![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 11 to 35 of 35. Go back in thread:
Posted by Deneb on January 27, 2007, at 22:09:03
In reply to Re: I'm a lot better these days, but why still DSH? » tofuemmy, posted by Phillipa on January 27, 2007, at 21:56:52
Thanks for the link about DBT. I don't know if DBT is for me. I don't think I have a severe borderline personality.
I think I'm OK. I'm just desperate about my school situation and I have no direction in life.
I'm worried my pdoc thinks I'm hopeless now. I've seen her so so long yet I'm still doing poorly. I feel better than before, but I still have so many problems!
I definitely feel better now than before, much better. I still have my bad days, but I'm much better now.
It's still not enough. I need to increase my productivity.
Deneb*
Posted by Michael83 on January 28, 2007, at 0:02:56
In reply to Re: I'm a lot better these days, but why still DSH?, posted by Deneb on January 27, 2007, at 22:09:03
Deneb, just focus on what you're going to to, not what you haven't done. Just slow, a step at a time, and eventually you'll get where you want to be. The way you blame yourself is so unfair. You'll be fine. =)
Posted by tofuemmy on January 28, 2007, at 0:05:32
In reply to Re: I'm a lot better these days, but why still DSH? » tofuemmy, posted by Phillipa on January 27, 2007, at 21:56:52
I think you misunderstood. That behavior could, per Linehan, result in a child with BPD.
em
Posted by 10derHeart on January 28, 2007, at 0:06:41
In reply to Re: I'm a lot better these days, but why still DSH?, posted by Kath on January 27, 2007, at 20:03:35
>>Laima posted that link in 'blue' form.
And so did you!
>>I don't know how to copy it so you can click on it.
oh yes you do, 'cause you did! :-)
(fyi...I think the thing is, when writing a post w/a link in it, it doesn't look different *then* - but, as soon as you confirm and post, it shows up correctly... the key is getting the http:// in there, if I recall...)
Don't sell yourself short....and I know you can even chat in any color you want to now, too ;-)
And Deneb, that's a great link. Hope you explore it. Looks to me like if you check the "Contact us" area they have a regional office that might be closer for you. Don't know if the DBT groups are only in Toronto, but it sure wouldn't hurt to find out more info...
I can't remember, have you ever brought up DBT to your T/pdoc? If it's feels weird or uncomfortable, you could bring some posts where others have suggested it, and kind of frame it that way, since I think I recall she's pretty much in favor of the support you get from Babble and Babblers. It's a thought....from me to you.
Posted by madeline on January 28, 2007, at 6:54:41
In reply to I'm a lot better these days, but why still DSH?, posted by Deneb on January 27, 2007, at 17:49:01
I think you need to ask yourself what you really want and what you are prepared to do to get it.
If you want help in dealing with self-harm issues, then DBT is one way develop the skills to deal with it.
DBT is independent of borderline personality disorder - which may or may not even exist in my opinion.
But it's up to you to decide for yourself (obviously).
Posted by Larry Hoover on January 28, 2007, at 8:11:50
In reply to Re: I'm a lot better these days, but why still DSH?, posted by Deneb on January 27, 2007, at 22:09:03
I collected two posts together, and did some editing:
> I don't think there is anything really wrong with me. I think it's all psychological. I don't think there is any med out there that can help me stop harming myself. I'm already better.
Maybe for now?
> I'm so much better these days, but I'm still doing so poorly!
I want you to focus on this apparent contradiction. It is the dialectic you struggle with.
> I think I have a borderline personality disorder. It's all psychological. Only therapy can save me.
That's insightful. Very insightful.
> I don't know if DBT is for me.
I would ask that you take another look at it. DBT is not just for borderline personality disorder, although it was first used there. It is a technique. A tool. It is used for behaviour modification in a number of psychologically distressing mental health issues.
I snipped (and slightly edited) the following from a descriptive website, employing the DBT technique for an entirely different diagnosis than the one you are worried about. See if these *ideas* aren't what you seek.
"DBT assumes that self-destructive behaviors are maladaptive attempts to avoid or diminish intolerable negative emotions. The focus of DBT is to teach these patients to face, reduce, eliminate, and/or tolerate their painful emotions. The four components of DBT are:
1. Mindfulness training (becoming aware of emotions).
2. Emotional regulation (reducing or eliminating negative emotions).
3. Distress tolerance (learning to tolerate painful emotions).
4. Interpersonal effectiveness (interpersonal skills training).
Patients use “diary cards” to record emotional experiences, behaviors, and the DBT skills they practice. Patients also complete “Behavioral chain analysis” forms where they record sequences of situations, internal reactions, and maladaptive behaviors. Each week, patients discuss this information in the first hour of their group session. In the second hour, patients learn and practice new skills. Each patient also has one individual therapy session per week.
