Euphoria At The Burger Joint

The line at the popular local burger joint was much shorter than usual when my fiancée and I arrived arrived with visions of freshly seared beef and milkshakes dancing in our heads. We couldn’t believe our luck: aside from the people currently ordering, there was only a middle-aged woman and a young couple standing in line in front of us. We didn’t notice anything amiss, at first.

Then I saw that the woman was not actually in line, but she was approaching the couple in front of us, apparently looking to strike up a conversation. Her hair was a bit unkempt, her make-up slightly excessive. And she was holding a thick wad of cash in one hand. She was beaming from ear to ear as she asked the couple in front of us, “Are you two on a date?”

“Yeah, it’s our first date,” said one member of the couple.

“How wonderful!” the woman exclaimed. “I can see love, and I can just tell that you two were meant to be together.”

The couple chuckled nervously, and the the woman started talking to them about the importance of Love in the Universe.

I watched what was happening in front of us with growing unease. I’ve seen this kind of irrational exuberance—and lack of boundaries—before during various psychiatric rotations, in patients who were manic or high. It usually didn’t end well. I noticed that my fiancée and I were standing closer together by now, and I glanced at her with a worried look that said, “What do we do?” She shot me a look back that said, “You’re the psychiatrist, you tell me!” We were both quite hungry, so leaving was out of the question. We stayed in line to await the inevitable.

Eventually, the woman held out a $20 bill to the male half of the couple and said, “Here, take this! I want to celebrate your beautiful young love!” As he reached for the money, the woman moved in closer, wrapping her arms around the guy and giving him a big kiss on the cheek. I think it would have been on his lips had he not turned his head at the last second. “Whoa!” he said, as he hastily backed away to free himself of her, with a new $20 bill in his hand.

Thoughts of worst-case scenarios crossed my mind. What if this lady got really agitated if we didn’t want to talk to her, or we didn’t want to take her money (or kiss her, for that matter)? I tried desperately to remember the brief training I got as a psychiatry resident on how to maintain a defensive stance when dealing with potentially aggressive patients. I stood a bit sideways to the woman, so my vulnerable belly was not as exposed. I kept my right foot, which was closer to her, pointed towards her and my weight on my left foot, in case I had to move in either direction. I crossed my arms and then pretended to stroke my chin with my right hand, so my arms would not be sitting uselessly by my side if I needed them.

Sure enough, the woman approached and asked us, “Are you on a date?”

I made sure not to look at her too directly as I mumbled, “Not really, just here for some burgers.”

Still, she held out a $20 and said, “Here, I have a present for you!” Not wanting to escalate the situation by saying no to her, I decided I might as well take it. I stuck my arm out as far as I could towards her, so that it would be more difficult for her to step closer for a smooch. I held my breath as she put the money in my hand and swiftly moved on to the next person in line behind me. “Whew,” I thought. “Guess that training really worked!”

As I looked at the $20 bill in my hand, I asked my fiancée, “What should we do with this?” Again, she would not let me off the hook. “You’re the one who took it, you decide!” I briefly debated paying for our meal with that money, but it just felt a little…crass. I paid with a credit card instead, and put the bill in my wallet. Once we got our food, I turned back towards the entrance to see what the woman was up to, but she had left, presumably to do good deeds elsewhere. I felt guilty, of course. It would certainly have been worse if she had been giving away Benjamins, but who knows what percentage of her personal savings she was wasting like this, one 20-dollar bill at a time?

But would it have made sense to call the police on her for causing a disturbance, or for sexual harassment, given her unwanted kissing? Even if they came, took it seriously, and hauled her to the nearest psychiatric ER, would there have been enough to involuntarily detain her? What if she had just won the lottery and was being very happy and generous?

Still, those burgers and shakes were tasty, and well worth the time spent standing in that particular line.

Readers, what do you think you would have done in this situation?

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.

A Simple Case of Depression

Note: All patient stories have potentially identifying details changed to protect privacy, and composites of multiple patients may be used.

