Disruptive Mood Dysregulation Disorder Revisited

In the brief history of this blog, the post where I shared my thoughts on DSM-5's disruptive mood dysregulation disorder (DMDD) has gotten by far the most pageviews. It's been almost two years since I wrote that post, and I would like to revisit DMDD with some updated thoughts on this diagnosis.

As you may recall, DMDD sprang out of a desire to have a diagnosis other than "bipolar disorder" to describe children who are chronically irritable and have explosive tantrums. Almost all of the children with DMDD also meet the criteria for oppositional defiant disorder (ODD) and are at higher risk of developing depression but not mania. The NIMH researcher Ellen Leibenluft, whose work on severe mood dysregulation (SMD) strongly influenced DMDD's creation, had commented in the past that she was not 100% sure that DMDD was a good idea.

In the last few years, I have only seen a handful of children who met the criteria for DMDD. Here is what I noticed in my own practice:

• One boy was being raised by a single mother who worked full time, so his grandparents were very involved in childrearing. The mother tried to set rules, but the grandparents were much more permissive, and whenever the mother tired to enforce her rules, explosive tantrums resulted.
• Another boy was very violent toward his mother on an almost daily basis. His father was home but did not intervene, while the mother had anxiety and literally appeared fearful of her son during their visits with me. When he hit her, she would tell him verbally that it was wrong, but did not do anything else (like using a time-out) to try to change his behaviors.
• There was a girl (who I'd written about previously) whose mother was very emotionally distant and pulled away further every time the girl acted out because the mother was reminded of her own emotionally intense mother. This distancing seemed to lead to the daughter becoming even more irritable.
• And then there was a boy who was extremely aggressive at home, constantly fighting with his 3 siblings. The household was very chaotic, with parents still married but frequently arguing with each other. Both parents often resorted to spankings, which did not seem to decrease the boy's aggression or irritability.

Certainly, correlation between the parental characteristics and the children's behaviors does not tell us about causation. It is very stressful raising irritable, explosive children, and the children described above definitely had intense, strong-willed temperaments. My intuition is that it's an interactive process where both parental and child characteristics trigger maladaptive behaviors in each other that escalate over time. But are these families typical of cases of DMDD? I searched Pubmed for "disruptive mood dysregulation disorder" and found 20 papers published in the last 2 years (out of 29 total).

Of the 20, most were reviews/commentary, and only 6 papers were original research. One was a brain imaging study looking at "neural mechanisms of frustration in chronically irritable children." Another examined the prevalence of SMD 2 and 4 years out from initial diagnosis, and found that 40% still met full criteria at 4 years, but a significant number not meeting the criteria were still moderately impaired. Another study from Duke's developmental epidemiology program used a large database to examine the adult outcomes of those who would have met DMDD criteria as children and found higher adult rates of depression, anxiety, adverse health outcomes, impoverishment, police contact, and lower educational attainment.

To my pleasant surprise, there were actually several papers that included data on family characteristics of children with DMDD. The first was a cross-sectional study of a community sample of 6 year-old children, which found that 8.2% of them met DMDD criteria based on a structured interview of parents. Impressively, the study examined 6 domains ("demographics; child psychopathology, functioning, and temperament; parental psychopathology; and the psychosocial environment") for correlates of DMDD. The parents were also interviewed about what things had been like when their children were 3 years old, and here's what the researchers found:

The age 3 years predictors of DMDD at age 6 years included child attention deficit hyperactivity disorder, oppositional defiant disorder, the Child Behavior Checklist - Dysregulation Profile, poorer peer functioning, child temperament (higher child surgency and negative emotional intensity and lower effortful control), parental lifetime substance use disorder and higher parental hostility.

The second study was a prospective one that "followed 317 high-risk children with early externalizing problems from school entry (ages 5-7) to late adolescence (ages 17-19)." The children sorted into 3 groups by the time they were adolescents: one group with conduct/criminal problems and anger, one group with mood dysregulation, and one group with a low level of symptoms. The authors found that generally, those who were more overtly aggressive as children tended to have conduct problems as adolescents, while more emotionally dysregulated children had more mood dysregulation in adolescence. The key finding:

For children with early emotion dysregulation, however, increased risk for mood dysregulation characterized by anger, dysphoric mood, and suicidality - possibly indicative of disruptive mood dysregulation disorder - emerges only in the presence of low parental warmth and/or peer rejection during middle childhood.

Another study (with 13! authors) was published in a much more prestigious journal than the previous 2 papers, and to me it was the least enlightening. The study examined the risk of DMDD in offspring of parents with bipolar disorder and found a much higher risk of DMDD (odds ratio = 5.4 "when controlling for demographic variables and comorbid parental diagnoses") compared to offspring of control parents. Given what those two other studies found, I'm not surprised that parents with bipolar disorder, one of the most severe psychiatric illnesses, would have children at risk of DMDD.

One last noteworthy paper that turned up in my Pubmed search is a recent article on whether DMDD should be included in ICD-11. The International Classification of Diseases is the World Health Organization's standard system for classifying every health problem imaginable, and the 11th revision is due in 2017. Even in the U.S., the ICD diagnostic codes are the standard for coding and billing purposes, and each DSM diagnosis is mapped to a corresponding ICD code. In this paper, the authors, who were members of a task group convened by the WHO to provide recommendations on the classification of disruptive behavior disorders, wrote:

The task group has recommended that WHO not accept DMDD as a diagnostic category in ICD-11, but rather approach the issue in an alternative, more conservative and more scientifically justifiable way. Specifically, the group has proposed that ICD-11 include a specifier to indicate whether or not the presentation of ODD includes chronic irritability and anger. We believe this option provides the most parsimonious basis for identifying and appropriately treating children with this maladaptive form of emotional dysregulation.

