Tag Archives: Diagnostic and Statistical Manual of Mental Disorders

The Importance of Properly Diagnosing Early Onset Bipolar Disorder

Although early onset bipolar disorder (EOBD) was first described in 150 AD, the diagnosis remains surrounded in controversy because no such diagnosis exists. A person either meets the criteria for bipolar disorder set forth in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) or not. The problem is that, as with DSM-IV, the criteria describe bipolar disorder as it exists in adults. The child phenotype differs markedly from adult onset bipolar disorder. Children with this disorder exhibit a more chronic form of irritability, more rapid mood swings, intense emotional outbursts, and impulsive aggression.

An additional complication when making the diagnosis in children is that most of the symptoms associated with EOBD also exist in ADHD, OCD, and ASD. Moreover, children with EOBD also have high rates of comorbid conditions.

Though it was hoped that DSM-5 would resolve the main concerns, the following issues remain unaddressed:

  1. Technically, EOBD diagnosis still does not exist.
  2. Teens and children must meet adult criteria to be diagnosed as bipolar.
  3. Many children who would have received a diagnosis of bipolar disorder prior to the publication of DSM-5 will now receive a diagnosis of disruptive mood dysregulation disorder (DMDD).

Despite the hope for some consensus, experts in the field have yet to reach agreement on (a) what symptoms constitute the core features of EOBD, (b) how to differentiate bipolar disorder from other childhood disorders, and (c) how best to manage children who have the disorder.

When Drs. Richard M. Marshall and Berney J. Wilkinson began seeing children who exhibited severe symptoms of bipolar disorder, they used omnibus rating scales as part of their initial diagnostic assessment. To their surprise, many of the scales completed by parents and teachers had ratings in the normal range even though the children had symptoms of bipolar disorder. An item analysis revealed that existing rating scales did not contain a sufficient number of items associated with the disorder. To address these shortcomings, Marshall and Wilkinson developed the Pediatric Behavior Rating Scale (PBRS), a standardized, norm-referenced parent and teacher rating scale for use with children ages 3 to 18 years.

Rather than providing specific diagnoses, the PBRS enables clinicians to identify the core features of EOBD, thereby serving as the critical first step in differential diagnosis and intervention planning. The PBRS provides clinical researchers with another tool to assist in (a) defining this disorder, (b) differentiating EOBD from related disorders, and (c) evaluating the efficacy of interventions aimed at alleviating its symptoms.

Approximately 20% of our nation’s 50 million K–12 students meet diagnostic criteria for a mental disorder, and 10% experience significant functional impairments at home, at school, and with peers. Nevertheless, children exhibiting such symptoms are often punished for willful disobedience rather than receiving effective treatment. In fact, 80% of children with mental illness remain undiagnosed and untreated, resulting in increased risk for suicide, school failure, and criminal behavior. Accurate differential diagnoses of EOBD and related disorders is the key to effective interventions.

Unless otherwise cited, source material is attributed to:
Marshall, M. M., & Wilkinson, B. J. (2008). Pediatric Behavior Rating Scale. Lutz, FL: PAR.

What do you think? PAR wants to hear from you, so leave a comment and join the conversation!

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The New Normal? Science Museum Explores the History of Mental Health

A new exhibit called “The Changing Face of What is Normal: Mental Health” opened recently at the Exploratorium in San Francisco. A world-renowned science museum, the Exploratorium features a new gallery that focuses on human behavior. The mental health exhibit is designed to explore the ways society defines, perceives, and responds to those whose behavior is considered “abnormal.” Visitors are encouraged to consider that normality is a fluid concept with a range of definitions that change depending on contexts such as time and place.

The Exploratorium Web site describes three elements that make up the exhibit:

  • Artifacts from the suitcases and trunks of 14 patients who were confined at the Willard Psychiatric Center, a New York mental institution that was decommissioned in 1995. The personal items provide insight into the lives of residents before they were institutionalized.
  • A display tracing the evolution of the Diagnostic and Statistical Manual of Mental Disorders as a guide used by psychiatric professionals to diagnose and treat cognitive, emotional, and behavioral disorders. This part of the exhibit also includes videotaped interviews with clinicians and clients speaking about their experiences and commenting on the difficulty of categorizing human behavior.
  • An interactive installation called “Restraint,” which explores the ways psychiatric patients have been restrained over time. Visitors can view, experience, and comment on various types of restraints, including the ways societies and cultures constrain everyday behavior and the ways we must often restrain our own impulses.

