Is Bipolar Disorder Overdiagnosed in Children and Adolescents: A Virtual Debate

Kiki Chang, MD; Gabrielle Carlson, MD; Stephen M. Strakowski, MD


September 10, 2010

In This Article

A Multidimensional Approach to Diagnosis?

Dr. Chang: I agree -- but without good biologic markers it is hard to come up with a nuanced diagnostic algorithm. However, perhaps to satisfy the developmental piece, and the spectrum of severity and phenotypes that exist, we could use a staging mechanism as they do in cancer. But this would entail a more longitudinal naturalistic study of BD evolution. For now I always say BD is simply the DSM-IV criteria -- because that is how "we" defined it. But to really understand how what we now call BD is related to what Gaye refers to as Cade's disease, we need a much more nuanced and dimensional approach, including probably genetics, brain markers, family history, and careful elicitation of symptoms, including some outside the DSM-IV criteria.

I agree with Gaye regarding differences between a structured interview like the K-SADS and a clinical interview. Yet, I feel that the K-SADS is not only adequate, but also necessary for a research-based diagnosis of BD. I do not think that is perfect, but given the way BD is currently defined, I feel that it is necessary to attempt to speak the same language across research sites and to inform clinical care. While it is true that still different sites may interpret K-SADS questions differently and use different "anchors," I feel it is still more homogenous and standardized than what happens in the community when practitioners diagnose BD in children. In my clinical practice it is different, as I have integrated more subtle considerations into my diagnosis -- mostly considerations that I can't even describe here due to their abstract form. But to be true to the research field, I try to remove those abstractions for the research diagnostic process. Until we have a better way, then I feel this is the hand we were dealt and adding our own opinions potentially misrepresents the research and makes cross-site comparisons less meaningful.

Clinically I also do this all the time -- I tolerate and share the ambiguity with parents and children. For research purposes, I feel it is, as I wrote above, necessary to have less tolerance for ambiguity unfortunately.

Dr. Carlson: I'd like to put off TDD-D for a minute and address Kiki's PDD comment. I agree with you Kiki. Many of the "bipolar" kids are PDD-like kids. They used to be carried under the "minimal brain dysfunction" category. Or, we used to not ask all of the questions we ask now. I reviewed the 100 UCLA cases that I saw in 1976 for my K-award equivalent a while back for the fun of it and there were several I diagnosed with anxiety disorders that I would now call Asperger's syndrome. I don't know if there are more of these kids now. I see more of them because they are the ones who see me with charts that weigh more than I do. We have a "blind man and elephant" phenomenon according to our referral biases. But, it sure does feel like there are more of them, and DSM is not helping us parse those kids so we'll never know much about them. Jean Frazier and I did a Journal of Clinical and Adolescent Psychiatry special issue (June, 2005) on them several years ago.

By the way, some of those kids made it into our Suffolk County Mental Health Study database. They were just as muddy diagnostically in adulthood as they are in childhood.[8]

Dr. Chang: Yes, I remember that issue and the problem has not disappeared, just increased. I really do feel we are now seeing a wave of atypically developing kids, who have mood dysregulation, a bit of ADHD symptomatology, and PDD-like social deficits and sensory sensitivities. Why? Genetic and environmental interactions is the easy answer, but determining what genes and what environmental factors might be contributing is the tough part. I for one believe in environmental toxins as a significant, although difficult to prove, cause. I wonder Gaye, if you took those 100 cases now, would they look different? More severe? More PDD-like as you mention? Or is it partly that the way we perceive these kids has changed, not the kids themselves? I firmly believe it is not just that.


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