In my previous post on DMDD, I thought that it was overall a positive step away from the rampant over-diagnosis of pediatric bipolar disorder. But I did not end up using it; I was not about to diagnose those children with bipolar disorder in the first place. Thus, I find myself agreeing with the WHO task group. With ODD, the standard first line treatments are interventions that help parents better manage their children's behaviors and/or improve the parent-child relationship. I still worry about drug companies trying to market a medication for DMDD that supposedly targets a problem in the brain of the child. Thankfully, at least Abilify hasn't been approved yet for treating DMDD and hopefully never will, having gone off-patent this year.

The Impact of False Diagnostic Labels

Back in April, an extraordinary article was published by Dr. Peter Parry, an Australian child psychiatrist, about his correspondence with an American adolescent who had been diagnosed with pediatric bipolar disorder (PBD) during the PBD craze in the early 2000's. I had linked to the article on Twitter, but I haven't had a chance to write about it until now.

The power of this article comes from the fact that it includes a detailed first-person account from the patient "Adam." He comes across as an extraordinarily thoughtful young man, who had a tragic but far from uncommon encounter with psychiatry. Here's what Adam had to say about being diagnosed with PBD and treated:

I was 12 when first diagnosed. I had suffered depression and anxiety including severe OCD, which has since disappeared. It should also be mentioned I come from a screwed-up family and was physically abused by a sibling. Parents divorced young. My mother had a lot of issues, etc. So it goes without saying there was a lot the psychiatrist should have asked if he was ever so inclined. But unfortunately, he holds a faculty appointment at [edited—A PBD oriented child and adolescent psychiatry clinic].

Within about three months, I was on 8 different medications at one time. Very scientific treatment—all the best—several anticonvulsants, several antipsychotics, a couple of antidepressants and lithium too.

Things got so bad, that I ended up being referred to the neurology department, for different opinions about strange symptoms I began having on this cocktail. Which resulted in their giving me a working diagnosis of some kind of mitochondrial myopathy. "Bipolar plus mitochondrial disease" as it went. Which I have been told only recently could have been precipitated by the huge amounts of divalproex I was taking. The symptoms quickly disappeared when I coincidentally stopped the drug for unrelated reasons. Oh well, but it is a clear illustration of what one of the "best" academic medical centers in the world has to offer a struggling young boy.

And here is Adam's perspective on how the diagnosis and treatment affected him:

But the worst part of this, which I have only been recently able to shake within the last year (2008/9), is the defectiveness I felt. Just kind of in some core way. Like I'm totally different. When I was younger, that feeling was a lot stronger and more prominent. Now I feel like a fool for even having given thought after eight years to the question of whether I might go to sleep one night and wake up manic. I decided with my (new) psychiatrist's support a year ago to stop my medicines. I’m not doing especially well now, but I have at least been able to shake the feelings the diagnosis itself carved into me. The same can’t be said for its physical and social effects though.

It's not just children and teenagers who are vulnerable to being misdiagnosed with bipolar disorder; it can even happen to an NBA millionaire. A couple of weeks ago, I read one of the best articles that I've ever encountered on mental health in professional sports, titled "Why Isn't Delonte West in the NBA?" As a casual basketball fan, I knew that West had been a part of the Cleveland Cavaliers during the LeBron James years. I've heard that he struggled with mental illness and had been diagnosed with bipolar disorder. I recalled that he had been arrested after being found driving around with multiple weapons, and there were even rumors that he had slept with LeBron's mother. But this article provides the inside story of what actually happened, and the facts were deeply unsettling.

Delonte West grew up without a stable home, with a single mother who worked multiple jobs just to keep afloat after his parents divorced.

West has an older brother, a younger sister, and a vast extended family that he refers to as "a village." He stayed with many of those relatives growing up. "I lived off of every exit," he says, rattling off 11 specific ones from memory. "I lived in so many apartments … with cousins, uncles, and aunts, just making it."

In the NBA, he had several outbursts of anger, which led to him seeing a psychiatrist.

West was diagnosed as bipolar by a D.C.-area specialist. He says that when he saw the doctor, he’d been feeling down, having days when he was sad and tired and didn’t want to get out of bed. But he told the specialist that there were also times when he "might just go out and buy a car. Or go to the mall and spend 25 grand." West doesn't think the doctor took into consideration that such behavior might not be unusual for a professional athlete with a big paycheck. He now thinks that he was suffering a temporary bout of depression, not exhibiting symptoms of a chronic disorder.

Another part of the article provided additional context for West's inner struggles:

As a kid, moving from school to school, he often found himself the target of playground taunting. "I was real funny-looking," he says, with big ears, a mole on the back of his head that he had removed once he got to the NBA, and a birthmark below his lip that he's also had partially removed. His light skin and red hair stuck out, too. "I was made fun of a lot growing up, but I just knew the basketball court was the place where you couldn’t make fun of me, you had to respect me." He says he always had "more jokes for me than you had," but that he internalized the cruel things kids said to him. Last year, West told an interviewer that he believed his real problem was not bipolar disorder, but "self-loathing."

This was what actually happened in the weapons incident that contributed to derailing West's NBA career:

It was the offseason, and a few of West's cousins had come over to his house with their children. West's mother was looking after the kids while he slept and the other adults went out. At some point in the evening, West's mother woke him up. She said the kids had gotten into a closet in his small, in-home music studio, where he stored guns that he had bought, legally, in Cleveland. He needed to do something about those weapons, she told him.

