This is part 5 of my series on the DSM-5. Previous posts covered general impressions, PTSD, ADHD, and autism.
Though I did not want to focus on the whole pediatric bipolar controversy in this post, it would be hard to discuss bipolar disorder in the DSM-5 without some historical context. Briefly, in the 1990's, different groups of researchers started to apply the label of bipolar disorder to children. Janet Wozniak at Massachusetts General Hospital (see this NPR story for a good summary) characterized a population of children with ADHD (and often oppositional defiant disorder) whose severe irritable moods and tantrums seemed extreme to the point of appearing "manic-like."
Another major proponent of childhood bipolar disorder was Barbara Geller at Washington University in St. Louis. Her perspective was that children who had bipolar disorder were not just irritable or had severe tantrums, but displayed classic manic symptoms like grandiosity, euphoria, and increased goal-directed activity. However, her child patients had these symptoms in much briefer episodes than adults did, with ultra-rapid cycling of moods over the course of a day for many months or even years in a row. This eventually led to a study in which the children and teens who participated had "manic episodes" lasting almost 5 years in duration.
Around the same time, there was certainly a strong trend of adults with chronic irritability (e.g. those with borderline personality disorder, substance dependence, PTSD, etc.) being diagnosed with bipolar disorder because of "mood swings." This is despite the fact that manic or hypomanic episodes have to be episodic (instead of chronic) and present for at least 4 days (for bipolar type II) or 7 days (for bipolar type I) in order to meet the DSM-IV criteria. Clearly, many clinicians just ignore those criteria and go with their gut or with what's diagnostically in vogue. And even though I typically like NOS diagnoses, "bipolar disorder, not otherwise specified" is especially insidious since it allows someone to be diagnosed as "bipolar" even though they've never really had a manic or hypomanic episode.
Using a nonspecific bipolar diagnosis seemed to happen more often with children, since so few have "classic" (or "narrow phenotype") bipolar disorder. It certainly didn't help that many of the manic symptoms seen in adults with
bipolar disorder (increased energy, racing thoughts, hypertalkativeness,
and distractibility) are also found in kids with ADHD. With the publication of the popular book The Bipolar Child, rates of diagnosis of bipolar disorder in children reached epidemic proportions by the mid-2000's, and many kids were put on antipsychotic medications (see this detailed post at 1 Boring Old Man for a good summary).
With respect to bipolar disorder in the DSM-5, it would appear that the proponents of narrow spectrum bipolar disorder have won the day. Thus, there is no change in the DSM-5 definition of mania or hypomania, and no modifications to loosen the criteria in children. The DSM-5 also places greater emphasis on the fact that bipolar is an episodic disorder. The mood disorders work group tried to clean up bipolar NOS as well, adding a category called "other specified bipolar and related disorder," which includes those who have hypomanic episodes lasting 2-3 days, hypomania without a depressive episode, depressive episodes with some hypomanic symptoms, and short duration cyclothymia. Additionally, "rapid cycling" still refers to 4 or more mood episodes per year, rather than what Dr. Geller and her colleagues described.
So what about those kids who seem like they're constantly "manic?" Stay tuned for my post on disruptive mood dysregulation disorder (DMDD).