A Psychoanalytic Perspective on Child Bipolar Disorder

Child Psychoanalyst Critical of Child Bipolar Disorder

Posted Oct 02, 2011

Use of child psychiatric research interviews instead of analytically oriented clinical interviews has contributed greatly to the overdiagnosis of bipolar disorder in childhood, according to child psychiatrist and child psychoanalyst, Timothy Dugan, M.D.  Dr. Dugan has been closely involved with the child psychiatric inpatient unit at Cambridge Hospital in Boston, Massachusetts.  The unit cares for many children who have been diagnosed with bipolar disorder at Harvard-affiliated child psychiatry clinics.  This includes the nationally known child psychopharmacology clinic at Harvard where the diagnosis of bipolar disorder in children was developed and disseminated under the direction of Dr. Joseph Biederman.

Dr. Dugan presented his observations at the Second Annual Psychotherapy and Psychopharmacology Conference of the Psychoanalytic Center of Philadelphia and the Regional Council of Child and Adolescent Psychiatry of Eastern Pennsylvania and Southern New Jersey on September 24, 2011. According to Dr. Dugan, the conflict between the two interviewing strategies gained new urgency with the controversy surrounding the diagnosis of bipolar disorder in children; overreliance on research interviews and underutilization of psychoanalytically oriented play interviews has led to overdiagnosis of the disorder. 

Dr. Dugan has found that many children admitted to the Cambridge Hospital child psychiatric unit for angry behavior and misdiagnosed as bipolar disorder have had traumatic psychological experiences that are related to their anger and misbehavior.  The children's disclosure of these experiences is best elicited with a supportive free play unstructured interview, he believes, in which the child can establish a sense of trust and acceptance with the interviewer.  Often the children have received a structured research symptom-based interview at another site before admission.  According to Dr. Dugan, the structured interview's emphasis upon factual questions, yes and no questions, and interview sessions held jointly with the children and their parents support the children's failure to disclose traumatic events and family conflicts.  He believes that the failure to appreciate the history of trauma and interpersonal conflict in the children's lives, coupled with a need to explain the children's anger, leads to a premature and erroneous diagnosis of child bipolar disorder.

Psychoanalysis, the study and treatment of patients using the theories and techniques developed by Sigmund Freud in the early part of the twentieth century, has largely been abandoned in the search for a more scientific approach to psychiatry.  One of the most important recent innovations in psychiatry and child psychiatry is the structured psychiatric interview.  With the structured interview, each question has been written down in a prepared questionnaire and the interviewer asks the question as written and records the response.  In a semi-structured interview the interviewer has more leeway and may develop follow-up questions as seem appropriate based on the patient's initial response to the prepared questions.  Suggested prompts are provided, but the interviewer can select the prompts to use or can develop his or her own prompts.    Some form of the semi-structured or structured interview is used in all psychiatric research in which a diagnosis is part of the gathered data.  Semi-structured and structured interview questions are aimed at gathering factual information such as presence or absence of symptoms, severity of symptoms, and dates of onset of symptoms.  The reported symptoms are grouped together to confirm or disconfirm a diagnosis.  Providing a rigorous evaluation of symptoms and diagnoses, the structured or semi-structured interview attempts to provide a solid scientific basis for the study of psychopathology in adults and children; it is a major technological advance.

The non-directive play interview favored by psychoanalysts and others contrasts sharply with the structured research psychiatric interview; its purpose is to promote the child's self expression and fantasy life.  Play materials are provided and the interviewer invites the child to play.  The   interviewer comments enthusiastically on the progress of the child's play.  The interviewer may chat with the child about specific issues or symptoms but this is usually done in the latter part of the interview.  This approach to interviewing has been harshly criticized.  If a child enacted two cars crashing, should this be understood as the child having witnessed a conflict between two people, should it be understood as the child having witnessed an automobile crash, should it be understood as the child's taking pleasure in the expression of aggression? Although many criticisms can have been leveled at the non-directive interview as an information gathering tool, it is generally acknowledged to have strengthened the trust or alliance the child had with the interviewer.  According to Dr. Dugan, the development of this trust in the interviewer is a necessary condition for a traumatized child to disclose traumatic events such as physical and sexual abuse.

Dr.  Dugan noted that in many of the early studies of child bipolar disorder the children were never interviewed; rather only the parents were interviewed about their children's behavior.  In later studies the children received structured or semi-structured interviews, not nondirective clinical interviews.  Many structured interviews mandate that the child is interviewed separately from the parents.  Unfortunately, in several NIMH funded studies of bipolar disorder in children, the children and the parents were given the interview together.  Dr. Dugan believes this tended to inhibit the children's complaining about poor treatment from the parent or reporting abusive or sexually assaultive behavior by others.

Another aspect of Dr Dugan's psychoanalytic critique of child bipolar disorder was his discussion of normal manic like defense mechanisms in childhood.  Defense mechanisms, first described by Freud and his daughter Anna Freud, are unconscious psychological devices to reduce anxiety.  In children the manic-like denial of smallness and helplessness in the face of the threatening adult world is normal during childhood.  Denying helplessness by the thought that you can do things yourself (run the school, teach the class) or denying weakness with the thought that you are strong is not pathological manic beliefs but rather healthy defense mechanisms found in normal children.  Those who diagnose bipolar disorder in children, according to Dr. Dugan, mistook those normal defense mechanisms as evidence of bipolar disorder.

The absence of the traditional individual child psychiatric interview from the research child psychiatric evaluation has served to reduce the diagnostic value of the structured psychiatric interview and add to the overdiagnosis of bipolar disorder in children.

Copyright: Stuart L. Kaplan, M.D.

Dr. Kaplan is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created The Diagnosis.