With the driveway crowded by his cousins' cars, West got on his motorcycle so he could bring the guns to another residence. Earlier in the evening, he'd taken Seroquel, which is often prescribed for bipolar disorder. Seroquel makes you drowsy, and as he headed out on the highway, he found that he was dozing in and out. After he felt himself drifting off, West was pulled over for making an unsafe lane change, and he told the officer that he was carrying weapons. The day after the arrest, a police spokesman said that West was "very cooperative the entire time."

After his arrest, West played for the Cavaliers for another season, but the article makes the plausible argument that because West had been labelled with a mental illness, people were willing to believe whatever crazy things they heard about him, including the false rumor that he had slept with his teammate's mother. Undoubtedly, taking Seroquel contributed to his arrest. Without the "bipolar disorder" label, if instead the narrative had been that West had emotional issues due to childhood stresses, he may well still be in the NBA.

Earlier this week, Dr. David M. Allen had a blog post on misdiagnosis: "Is Your Psychiatrist Committing Malpractice Even if Doing What a Lot of Other Psychiatrists Are Doing?" (The short answer is "yes.") However, according to Dr. Parry's article, when Adam looked into his legal options, he was told "his treatment would be deemed 'standard practice' where he lived," which is a big deterrent for the lawyers when it comes to medical malpractice lawsuits. What a sad irony: the crappier the standard diagnosis and treatment becomes, the more the practitioner is protected by the herd.

When I was in medical school at a very biological psychiatry-oriented institution, the psychiatry professors made sure to educate us on the past evils of blaming refrigerator mothers for schizophrenia. And yet, as Dr. Parry pointed out, we have gone from the "brainless psychiatry" of the psychoanalysts to today's symptom-focused "mindless psychiatry" that tends to ignore the patient's inner life and the developmental biopsychosocial context. Here is my favorite section of Dr. Parry's article:

In addition to being a method of inquiry, science is a social process and there is a vast research literature concerning the sociology of science. Scientific disciplines do not build on knowledge in a purely linear fashion, but at times undergo dramatic upheavals according to paradigm shifts. The dominant paradigm governs what is acceptable to study, research, publish and practice. Softer sciences like psychiatry can be more susceptible to extreme paradigm shifts. The history of psychiatry reflects this. 

One of my biggest frustrations while reading Dr. Parry's words is that his wisdom is relegated to an opinion article published in a little known open-access journal, while the leading child psychiatry journal, which claims to be "advancing the science of pediatric mental health and promoting the care of youth and their families" [emphasis mine] would never permit such a sharp critique within its pages.

Why Aren't Mental Conditions Like Physical Ones?

Earlier this week, Dr. David Rettew tweeted me his article on Psychology Today, "What If We All Got Mentally Ill Sometimes?" I thought it was well reasoned and thought-provoking. Here's the last paragraph, which summarizes his argument:

What I am really trying to say here, I think, is that scientifically there is very little to go on to help us figure out where the lower thresholds of psychiatric disorders actually exist. To deal with this reality, we can either reserve the term mental illness for those with the most extreme levels of pathology or admit that the brain, the most complicated thing that has ever existed on this planet, gets a little off track once in a while for most of us and needs a little maintenance.  This maintenance does not and should not be confused with prescription medication or five times per week psychotherapy for all.  There needs to be some productive middle ground between a response of, for example, “It’s ADHD and you need this medication” and “It’s not ADHD (or there is no ADHD) so go home and fend for yourself.” 

My quick response was:

@pedipsych I'm sympathetic to your POV, but in our current culture, more diagnosis = more meds. So better to tackle 15 min med checks 1st.
— Psycritic (@psycrit) March 11, 2014

Here, I'd like to expand on my thoughts a bit more.

In an ideal world, everyone would recognize that the brain is the most complex organ that we have, indeed the most complex object that we know of in the universe. Thus, it would not be surprising that it does not function perfectly all of the time, and putting a label on what (we think) is going on would be as unremarkable as calling an upper respiratory viral infection "a cold." Just as most people get sick with colds twice a year, or suffer multiple orthopedic and soft tissue injuries throughout their lives, shouldn't mental conditions be as commonplace and non-stigmatized?

The problems, though, are many-fold. The first is what happens when someone shows up at the doctor's office looking tearful, depressed, or anxious. The majority of psychiatric medications are already being prescribed by primary care providers. As a medical student, I got to see many general internists rushing from one patient to another, spending 10-15 minutes on each encounter. These doctors had very little time to spend delving deeply into their patients' lives (this answers 1boringoldman's question, "what's the hurry?"). The more patient docs would listen empathetically for a few minutes, and then offer an SSRI or benzodiazepine, letting the patients make the choice as to whether they would like to try medication. So if more people thought that they had some kind of mental condition, more would probably opt for the meds. Psychiatrists, of course, should know better, but we are often just as culpable in taking a "medication-first" approach to treatment, especially when working in settings where we function as little more than medication prescribers/consultants. As the saying goes, if all you have is a hammer…

Dr. Rettew tweeted the following response:

@psycrit In our child psychiatry clinic, 15 minute med checks are banned. It is possible.
— David Rettew (@pedipsych) March 11, 2014

I think it's wonderful that his clinic doesn't do 15 minute med checks. Most child psychiatry clinics at least acknowledge the importance of parents in a child's life, so the minimum is usually 30 minutes to allow time for a psychiatrist to work with the whole family. Unfortunately though, that method of practice is not the default for most mental health care that takes place in this country, and I worry about what will happen with the increased adoption of collaborative care models (nice anecdote here).