It started off as a seemingly straight-forward case, as it often does. The patient ("Kevin") was a shy, quiet 13 year-old young man, one who had "never caused any trouble," according to his parents. Until earlier this year, he had gotten straight A's, enjoyed reading, and regularly hung out with several friends. Then, during the second semester of the previous school year, he just stopped doing his homework. He also started spending more time on the computer and less time with friends. His grades dropped to C's and D's, and two weeks into this school year, he was still not doing his homework, which is what prompted the evaluation.

Talking with Kevin, his face was a blank mask. He did not feel sad or depressed, but he no longer enjoyed reading or felt motivated to do homework like he used to. He spent all his time on Facebook or playing computer games. He stayed up late and woke up early, felt tired all the time and had trouble concentrating at school. He occasionally had thoughts of not wanting to live, though he has never seriously contemplated suicide or harmed himself. He was also eating less than usual, and often had negative thoughts about himself, that he was a failure.

He clearly met the criteria for a major depressive episode, and if I were using a purely biomedical approach to psychiatry, I might have been satisfied with starting him on a serotonin reuptake inhibitor and hoping that he will be feeling better in about a month. However, his seemingly out-of-the-blue changes in mood and behavior struck me as odd. I was also struck by the fact that he was only now being evaluated, even though his grades started dropping over 6 months ago.

During the initial visits, Kevin's parents had insisted that there was no family history of any mental illness or substance abuse. They had a close relationship with their son, and they frequently went to the movies or baseball games as a family. However, the more I talked to Kevin, the more I learned about the nuances of his family. His parents were widely inconsistent in how they approached his struggles. His mother yelled at him when he got bad grades and told him he could not use the computer, while his father was more lenient, did not set limits, and even bought him an iPad after his grades started slipping. When one parent's approach did not seem to work, the other parent took over for a while, until that approach failed as well.

I spent a good deal of time talking with Kevin's parents about the importance of them both agreeing on their parenting approach, so they can set reasonable limits around electronics use and enforce bedtimes that allow Kevin to get adequate sleep. After a couple of weeks, Kevin's sleep improved, and he felt less tired during the day, but he still was not doing his homework. I continued to talk with Kevin about his family life, having him walk me through what happened in the evenings. The picture that emerged was not that of a close-knit family. Over the last few years, the family had stopped eating together at the dinner table since Kevin's father had been getting home later from work. After work, both parents tended to unwind by drinking. Their jobs have gotten more stressful in the past year, and Kevin told me that they have been drinking more as a result, at least 3 to 4 drinks per parent per night. He was essentially left to his own devices while his parents enjoyed their beverages.

I have no way of proving this, but I thought it was a strong possibility that Kevin's refusal to do homework was an attempt to get his parents to notice him and reengage with him. When I brought up the issue of alcohol with Kevin's parents, they both seemed surprised that he was aware of their drinking habits. They told me that they were doing most of their drinking when Kevin was already asleep, which really made me wonder just how much they were drinking. I did not tell them outright to stop drinking, but I asked them to think about if and how their drinking may be impacting Kevin.

After that, I never heard from them again. Perhaps I came across as judgmental, or perhaps I tried to push for too much change before I had established enough rapport with the family. But it was clear to me that Kevin's "depression" could not really improve without some serious behavior change from his parents. Sometimes I think about the appeal of simply focusing on the identified patient and what brain chemicals may be awry. But then I remind myself that complexity is what drew me to psychiatry in the first place. With a more comprehensive approach, at least I sometimes feel that I get a peek behind the curtain at what's really happening, even if I am often unable to do more to influence the outcome.

The Treatment of Early Age Mania Study Revisited

The Treatment of Early Age Mania (TEAM) study is not news, and more diligent and timely bloggers have already written about it. However, it is one of the more infuriating outcomes of the whole pediatric bipolar disorder phenomenon; in the last few years, few publications have irked me as much as the ones from this study. Thus, I'd like to chime in as well. 1 Boring Old Man had a lengthy blog post (the sound and the fury...) summarizing the main findings [I added the links]:

The first report shows that these children respond better to Risperdal® than either Lithium or Depakote®. That’s no surprise. They don’t respond to the traditional anti-manic treatments [that suggests to me that they don't have mania]. They do respond to Risperdal®. That’s something we knew before we ever heard of Risperdal® – you can control disruptive behavior with antipsychotic medications. It also showed that the metabolic side effects of Risperdal® were already apparent at only 8 weeks. Notice that there’s no placebo group in this study so we can’t really say that the Lithium or Depakote® responses were clinically significant.

