Ellen Leibenluft, M.D. is an important exception to Upton Sinclair’s maxim, “It is difficult to get a man to understand something when his salary depends on his not understanding it.” As the Chief of the Section on Bipolar Spectrum Disorders at NIMH, she might be understood as having a vested interest in promoting the existence and study of bipolar disorder in children and adolescents. Instead, she has been a vigorous advocate for several major studies expected to lead to results that would significantly diminish the use of the bipolar disorder diagnosis in childhood. She provided the impetus for recent follow up studies in which chronically aggressive, irritable children were followed over time. Chronic severe anger and irritability in children and adolescents are the most frequent sources of the misdiagnosis of bipolar disorder in children and adolescents.
The ingenious facet of the studies was to exclude aggressive children with other symptoms of bipolar disorder such as exaggerated self esteem and elation. To oversimplify, these chronically irritable children without other symptoms of bipolar disorder did not develop adult forms of bipolar disorder. They became depressed and anxious several years after they were initially studied. If chronic severe aggression alone were a form of bipolar disorder or a precursor to bipolar disorder, as many believed, it would be expected that the children would develop adult forms of bipolar disorder as they aged. The failure of these children and adolescents with chronic irritability to develop bipolar disorder at follow- up served to provide strong evidence that these children did not have bipolar disorder.
Dr. Liebenluft and colleagues have proposed adding a new disorder to the DSM-V that would provide a diagnostic home for these children instead of the incorrect diagnostic home of bipolar disorder. The DSM-V children’s committee believes these important studies will serve to decrease psychiatrists’ excessive diagnosis of bipolar disorder and is advocating the adoption of the new diagnoses of severe mood dysregulation (SMD) or temper dysregulation with dysphoria (TDD). There are some technical differences between these two diagnoses, but for purposes of this discussion, they can be considered the same diagnosis. It is believed by the DSM-V children’s committee that the chronically aggressive, irritable unhappy children with frequent temper tantrums captured by these diagnoses account for many of those who have been previously incorrectly diagnosed with bipolar disorder.
Some of the specific diagnostic criteria for SMD/TDD are severe recurrent temper outbursts, three or more times per week for the past twelve months, with the mood in between the temper tantrums predominately negative. The patients must be at least six years of age and the disorder must have begun before the age of 10 years. Children and adolescents with symptoms of bipolar disorder are specifically excluded from the diagnosis. For example, an important criterion for the diagnosis is never having had a period lasting more than one day of elevated or expansive mood accompanied by three or more of the following symptoms: grandiosity, decreased need for sleep, pressured speech, flight of ideas, increase in goal directed activity, or other symptoms of mania.
In the NIMH studies the children who met criteria for the SMD/TDD diagnoses were similar in many important areas to those who have been given the diagnosis of bipolar disorder. The level of impairment, the number of medications, and number of lifetime psychiatric hospitalizations was the same in both groups. The SMD/TDD diagnoses seem to be common, with approximately 3.2 per cent of children and youth affected.
Although there are a variety of additional technical issues that the SMD/TDD diagnoses raise, the central issue is whether these diagnoses are mood disorders or behavioral disorders. Mood disorders or “affective disorders” are disorders related to feelings such as depression and mania. Bipolar disorder is a mood disorder.
If SMD/TDD were classified as mood disorders they would likely reappear as a form of bipolar disorder (“bipolar-lite”?) As mood disorders, SMD/TDD would be treated, according to the DSM-V children’s committee, with agents used to treat adult bipolar disorder such as valproate (Depakote) and antipsychotics.
The DSM-IV currently categorizes “Attention Deficit Hyperactivity Disorder and Disruptive Behavior Disorders” differently from “Mood Disorders.” For DSM-V, the choice of how to categorize SMD/TDD will dramatically affect the treatment of the patients diagnosed. If categorized as a Mood Disorder, the children and adolescents so diagnosed would be less likely to receive stimulant medication to treat their frequently co-occurring ADHD, and would be more likely to receive drugs used for the treatment of adult bipolar disorder. Stimulants for ADHD are often incorrectly believed to make bipolar disorder worse and are often withheld.
Understanding that SMD/TDD children have ADHD and, typically, the disruptive behavior disorder “oppositional defiant disorder” (children refusing to do what they are told to do) leads to safe effective treatment recommendations. ADHD is often (80-90%) successfully treated with stimulant medication. The difficulties with behavior such children may continue to display such as defiance, temper tantrums and irritability can usually be managed with a behavior modification program.
The DSM V children’s committee continues to ponder whether to consider SMD/TDD as mood disorders or behavior disorders.
Copyright: Stuart L. Kaplan, M.D.