What Dr. Rettew proposes requires an adequate framework to provide checks and balances, i.e. using a true biopsychosocial model so that what is happening in the brain is not the only point of emphasis. A (very) rough analogy would that the use of needles to inject medications directly into the body can be a good thing, but it requires a framework of basic sanitary practices like sterilization of used needles and/or disposal, without which the technology could actually cause more harm than good. In The Hot Zone, for example, Richard Preston described how re-use of dirty needles led to ebola outbreaks in Africa. Another example, detailed by Steven Pinker in The Better Angels of Our Nature, is that when democracy replaces autocracy in places that don't have a culture that values pluralism and human rights, the result is often even more chaos and bloodshed.

Additionally, the effect on people of telling them that they have a brain condition is vastly different from telling them that they are suffering from indigestion or hypertension because of the stigma associated with mental illness. I don't think that labeling a significant proportion of the population with a mental illness is a good way of overcoming this stigma, especially when most doctors do not have time to explain the nuances behind psychiatric diagnosis to their patients. To the average patient, a diagnostic label implies a level of knowledge that we do not have. I have seen multiple cases where after receiving a diagnosis with inadequate explanation, patients have felt that there was something wrong with their brains, which for many resulted in more harm than good.

Overall, I agree with Dr. Rettew's message that there should be some middle ground between "diagnose + medicate" vs. "no diagnosis + no treatment." However, I don't think that the medical model is well suited for much of mental health since what contributes to both mental anguish and well-being is so multifactorial. That is why I love NOS/NEC, and I often find myself using "no specific diagnosis + multimodal treatment."

A Child Psychiatrist's Thoughts on DSM-5: Disruptive Mood Dysregulation Disorder

This is part 6 of my series on the DSM-5. Previous posts covered general impressions, PTSD, ADHD, autism, and bipolar.

One of the most controversial additions to DSM-5 has to be disruptive mood dysregulation disorder (DMDD), née temper dysregulation disorder with dysphoria (TDDD). The name was supposedly changed because some objected to the negative connotations of saying a child has a temper disorder. This diagnosis tries to answer the question: "So what do we call children who display chronic irritability and have severe tantrums, but do not really have the classic manic or hypomanic symptoms of bipolar disorder?"

The DMDD diagnosis largely grew out of research by Ellen Leibenluft at the NIMH. Her studies examining "broad phenotype" bipolar disorder (the kind of BD advanced by Wozniak, Biederman, et al, which Leibenluft prefers to call "severe mood dysregulation", or SMD) showed that children with this condition were more likely to be diagnosed with depression as young adults, but did not appear at elevated risk of developing actual manic episodes. JAACAP just published a very good review article in May that summarizes the differences between SMD and bipolar.

The DSM-5 mood disorders work group took SMD and modified it to become DMDD. The two are largely similar, with the main difference being that DMDD does not require hyperarousal symptoms such as insomnia, racing thoughts, or intrusiveness. One can certainly argue that there's less evidence to support SMD/DMDD as a distinct entity than there is for other conditions (such as melancholia) which did not end up in the DSM-5 as a separate disorder. Obviously, the DSM is based on an expert consensus process, which reflects politics and cultural trends, not just science. This is neither good nor bad, but just the way the DSM has always been.

Most online reports about DMDD that I have seen have been wrong or misleading (example 1, example 2) because they tend to focus on the mistaken notion that DMDD is just about temper tantrums. The actual diagnostic criteria include: 1) Severe recurrent temper tantrums, inconsistent with developmental level, that are out of proportion to the situation, occurring 3+ times per week; 2) Mood between tantrums is angry or irritable for most of the day, almost every day; 3) Symptoms have lasted more than a year; 4) Must be present in at least 2 settings (school, home, peers).

The symptoms must have an onset by the age of 10, so that the irritable mood of adolescence does not become a confounding factor, and the diagnosis cannot be made for the first time before age 6 or after age 18. The diagnosis also supersedes oppositional defiant disorder (ODD), and can be viewed as a more severe form of ODD. These are pretty stringent criteria, designed specifically to capture severe impairment. In Dr. Leibenluft's SMD population, around 38% of those children have had at least one psychiatric hospitalization. In the past year, I have seen 2, maybe 3 children who would meet the criteria for DMDD.

At last year's American Academy of Child and Adolescent Psychiatry meeting, Dr. Leibenluft, when asked about the new DSM-5 diagnosis, said "I'm about 65% pro-DMDD." I think that's as good an illustration as any that there's very little certainty in psychiatry, and there are pros and cons to the creation of any new diagnosis.

In this case, I think it's good that there is an alternative to labeling irritable, tantrum-prone children as having bipolar. Currently, like ODD, there are no medications for DMDD, so the focus should be on psychotherapeutic and family interventions. On the other hand, I'm sure many folks will end up ignoring the diagnostic criteria altogether and call any tantrum-prone child "DMDD." Also, I'd be surprised if Abilify does not become FDA-approved for treating DMDD by 2016.

Update (4/15/15): I've written a new post with my current thoughts on DMDD, including a review of recent research. You can read it here.

A Child Psychiatrist's Thoughts on DSM-5: Bipolar Disorder

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).

A Most Influential Professor

On the first day of Abnormal Psychology class, The Professor sat on stage, just him with his cane, no notes or Powerpoint. His jowls hung low, giving him a bulldog look. Instead of appearing mean, however, he seemed almost bored, in a wizened sort of way. The Professor began by asking the class to come up with all of the different names that exist in our culture for someone who is "crazy." Students got into it, enthusiastically shouting out dozens of nouns, ranging from the clinical (psychotic, delusional) to the pejorative (nutso, wacko). A graduate assistant wrote all of the words down on a chalkboard while The Professor continued to sit, expressionless. There were almost 50 words on the board by the time people started running out of ideas. "What is the purpose of all these words," The Professor asked us, before answering himself that they are labels, used by those who were "well" or "normal," to define those who were "not normal."

