescent’s sense of self and ownership of his emotions. This labelling and identity problem from the diagnosis is something “Adam” is still working through.
The big question is what drove the swing to such an extreme biologism? There was a paradigm shift in psychiatry following the publication of the DSM-III in 1980 from a psychodynamic paradigm influenced by psychoanalysis and the more eclectic common-sense biopsychosocial model to a biomedical reductionist paradigm. This paradigm shift was greater in the USA because of two big business enterprises: (1) the unique privatised US health system that funds care based on diagnoses – rather than severity of problems, and (2) the pharmaceutical industry influence in medical education, research and direct to consumer advertising (DTCA) of prescription medications. DTCA is in fact illegal in all nations outside the USA and NZ.Training in psychiatry in many US medical schools became excessively biological and technological.
A further factor, perhaps accentuated by the individualistic culture of the USA, is seeing problems in individuals alone rather than in relationships between individuals and societal forces. As “Adam” informed me in 2013, his mother developed what sounded like her own case of Munchausen’s disorder, once he left the family home, and his PBD can be construed as a case of Munchausen’s disorder by proxy. Being labelled with a biological disorder provided some access to help while allowing avoidance of the real deeper problems.
DSM symptom check-lists often mean neglect of contextual factors. Even the heads of the DSM-III (Prof Robert Spitzer) and DSM-IV (Prof Allen Frances) task forces have recently lamented this lack of context problem in psychiatric diagnosis. “Adam” eloquently describes it and he elaborated further recently in an online blog discussion about our article. I shall leave the final word to him – click to this excellent blog by American psychiatrist Dr Mickey Nardo - [ http://1boringoldman.com/index.php/2014/04/09/munchausens-by-proxy/ ].
Dr Peter Parry
15 May 2014