“The Changing Face of What Is Normal: Mental Health” will be on display at the Exploratorium until spring 2014. Have you seen it? PAR wants to hear from you, so leave a comment and join the conversation!

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Is ADHD on the rise?

Though several sources agree that attention deficit/hyperactivity disorder (ADHD) is is on the rise, new numbers question how much. According to a recent study published in JAMA Pediatrics, diagnoses of ADHD increased 24 percent in Southern California over the past 10 years, bringing to issue previous estimates.

 As part of the study, doctors reviewed the charts of children treated at the Kaiser Permanante Southern California physician’s group from 2001 to 2010 – 842,830 children in all. They found that in 2001, 2.5 percent of children age 5 to 11 were diagnosed with ADHD, but that number increased to 3.1 percent in 2010.

The Centers for Disease Control and Prevention (CDC) estimates that about 9.5 percent of children age 4 to 17 have ADHD. Researchers in the California study believe their estimate gives a more accurate picture of the rate of ADHD in Southern California because they reviewed actual medical records, rather than relying on parents to respond to telephone surveys, which is how the CDC got its number. Furthermore, the majority of ADHD diagnoses in the California study were made by specialists using strict Diagnostic and Statistic Manual of Mental Disorders (DSM-IV) diagnoses. This complicates previous estimates, as new research found that only 38 percent of primary care physicians actually use the DSM-IV for diagnosing ADHD.

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What Do You Have to Say About the New DSM?

Want your voice to be heard when the American Psychiatric Association (APA) publishes the upcoming fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5)? The organization is now taking comments on its most recent draft and welcomes opinions until June 15, 2012. Simply register to participate in the public commentary period. This will be the third time the draft has been made available for comment and will be the final opportunity for feedback on the text. A final version of the text will be presented to the Board of Trustees of the American Psychiatric Association later this year in order to meet a May 2013 publication date.

Interested in reading what is new in the DSM-5? APA provides an ongoing list of the proposed updates.

The World Health Organization (WHO) will be releasing the eleventh edition of the International Classification of Diseases (ICD-11) in 2015. If you are interested in participating in the revision, making comments, or reviewing proposals, visit the WHO site to register. Want more information about how the ICD-11 update will affect you? Visit the ICD-11 fact sheet for more information.

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Psychiatric Community Considers Name Change for PTSD

What’s in a name? For young veterans and others coping with post-traumatic stress disorder, a name could mean the difference between seeking treatment and suffering alone. Psychiatrists and military officers are now considering the implications of a name change for PTSD in an effort to reduce the stigma associated with this diagnosis. The new name under consideration? Post-traumatic stress injury, or PTSI.

“No 19-year-old kid wants to be told he’s got a disorder,” said General Peter Chiarelli, in a May 5 interview with the Washington Post. Until his retirement in February of this year, Chiarelli was the nation’s second-highest ranking Army officer, and he led the effort to reduce the suicide rate among military personnel. He and other supporters of the name change believe that using the word “injury” instead of “disorder” will reduce the stigma that stops soldiers and others from seeking treatment. According to Chiarelli, “disorder” suggests a pre-existing condition that “makes the person seem weak.” “Injury,” on the other hand, is appropriate because the condition is caused by the experience of specific trauma, according to supporters of the change. Injuries, they point out, can often be healed with treatment.

This issue is coming to a head because the American Psychiatric Association is working on a new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM), expected in May 2013. Not everyone is in favor of the name change; one of the major concerns, according to psychologist Sherrie Bourg Carter, is that “altering a diagnostic label may have far-reaching financial implications for health insurers and disability claims. Specifically, some insurers and government agencies may not be willing to reimburse mental health providers for a condition that isn’t considered a disease or disorder” (Psychology Today blog, May 6).

American Psychiatric Association President Dr. John Oldham has suggested that he would be open to considering the name change. “If it turns out that that [the word ‘injury’] could be a less uncomfortable term and would facilitate people who need help getting it, and it didn’t have unintended consequences that we would have to be sure to try to think about, we would certainly be open to thinking about it,” Oldham told PBS NewsHour in a December interview.

What do you think? Would a name change help reduce the stigma associated with post-traumatic stress and encourage people to seek the help they need? PAR wants to hear from you, so leave a comment and join the conversation!

 

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