He proceeded to launch into an explanation of his background. "I am an insight-oriented object-relations psychodynamic psychotherapist," he began, and while I had no idea what that actually meant, I was impressed by his certainty. Mental illnesses, he explained, are nothing like physical illnesses. Psychiatric labels are cultural inventions, a "word game" that cannot be separated from the time and the place in which those words originated. "I do not believe in biological reductionism or determinism," he continued, speaking in composed paragraphs to students who were used to hearing bullet points. He lamented how biological treatments have taken over much of mental health, and he told us that we would spend little class time covering conditions like depression, anxiety, or schizophrenia. Instead, he focused on conditions for which there were no medications (at least at the time): Conversion and other somatoform disorders, dissociation, addictions, eating disorders, and of course, personality disorders.

Over the course of the semester, The Professor repeatedly emphasized to us that human traits are on a continuum, even though the DSM tried to fit everything into discrete categories. He used his own dimensional scale to rate each patient on various traits such as impulsivity, neuroticism, and even adaptive regression in the service of the ego. He staged live demonstrations in front of the class in which he interviewed actors trained to portray patients with various psychopathologies; the auditorium was so crowded on those days that I'm convinced he could have sold tickets.

The Professor told us many stories, colorful and memorable. He mesmerized us with tales of 18th century mass hysteria. He lectured authoritatively on the superego lacunae present in those with narcissistic and antisocial personalities, and I could not help but visualize Swiss cheese. He recounted many of his own experiences with patients, especially those with histrionic and borderline personalities, whom he described as very "kiss kiss bang bang." Though I missed the James Bond reference (there was no Google back then), that description still strikes me as particularly apt.

Of course, The Professor was far from infallible. Humility and self-doubt were not part of his repertoire. He was prone to broad generalizations, delivered matter-of-factly: Bulemics were histrionic and attention-seeking, while anorexics had more severe super-egos and conflict with their mothers. Women who were sexually abused as children became obese as an unconscious defense against further advances. People who suffered severe enough abuse could develop multiple personalities as a way of coping. The Professor, after the first day of class, never stooped to acknowledge any other perspectives besides those which he knew to be true.

A friend of mine, who took Abnormal Psychology with a different professor, hated the class because his professor treated the DSM diagnoses as if they were naturally-occurring phenomena like planets or animal species. Looking back on my journey through psychiatry, this was often the perspective of the teachers I had from medical school onward. Therefore, I'm especially glad I had The Professor so early on. He was not a big name at the university, as a clinical psychologist in a department filled with researchers and "cognitive neuroscientists." Yet he has influenced me more than anyone else with regard to how I think about psychopathology and psychiatric diagnosis. In particular, the dimensional system just made sense. The DSM-5 even incorporates some dimensional scales to rate symptom severity, though I was disappointed when the APA Trustees voted down efforts to add a dimensional element to personality disorders in DSM-5.

I also learned from The Professor the importance of recognizing the limits of our knowledge and perhaps why psychoanalysis had fallen out of favor, even though those were not lessons he was explicitly trying to teach.

A Child Psychiatrist's Thoughts on DSM-5: Autism

This is part 4 of my series on the DSM-5. Previous posts covered general impressions, PTSD, and ADHD.

Quick, according to the DSM-IV section on pervasive developmental disorders (PDDs), what are the differences between autism (offically "autistic disorder"), high-functioning autism, Asperger syndrome, and PDD not otherwise specified (PDD-NOS)? If you can tell me without looking it up that autism requires 6 total symptoms from 3 categories, Asperger syndrome requires 3 symptoms from 2 categories, PDD-NOS requires only 1 symptom, and there's no such thing as "high-functioning autism" in DSM-IV, then you're much more knowledgeable than I am.

Hopefully, it is easy to see why the workgroup tasked with revising the autism diagnosis in DSM-5 tried to simplify this complex chimera into something more comprehensible. Most experts post-DSM-IV have concluded that all of these conditions overlap quite a bit and are best conceptualized as different presentations along a continuum (clinically-speaking, of course; research into etiology is a whole different ball of wax). Hence the term autism spectrum disorder (ASD). Academia has favored using ASD instead of PDD for a while now, and this seems to have filtered into the popular culture over the past decade, as you can see in Google Trends. So what does the DSM-5 change when it comes to the diagnostic criteria for autism?

The 3 categories of autism symptoms in DSM-IV encompass impairments in social interaction, communication, and repetitive or stereotyped patterns of behavior. DSM-5 eliminates the communication category, partly by combining social communication deficits (such as difficulty initiating or sustaining a conversation) with the other social impairments (such as inability to make eye contact or share enjoyment) into one category. Thus, the 2 categories in DSM-5 are "social communication & interaction" and "restricted, repetitive behavior," and impairment in both have to be present to diagnose someone with ASD. The restricted behaviors can now include hypo- or hypersensitivity to sensory stimuli, which is seen in many who are on the spectrum. Language delay, which formerly distinguished autism from Asperger syndrome, is no longer part of the criteria for diagnosing ASD, since that is now felt to mainly reflect differences in IQ.

