More B.S. About Bipolar Spectrum

A psychiatrist who works at the University of Texas Medical Branch in Galveston occasionally writes for a newspaper for psychiatrists called the Psychiatric Times, which is usually relatively unbiased in its coverage of the field despite heavy advertising from pharmaceutical companies. Dr. Wagner is, however, one of those “experts” who advocate labeling children who exhibit behavior problems with what I believe to be phony brain diseases like ADHD and then drugging them.

We know that true bipolar disorder is a real brain disease that has a significant genetic component. Earlier studies indicated that if you have a bipolar parent, your odds of developing the disorder are 5 to 10 times higher than the general population. Since the prevalence in the general population is about 1 percent, that means you have a five to ten percent chance of developing the disorder yourself. True bipolar disorder usually manifests itself in the late teens or early 20’s, most frequently with a depressive rather than a manic episode. Although rare, I saw one patient who had his very first manic episode in his 80’s!

Doctor Wagner wrote a column about a study by Birmaher and others (Archives of General Psychiatry 2009, vol. 66, pp 287-296) that allegedly studied the children of bipolar patients. Birmaher’s data is already suspect in my mind because a third of his sample of parents was diagnosed with something called “bipolar II” disorder rather than actual manic-depressive illness. In over thirty years of practice and teaching residents in both the public and private sector in two states, I have seen only two or three patients that actually meet the DSM criteria for this supposedly common disorder, and I suspect that these patients were all just mild cases of Bipolar “I,” because they all responded to lithium.

Bipolar II as described in the literature is said to rarely respond to lithium, most likely because it is not bipolar disorder at all. In my experience, many patients seem to endorse some of the criteria for bipolar II when asked about them by a psychiatrist because they really do not understand what the doctor is getting at. This becomes readily apparent if the doctor follows them closely for an extended period of time. As I discussed in a previous post, many patients with borderline personality disorder are misdiagnosed as bipolar II by doctors who use symptom checklists.

The children in Birmaher’s study, according to Wagner, were studied when they were on average about 12 years old. In truth, we rarely have any idea whether a 12 year old is going to eventually have a manic episode. Yet supposedly 10% of the children in the sample were diagnosed as bipolar! This means that they had to have some version of a manic episode, because you cannot tell if a depressed adolescent will turn out to have bipolar disorder or unipolar depression.

Of this group, the rate of Bipolar I in the children was stated to be about 20% of the supposedly bipolar sample. Some 12 year olds actually do have mania and are psychotic, but they are extremely rare. I doubt that the diagnoses of these young children were accurate. Another hint that the diagnoses might be bull was that about three quarters of the allegedly bipolar children were diagnosed with “bipolar NOS.” NOS means “not otherwise specified,” and is now used by those who believe that any moody, difficult or temperamental child has bipolar disorder. Bipolar NOS can be and often is applied to kids with “mood swings” or even temper tantrums that last for only a few minutes! The authors in the study toss out the “Bipolar NOS” term in the paper as if it were a well-validated and well-accepted psychiatric diagnosis.

The authors of the study claim at the beginning of the article that they evaluated the “family environment” of their subjects, but in the study methodology section of the paper, the only environmental factor mentioned as having been evaluated was the family’s socio-economic status. Nothing was said, of course, about the disciplinary practices of the parents.

Interestingly, the rate of post traumatic stress disorder (PTSD) from physical abuse, sexual abuse, witnessing death, or family violence was significantly higher in the “bipolar” children in the study than in the “normal” controls - 16% versus 3%. Now why would children with a supposedly biogenetic disorder like bipolar disorder have a higher risk of being abused? Could it be that a high percentage of the children in this study who were diagnosed bipolar came from dysfunctional families, and the source of their apparent mood swings was family dysfunction? Many of the parents were diagnosed with bipolar II after all, and could instead have severe personality disorders. Furthermore, family dysfunction has to be pretty severe to lead to clear-cut PTSD in a child, so perhaps the 16% feature was just the tip of the iceberg.

Some who want to explain this all away have argued that bipolar kids, being difficult, often create the very chaos that leads to both child abuse and marital conflict. Parents who are frustrated and cannot agree upon what to do with their child frequently do have angry interchanges, and punishment can get out of control. Talk about blaming the victim! Still, I must admit that it is probably true that a difficult child is somewhat more likely to be “punished” with physical abuse than an easy one. But how do the folks advancing this sort of explanation account for the childhood sexual abuse? How do we blame that on a rambunctious child? “She was driving me crazy, so I raped her.” I don’t think so.