We don't shy away from controversy here at Shrink Rap, and today, child psychiatrist Dr. Mota-Castillo joins us to discuss the idea that children with bipolar disorder are being misdiagnosed with attention deficit disorder and then being inappropriately treated with stimulants, which may be causing them more harm than good. I've already written about my thoughts on the diagnosis of Bipolar Disorder as a catch-all category, and if you'd like to revisit that, see my article on Rethinking Bipolarity in Clinical Psychiatry News. And now for our guest blogger:
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Does the APA have “The Belle Indifference”?
In 2003 I began to make noises (1) trying to get the attention of the American Psychiatric Association (APA) and the American Academy of Child & Adolescent Psychiatry (AACAP) but 10 years later, as should be expected from those social clubs, they have ignored not only this former anchorman from Dominican Republic but also some of their more prominent members.(2)
Today I want to turn my requests (many of them) into a public and formal demand for an explanation of a lack of action that, in my view, borders with complicity. Earlier this year (3) one of my favorite authors, Dr. S. Nassir Ghaemi pointed out a reality that many try to hide: like other human beings we make mistakes. These are some of his words:
“This false sense of simplicity hides a complex truth: We have lost the ability to accurately recognize our patients’ signs and symptoms; hence, we routinely misdiagnose, then we mistreat. And throughout the process, we have little clue that we might be wrong. And most of the blame has to do with DSM-III onward: simplistic criteria that are often wrong, partly because they are explicitly non–research-based; and when they might be right, DSM’s baleful influence of being a teaching tool, replacing careful phenomenology, has dumbed down the clinical capacities of my generation.”
I can’t express my thoughts with the artful use of the English language that Nassir has but if you can show your stoicism by putting up with my linguistic flaws maybe I would be able to get your attention to a very serious problem, persistently ignored by the APA and the AACAP. They are morally obligated to intervene because I have seen doctors coming out of training and still supporting concepts that have been outdated for decades, i.e. “children don’t get bipolar.”
These two organizations are also guilty of ignoring the concept of bipolar spectrum which could help trainees and families to understand that, similar to a Chihuahua and a Pitbull (both called dog) two individuals with bipolar spectrum disorder could look completely different. This is important because mood and anxiety disorders are frequently misdiagnosed as Attention-Deficit Hyperactivity Disorder (ADHD).
There is so much to say and so little time to read that I will present several brief real cases (demographic changed for privacy) and let you, the reader, to be the jury…should the APA and the AACAP be morally indicted or I am missing something here?
I realize that it will hard to believe but here is the awful truth: These patients are a small % of many others in a single week.
1- Two brothers taking an amphetamine drug for several years while having almost daily physical altercations and failing in school. On examination both had auditory hallucinations and insomnia. Father is an untreated bipolar who requested to be enrolled in treatment after he witnessed the transformation of his children in just 3 weeks without stimulants and on a mood stabilizer plus 1 mg of the antipsychotic drug risperidone.
2- Sixth grader girl that repeated the 5th grade while taking a high dose of amphetamines (started in 1st grade) was having frequent arguments with teachers and her grandmother. She admitted to “be tired of been angry all the time” and said that she requested to a previous doctor a change in medication because “my mother is bipolar and my father is in prison because he killed somebody.” I should point out that this patient does not have one single “ADHD symptom” that could not be explained by her racing thoughts, impulsivity and mood swings.
3- A girl in elementary school (Special Education) with Autism has been on methylphenidate (the famous Ritalin) for almost 2 years despite severe obsessive behaviors and a parent with bipolar disorder. A “comprehensive evaluation” at a teaching hospital kept the ADHD diagnosis despite the DSM restriction in the presence of autism. 4 psychiatrists and 1 psychologist failed to detect the link between the escalating aggression and obsessions and the stimulant drug she was taken.
4- Another elementary school student walk into my office and could not stop talking and clowning around. Without asking permission he moved 3 small chairs to place them in a perfect alignment and when I pointed this out to the father the answer was: “at home it is the same, everything has to be in perfect order.” The father also reported that Obsessive-Compulsive Disorder (OCD) runs in his family and welcomed the idea of replacing the amphetamine with the anti-anxiety medication citalopram.
5- A mother described her child as “a slow learner that does not understand right from wrong, that gets into everything and who acts out a lot.” This unfortunate case of Mild Mental Retardation (also a categorical no from diagnostic manual (DSM) to diagnose ADHD) was also taken a brand of methylphenidate even though the weight loss was persistent and the insomnia severe.
As I said before, I want to keep your attention and for that reason I will invite to those that want to hear about the hundreds of similar missed diagnoses to contact me and I will be glad to answer their questions. For now I want to end by reporting that I have seen children and adolescents with Social Anxiety Disorder, Post-Traumatic Stress Disorder, Absence Seizures, Generalized Anxiety Disorder, malnutrition and etc., in addition to those that are more commonly confused with ADHD such as OCD and bipolar spectrum disorder.
And one final question: If it is not the APA or the AACAP who else can fix this problem?
Manuel Mota-Castillo, M.D.
Lake Mary, FL