The impairments can also be "by history," which means that a child who previously had inability to make eye contact but improved after behavioral therapy can still have that count towards the diagnosis. The age criterion has been changed from "onset prior to 3 years" to onset during the "early developmental period." As with many other parts of DSM-5, there is now a dimensional aspect, with 3 different levels of ASD severity based on the extent of impairment in each individual. Also, different specifiers can be added to the diagnosis, e.g. ASD with intellectual disability, or speech delay, or regression in functioning, or specific genetic conditions.

No change is without controversy, and there are some big ones here. Not surprisingly, the elimination of Asperger syndrome as a separate entity sparked an outcry amongst some in the Aspie community. Another controversial aspect is that ASD, unlike other entities such as ADHD, now actually has tighter diagnostic criteria than some of the previous PDDs such as Asperger's and PDD-NOS, resulting in fear that some who already have those labels will lose their diagnosis after the DSM-5 comes out. In this month's Journal of the American Academy of Child and Adolescent Psychiatry, members of the DSM-5 Neurodevelopmental Disorders Workgroup sought to reassure the public (subscription required):

With respect to the PDDs, the DSM-5 has essentially moved from letter grades to a “pass-or-fail” system. Everyone with an existing autistic disorder, Asperger disorder, or PDD-NOS diagnosis (e.g., “A,” “B,” “C”) should simply be reassigned (e.g., “pass”), and not formally rediagnosed unless there is some clinical reason to do so.

It will be interesting to see whether this guidance is followed out in the real world. While the DSM-5 taketh away, it also giveth, in the form of a new category called social communication disorder (SCD). This diagnosis is for someone who has difficulties with "using verbal and nonverbal communication for social purposes" but no restricted, repetitive behaviors. Some of the people who previously would have been diagnosed with PDD-NOS would likely fall under this category. It will also be all too easy to conclude that the DSM-5 is pathologizing social awkwardness and turning it into a disorder, just as many felt that DSM-IV turned shyness into a disorder called social phobia. The truth, unfortunately, will take time to emerge and will likely be complicated, as in the case of shyness vs. social phobia.

For me as a practicing clinician, the new ASD diagnosis is one of the best changes in DSM-5. Soon, I may not even have to reach for a reference book to see if someone meets criteria for an autism spectrum disorder.

NOS Is Dead; Long Live NEC!

In a recent Shrink Rap post on the DSM-5, Dr. Steven Reidbord wrote the following comment:

I don't have much to add regarding DSM 5. I use DSM codes on super-bills I give to patients, so they can receive partial reimbursement by their health plans after paying me directly. Most of the time I use 300.00 (nonspecific anxiety) or 311 (nonspecific depression), and occasionally "parity" codes for major depression etc. I've read all the controversy over the new edition, and it saddens me that our field is so distorted by politics and money. However, I don't see it affecting me much directly.

I have to say that I, too, often use ICD (not DSM) codes 300.00 and 311, which in the DSM-IV are called anxiety disorder not otherwise specified (NOS) and depressive disorder NOS. Working with kids, two other favorites of mine are mood disorder NOS (296.90) and disruptive behavior disorder NOS (312.9). Why such a penchant for such nonspecific diagnoses? Well, for one thing, I believe it truly reflects the patients that I see. I often hear patients or family members talk about "rages" or "anger outbursts" or "mood swings" lasting minutes to hours, none of which are well-captured by a current DSM diagnosis.

I also think that the NOS diagnoses allow clinicians to be humble, by not claiming to know more than we do about the etiology of a patient's condition. Since there are no medications approved to treat NOS diagnoses, to me they feel less "biological." For example, when I say a child has "mood disorder NOS, disruptive behavior disorder NOS, and a parent-child relational problem," I am describing a child that is moody, often has tantrums, and does not get along with his parents. I explicitly say to the parents that I'm not saying there's anything biologically wrong with their child, that these are behavioral problems that can have a multitude of causes, including family dynamics, and that what's going to ultimately make things better is not a pill.

One criticism I've often heard about using a NOS diagnosis is that it is lazy, something done by a clinician who hadn't bothered asking enough questions to reach a firmer conclusion. This is certainly possible. However, in my practice I've generally seen the exact opposite (especially in a Medicaid clinic where I worked): Many patients being diagnosed with schizophrenia or bipolar disorder type 1 or major depressive disorder, when it is clear to me that they never met the criteria for those conditions in the first place. This "mania" for reaching a firm diagnosis, I believe, is largely driven by a need to medicate. If all you have is a hammer, everything looks like a nail.

Thus, I was somewhat peeved to read last year that one of the explicit goals given to the DSM-5 workgroups was:

Eliminate "not otherwise specified" (NOS) diagnoses within categories

The rationale for them wanting to do this is obvious. As blogged about elsewhere, the DSM-5 leadership had hoped to move diagnosis onto a firmer biologically-based footing, and what can be more "fuzzy," biologically-speaking, than diagnoses for which there are only loosely defined criteria? Not surprisingly, the biological psychiatrists had an "epic fail" when it came to biologicalizing DSM-5. Thus, even though DSM-5 has technically eliminated NOS diagnoses, nonspecific conditions will live on in the form of Not Elsewhere Classified (NEC). Here's the difference in their definitions:

NOS: Not Otherwise Specified - This designation is equivalent to the word "unspecified" and indicates that the documentation does not provide enough information to assign a more specific code.

NEC: Not Elsewhere Classified - This designation is used to indicate there is no separate specific code available to represent the condition documented. In this case, the diagnostic statement is specific, but the coding system is not specific enough.

What can I say, except that this actually looks like progress? Clinicians like Dr. Reidbord and myself can not only continue using our fuzzy nonspecific diagnoses, but also instead of having NOS imply that we're lazy clinicians and didn't document enough, we'll be using NEC and implying that it's the coding system (DSM-5) that's inadequate.

