Wednesday, March 23, 2011

Debunking De Biederman

Joseph Biederman, the Harvard guru who advocates for the use of antipsychotic medication on children, is a psychiatrist who almost single-handedly started the current craze of psychiatrists and primary care doctors diagnosing acting-out children as having bipolar disorder.  I discussed in previous posts some of the issues involved both in Dr. Biederman's behavior and in the diagnosis of "pediatric bipolar disorder," particularly in my post of March 9, 2010, Recipe for Producing Frequent Temper Tantrums in Children.

Dr. Joseph Biederman

Dr. Biederman argued that the symptoms of bipolar disorder in children are very different from those of adult bipolar disorder.  In particular, he said that manic or depressed mood episodes, required by the DSM to last for a minimum of four to seven days in adults for mania and two weeks for bipolar depression, could last for mere minutes in children. Symptoms of bipolar disorder seen in children but not in adults, he opined, included temper tantrums and "explosive irritability."  Not that he had any clear scientific evidence connecting such symptoms to adult bipolar disorder. I'm guessing he just pulled these ideas out of his butt.

Tantrums, rage, emotional instabilty, low frustration tolerance and the like are all symptoms of borderline personality disorder in adults.  These types of symptoms fall under the rubric of affective instability or mood dysregulation, also called neuroticism by personality theorists. 

Individuals high on this variable get depressed, anxious, or angry quite easily and take much longer to calm down than average person. Patients with borderline personality disorder are frequently misdiagnosed as bipolar in the world of today's psychiatry (see my post of April 7, 2010, Borderline or Bipolar?).

Is similar diagnostic bungling being seen today with out of control children who exhibit affective instability?  Well, according to a new review of all of the existing studies in the February 2011 edition of the American Journal of Psychiatry by Ellen Leibenluft, the anwer is quite clearly yes.

From the abstract: "An emerging literature compares children with severe mood dysregulation and those with bipolar disorder in longitudinal course, family history, and pathophysiology. Longitudinal data in both clinical and community samples indicate that nonepisodic irritability in youths is common and is associated with an elevated risk for anxiety and unipolar depressive disorders, but not bipolar disorder, in adulthood.

Data also suggest that youths with severe mood dysregulation have lower familial rates of bipolar disorder than do those with bipolar disorder. While youths in both patient groups have deficits in face emotion labeling and experience more frustration than do normally developing children, the brain mechanisms mediating these pathophysiologic abnormalities appear to differ between the two patient groups."

In the absence of validated biological laboratory tests for a psychiatric disorder, the time course of symptoms, clustering of the symptoms in close family members, and differences in brain physiology and mental abilities on various mental tasks are the most important indirect ways of assessing whether two similar appearing psychiatric syndromes have something important in common. In each of these ways, comparing short-term affective instability to the longer term symptoms seen in bipolar disorder shows that the phenomena are not the same thing.

It is also important to note that irritability is a criterion for at least six different psychiatric diagnoses in children (manic episode, oppositional defiant disorder, generalized anxiety disorder, dysthymic disorder, posttraumatic stress disorder, and major depressive episode).

Of course, not even Leibenluft discusses the possibility that -  just maybe - affective instability in children is reactive to a chaotic family environment.  Interestingly, in an interview in the January 21, 2011 Psychiatric News, she was quoted as saying, "The phrase we commonly hear from parents is that they have to 'walk on eggshells.'"

Translation: the kids in these families are determining what the adults do or say, not the other way around.  A situation in which parents seem to be afraid of their own children is very bad for children, who tend to badly need to be taken care of and given limits by their adult caretakers - despite the kids' protestations to the contrary.  There is very strong evidence from the attachment literature that such situations actually create affective instability in children.

So what might Biederman's answer be to this new data?  Amazingly, according the Leibenluft, Biederman's research group and some other groups maintain that it is "nonetheless reasonable to apply a bipolar diagnosis to children with such a clinical presentation. One important argument for this position is that children with severe nonepisodic irritability manifest severe mood symptoms and are as severely impaired as those with classic bipolar disorder, but without a diagnosis of bipolar disorder their access to the mental health services they need might be limited."  (p.129-130).

Wow. In other words, we should label kids who actually have behavior problems as having bipolar disorder, so instead of doing family therapy, we can treat them with sedating drugs that have not been approved as safe or efficacious in children, and which have a lot of potentially extremely serious toxic side effects (metabolic syndrome) in people including death. 

An amazing display of sick, twisted phony logic worthy of Ann Coulter.

(See a great review of the issues involved in the case of a child named Rebecca Riley who died at the hands of parents who were trying to bilk the psychiatric disability system.  It also shows how easy it is to fool some psychiatrists).


  1. As a therapist, I too am disturbed by Biederman's group applying a BD diagnosis to severe mood dysregulation. However, I am equally disturbed at the pathologizing of families, referring to them as dysfunctional, rather than requiring support and parenting skills. Then again, a book title like "Strengthening Families" would likely not provoke such a strong reaction and thus not sell so many books. Seems to work for Ann Coulter and let's face it, she doesn't seem to be helping too many people with her negativity...

  2. Anonymous,

    I agree with you that families need support and parenting skills, as well as communication skills and anger management and help with their own families of origin. Empathy is even more important.

    But whitewashing significant problems never helped anyone. "Dysfunctional" to me is a relatively benign descriptor.

    There are some folks who will react negatively to just about any word one cares to use, so the use of euphemisms is somewhat pointless.

  3. Dr Allen-
    I am fascinated by your perspective. My husband and I have been dealing with a "diagnosis" of bipolor of my 12 yr old stepson for the past two years, fighting their mother who WANTS to medicate him for his behavioral issues.

    Up until a year ago, she has had physicial custody of the boys for about 75% of the time. All of the extreme issues only occured with her. Not in our home, not in childcare and not in school. She is your definition of a "chaotic family environment". She "walks on eggshells" with him, and both of the boys are clearly IN CHARGE in her home. She herself is on medication for depression and anxiety and is a vicitim of sexual abuse in her childhood.

    After many monthes and multiple provider assessments with everything from ODD to Anxiety Disorder to ADHD (with the last one being a psychiatrist with the bipolar diagnosis who then recanted after six months) as a last resort, my husband made her a deal. Let the boys come live with us and after a year, if the behaviors persisted, he would entertain medication. She begrudgingly agreed, convinced they would continue. Lo and behold- almost everything subsided. The tantrums, the rebelliousness, the crying out of frustrations,the nightmares, the sleeplessness, everything. While he does have social development challenges with kids, as he is sensitive and can have a "short fuse"'s not been a problem that can't be supported with normal parentiing guidance.

    My husband and I aren't perfect by far- but we have always been very consistent with the boys-we are aligned, hold our ground and uphold consequences. The mother has always said they acted up with her because they were "closer to her" so they could be themselves.

    I write all of this to share that the drive for parents to medicate is indeed to "release" them of their parenting inabilities, of their guilt and to find a "reason" other than themselves...that would explain the child's behavior.

    Keep writing, I would loe to learn more from you.

    Thank You


  4. People identify externally with things and when you diagnose them they take on that diagnosis. How they think there helping people is beyond me.

  5. I need his mail ID to discuss about my Research on Bipolar disorder with him. Could anyone pl help??