The second report set out to define moderators of response. What it ended up showing was the extremely high overlap between ADHD and the presumed Bipolar Mania and the more ADHD, the greater the likelihood of a response. But there was another moderator of response – site. What in the hell does that mean? To me it suggests that there is bias in making this diagnosis or in measuring the response. I think that says something about the study and the diagnosis, not the afflicted. So in my reading, one thing it doesn’t mean is that Bipolar Disorder has some intrinsic regional difference.

1BOM used the study to illustrate how a fad diagnosis could become mainstream, to the detriment of children and their families, while benefitting pharmaceutical companies and the researchers (such as MGH's Joseph Biederman) they support. It's worth noting, though, that the TEAM study did not include the MGH group and was funded by the NIMH, not by pharma. The first author of the initial publication is Dr. Barbara Geller, and I've written about how her conception of childhood bipolar is different from Wozniak/Biederman's chronically irritable patients, with Dr. Geller trying taking into account more classical manic symptoms such as grandiosity. Thus, I've often wondered "what the hell happened?" when pondering this study.

Fortunately, Dr. Stuart Kaplan, child psychiatrist and author of Your Child Does Not Have Bipolar Disorder, has an excellent series of posts on his Psychology Today blog with additional insights into the TEAM study. In Dr. Kaplan's first post (The World Series of Child Bipolar Disorder), he describes a session from the 2011 AACAP meeting in which TEAM researchers talked about their study:

During the discussion, another nationally known presenter gave a wildly incorrect interpretation of defiance. The presenter claimed that defiant children are psychotic because they have a delusional belief that they can take on the far stronger adult world. Defiant children are not psychotic based on their defiance alone. They are mistaken in their belief that they can overpower the adult world, but this is a mistaken belief not a delusion. If the investigators believe that defiant children are delusional, this may explain how they found the high rates of psychosis in the children they studied (77%).

If defiance in children counts as psychosis, then my partner and I are both psychotic every time we argue, because we each have a false belief that we can convince the other with our arguments. Maybe some of the TEAM investigators would consider this folie à deux?

Dr. Kaplan's second post (Credulity Stretched) highlights the reasons why the children included in the study probably did not have bipolar 1 disorder, given the >90% comorbidity with ADHD, the 99.3% of patients with "daily rapid cycling" moods, and the fact that the average "manic" episode in the study lasted 4.9 years, which is about half the life of the average study participant (mean age 10.1 years). His third post in the series (Location, Location, Location) replicates the table from the second publication showing just how wildly variable the treatment response was at the various sites: "This was not a minor statistical artifact, but was the central finding of the study."

Besides highlighting the incredible (as in, not credible) aspects of the study that Dr. Kaplan already wrote about, I wanted to provide one additional anecdote: Several years ago, one of the renowned lead investigators of the TEAM study gave a talk at another institution. This mood disorder expert claimed that a 3-year-old who masturbates may be exhibiting the hyper-sexuality seen in mania. When audience members pointed out that a 3-year-old masturbating is actually normal behavior, the investigator appeared flabbergasted. Which makes me wonder if they thought 6-year-olds who were repeatedly touching themselves in defiance of parents telling them to stop were having manic episodes with psychosis.

One of the biggest problems in the field today is how biologically-oriented psychiatrists look at behavior in a vacuum without considering developmental, social, or familial factors. This study is one of the most egregious examples, not just of that problem, but also of how researchers at prestigious institutions, backed by NIMH funding, can get even the most ridiculous studies published. If I see a 16-year-old who is truly manic, I'm still going to seriously consider lithium over risperidone, "evidence-base" be damned.

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).