A Child Psychiatrist's Thoughts on DSM-5: ADHD

This is part 3 of my series on the DSM-5. Previous posts covered general impressions and PTSD.

If you've been reading the nation's leading mental health blog, you will have been inundated with news and opinion about the rising rates of Attention-Deficit/Hyperactivity Disorder (yes, the hyphen and the slash are both there in the DSM-IV) and abuse of prescription stimulants by college kids. And you may even have come across DSM-5 Taskforce Chair David Kupfer's letter to the editor, in which he defended the DSM-5 by saying "revisions were aimed at helping clinicians more precisely recognize the symptoms of individuals with A.D.H.D. to facilitate the right care for the right person."

Less clear from those articles is what exactly is changing in the DSM-5 when it comes to ADHD, and I hope this post would shed some light on that. But first, some background on the challenges of diagnosing ADHD. Something as broad as an "attention deficit," as dependent on many different parts of the brain working together, and as prone to abuse is inherently going to be a mess when it comes to "accurate" diagnosis. Who can really say at what point "laziness" or "prefers hands-on learning" becomes "ADHD, predominately inattentive?" Thus, misdiagnosis is rampant, and there is a problem of both over- and under-diagnosis of ADHD.

This is nicely illustrated in this study from 2005, which asked parents if their children have been diagnosed with ADHD, and also had the parents complete a standardized questionnaire (the SDQ) about past ADHD symptoms. From the abstract:

Prevalence of clinically significant SDQ ADHD symptoms is 4.19% (males) and 1.77% (females). Male prevalence by race is 3.06% for Hispanics, 4.33% for Whites, and 5.65% for Blacks. Significant differences in prevalence occur across gender (p < .01) and among males across race (p < .01), age (p < .01), and income (p < .02). In the full sample, 6.80% of males and 2.50% of females have a parent-reported lifetime ADHD diagnosis but are negative for SDQ ADHD. Likewise, 1.59% of males and 0.81% of females are positive for SDQ ADHD but negative for parent report of ADHD diagnosis.

Thus, the results support the rough rule of thumb that only about half of kids with ADHD have actually been diagnosed, but about half of those who have the ADHD diagnosis don't really have ADHD. Yes, it's a mess. ADHD is almost certainly over-diagnosed not just among well-off suburban strivers needing "study pills," but also among poor urban youth who may be presenting with behavioral problems under conditions of chronic stress in the family. However, many kids who do have the syndrome are not being diagnosed, for a complex multitude of reasons. Those kids often end up marginalized in school, fall in with the wrong crowd, turn to drugs and alcohol, and have poor outcomes reaching far into adulthood.

The DSM-5 version of ADHD does not change much, but is clearly geared towards decreasing under-diagnosis. The biggest change is that instead of requiring some impairing symptoms before age 7, that age limit is now raised to 12. This is because many children with attention problems, especially if they are intelligent and not especially disruptive in class, can breeze through elementary school without adults noticing that they are not really paying attention. However, once those children reach middle school, they often become overwhelmed by the more challenging material, the demands of going to a different teacher for each subject, and having to keep track of multiple assignments with different due dates.

The 18 diagnostic criteria remain essentially the same. Instead of calling the different forms of ADHD (like combined or predominately inattentive) "subtypes," the term "presentation" is used, since they are not really distinct entities (i.e. most hyperactive children will become less hyperactive over time while continuing to have issues with attention). Also, kids with both autism and ADHD symptoms can now be officially diagnosed with ADHD, since the exclusion for Pervasive Developmental Disorder has been removed. The inattention symptoms have a much needed clarification that they are not due to oppositional behavior or difficulty understanding.

For diagnosis of ADHD in adults, the DSM-5 criteria have been loosened so that patients only need to meet 5 of 9 criteria for inattention, instead of 6 of 9. The manual also provides more examples of symptoms that are relevant to adults.

Ultimately, the question for me is, will the DSM-5 actually solve any problems associated with the ADHD diagnosis in the real world? Sure, it might make the lives of researchers easier since more people would qualify for the full ADHD diagnosis rather than ADHD, NOS. However, I don't think the change in criteria will do anything to improve under-diagnosis, since parents who didn't want to take their hyperactive or inattentive kids to see a doctor before probably still would not do so. Obviously, the DSM-5 won't do anything to stem the tide of over-diagnosis, but I'm also not sure that it'll make the problem any worse. In adults, the problem with diagnosing ADHD is that it is harder to get the third party data like parent or teacher reports that clinicians rely on when making the diagnosis in kids. Anyone can look up the diagnostic criteria and tell their doctor they have those things.

Perhaps it would have helped if the DSM-5 could specify that the symptoms cannot be purely subjective and that objective reports are needed from other sources, but for better or worse, that's not what the book is about. It won't change how I approach those in their late teens or adulthood who come to me saying they have previously undiagnosed ADHD, since I ask those patients to undergo neuropsychological testing so I would have some objective data.

Of course, even with proper diagnosis of ADHD, treatment doesn't necessarily address all the issues or lead to normalized functioning. But that's a topic for another time.

A Child Psychiatrist's Thoughts on DSM-5: PTSD

One of my favorite books about children who have been traumatized is The Boy Who Was Raised As A Dog, by Dr. Bruce Perry and Maia Szalavitz, which highlights Dr. Perry's experiences working with children who have survived all sorts of horrors, usually perpetrated by the adults that the children trusted most. It is one of the most saddening yet hopeful books that I have ever read; I believe everyone should read it.

Trauma during childhood has been found to greatly increase the risk of an individual later having poor health, both mental (depression, psychosis, suicidality) and physical (obesity, chronic inflammation, and heart disease). Thus, recognizing and treating children who have been traumatized can have a very positive impact. Dr. Perry's book shows how much of a difference a nurturing environment and loving caregivers can have, even for the boy who spent months locked up in a cage with dogs.

Historically, children have been under-diagnosed with post-traumatic stress disorder (PTSD) for a multitude of reasons, highlighted in this review article from 2009. For example, children typically would not tell you that they are experiencing disturbing memories or flashbacks, and they often act out in seemingly inexplicable ways. In my own experience working with children in the foster system, I have seen manifestations ranging from extreme tantrums in response to loud noises to hiding feces in closets. Overmedication of such children is a rampant problem.

Academics who specialize in childhood PTSD have already modified the DSM-IV criteria for diagnosing PTSD to make them more appropriate for children. From the review article:

The alternative algorithm for PTSD in young children (PTSD-AA) includes modifications in wording for several items to make them more developmentally sensitive to young children. For example, the DSM-IV item for irritability and outbursts of anger was modified to include extreme temper tantrums. However, the major change is a modification to lower the requirement for the C criterion (numbing and avoidance items) from three out of seven items to just one out of seven items because many of the C criterion items are highly internalized phenomena that appear to be either developmentally impossible in young children (eg, sense of a foreshortened future) or extremely difficult to detect even if they were present (eg, avoidance of thoughts or feelings related to the traumatic event, and inability to recall an important aspect of the event).

The DSM-5 changes the diagnosis of PTSD in several ways. An individual no longer has to have a subjective fear response during the trauma. In addition to the previous symptoms domains of hyperarousal, re-experiencing, and avoidance, there is now a fourth symptom domain of alterations in mood and cognition. In children age 6 and under, there is a lower threshold for making the diagnosis: 2 arousal symptoms are required, along with 1 symptom of re-experiencing the trauma and 1 symptom of either avoidance or negative alteration in mood/cognition. I'm not sure what the implications are for adults with PTSD, but I do think the changes are for the better when it comes to accurately diagnosing PTSD in children.

Of course, many adults, even when properly diagnosed with PTSD, are still treated with multiple antipsychotics and mood stabilizers. But I believe the tide is starting to turn, and even the military is implementing many non-medication interventions for trauma. Even for young children with PTSD, there are effective treatments such as child-parent psychotherapy (CPP) and trauma-focused cognitive-behavioral therapy (TF-CBT). I hope that making the diagnosis of PTSD more widely accepted in abused children will lead to greater availability and use of such therapies.

A Child Psychiatrist's Thoughts on DSM-5: General Impressions

The soon-to-be-published 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) has been notable for the amount of controversy it has generated, including pointed critiques from Allen Frances, chair of the DSM-IV committee, and Robert Spitzer, chair of the DSM-III committee. There has been widespread media coverage of the controversies involved, in outlets ranging from the New York Times to The Verge. I won't recap all of the areas of contention, but I think the most insightful take about why the chairs of both DSM-III & IV would speak out against DSM-5 is offered by Dr. Nardo at 1boringoldman.com. In short, the DSM-5 committee explicitly set out to change DSM from an "atheoretical" perspective to one in which there are clearly defined biological causes of psychiatric diagnoses, but couldn't quite get there, leaving us with somewhat of a mess.

My own view of the DSM has always been that it's a very imperfect system, a necessary evil given how little we know. It tries to turn a spectrum of human behaviors and suffering into discrete categories, and frequently fails at that given how many patients I see who meet criteria for either multiple disorders (when presenting with one acute episode) or no disorder at all. It is necessarily subjective given that these disorders must cause "clinically significant impairment in functioning."

With the DSM-5, I think the biggest drawback is that the different committees that wrote the new criteria are all made up of experts in those particular areas. I'm not as concerned about their financial conflicts of interests (69% have received pharma funding) as I am about their innate desire to capture every possible case so that no suffering goes untreated. This approach (especially when it's applied outside of more "biologically-based" conditions such as autism or schizophrenia) can't help but lead to over-diagnosis when the manual is applied to an entire population by clinicians from all types of backgrounds.

As someone who treats adults in addition to kids and teenagers, I'm mostly disappointed when it comes to the DSM-5's changes to conditions generally diagnosed in adolescence and beyond. They did not really alter Major Depressive Disorder, which is so heterogenous a category that I highly doubt my patients with MDD who quickly get better after a month have a condition similar to the ones who remain hopeless and suicidal despite months of meds and therapy. I guess it's a diagnostic juggernaut with too many publications written about it already that's just too big to fail, kind of like the DSM itself. The criteria for Generalized Anxiety Disorder, a catch-all diagnosis like MDD, have actually been loosened. I'm also disappointed that there was ultimately no overhaul of the personality disorders to make them more dimensional. Some psychiatrists have complained that the new system would have taken too much effort, but I would argue that a personality disorder is not something that should be diagnosed based on a checklist; a clinician should actually observe a patient carefully over time before reaching the conclusion that a personality disorder is present.

One thing I do like about the DSM-5 is the change in name of the manual from the old Roman numeral system (i.e. "DSM-V"). The intent is supposedly that this is version 5.0, and that we won't have to wait a decade or two before new advances lead to versions 5.1, 5.2, and so on. It might be more aspirational than anything else, but being an optimist, I'm hopeful that this means changes could be more quickly made in response to...well, reality.

When it comes to changes in the DSM-5 for child psychiatry, I feel mostly positive. In future posts, I will explain why, as I examine DSM-5 changes in key areas such as PTSD, autism, ADHD, and the ever-controversial DMDD.