Here are some DBT techniques described by Wiser and Telch:1. Mindfulness training: Learning to fully experience thoughts, emotions, and action urges without attempting to suppress them or judge them, and without experiencing secondary emotions such as guilt or shame.
2. Identifying the antecedents and consequences of emotions.
3. Becoming aware of the bodily responses that accompany negative emotions.
4. Understanding the relationship between cognitions and emotions, and modifying cognitions that evoke negative emotions.
5. Learning adaptive methods of coping with negative emotions: relaxing, taking walks, socializing, taking a warm bath, listening to soothing music.
6. Getting adequate sleep and reducing excessive exercise and the use of drugs and alcohol.
7. Reducing negative emotions, for example by facing rather than avoiding feared situations, and by revealing rather than hiding feelings of shame.
Alert readers may have noticed a conflict between technique #1, experiencing emotions, and technique #7, reducing negative emotions. This conflict is the primary dialectic, from which DBT derives its name."
Lar
Posted by laima on January 28, 2007, at 9:00:21
In reply to Re: I'm a lot better these days, but why still DSH?, posted by Deneb on January 27, 2007, at 22:09:03
DBT is also for people with depression and anxiety.
> Thanks for the link about DBT. I don't know if DBT is for me. I don't think I have a severe borderline personality.
>
> I think I'm OK. I'm just desperate about my school situation and I have no direction in life.
>
> I'm worried my pdoc thinks I'm hopeless now. I've seen her so so long yet I'm still doing poorly. I feel better than before, but I still have so many problems!
>
> I definitely feel better now than before, much better. I still have my bad days, but I'm much better now.
>
> It's still not enough. I need to increase my productivity.
>
> Deneb*
>
>
Posted by cubic_me on January 28, 2007, at 12:00:19
In reply to Re: I'm a lot better these days, but why still DSH?, posted by laima on January 28, 2007, at 9:00:21
As part of some work experience I sat in on some DBT sessions (with full consent of the clients). It was for people with eating disorders, not borderline people, but focused on lots of things in their lives, not just their eating.
DBT was origionally applied to people with borderline personality disorder, but since then people have found it really effective with people with lots of other dificulties.
Deneb, therapy isn't something magic that will 'fix' you, you've got to put in a lot of work. You've got to be willing to change and willing to let people help you, but there's definately help and hope out there for you if you look hard enough.
Posted by Kath on January 28, 2007, at 13:21:38
In reply to Re: I'm a lot better these days, but why still DSH, posted by 10derHeart on January 28, 2007, at 0:06:41
Hi T,
Thanks!! - you're right - it did turn out as a clickable-on link address!!! Yay.
And yes - I CAN chat in colour now!! I tried it. Now it's just a matter of being on here when there are people on Chat! LOL
Hugs, Kath
Posted by Kath on January 28, 2007, at 13:29:17
In reply to Re: I'm a lot better these days, but why still DSH? » Deneb, posted by Larry Hoover on January 28, 2007, at 8:11:50
Larry - thanks so much for this information.
I think this could really help me. I've asked in another thread if you think this type of therapy would be offered from an OHIP-covered source.
Sometimes when I feel overwhelmed by worry or upset feelings, I feel like my whole body is sort of aching/feeling trapped/needing to writhe! I hate being so strongly affected by 'negative' or uncomfortable emotional feelings!
Kath
Posted by Larry Hoover on January 28, 2007, at 13:52:14
In reply to Re: I'm a lot better these days, but why still DSH? » Larry Hoover, posted by Kath on January 28, 2007, at 13:29:17
> Larry - thanks so much for this information.
>
> I think this could really help me. I've asked in another thread if you think this type of therapy would be offered from an OHIP-covered source.I believe it can be. Just stay away from psychologists in private practise. You may possibly need an official diagnosis, too.
> Sometimes when I feel overwhelmed by worry or upset feelings, I feel like my whole body is sort of aching/feeling trapped/needing to writhe! I hate being so strongly affected by 'negative' or uncomfortable emotional feelings!
>
> KathI'm sorry, Kath. I didn't realize that.
Upon looking at DBT, I realize that I am doing something very similar already, to learn how to cope with my chronic pain. I can whole-heartedly offer my endorsement.
Lar
Posted by Phillipa on January 28, 2007, at 17:48:51
In reply to Re: I'm a lot better these days, but why still DSH? » Phillipa, posted by tofuemmy on January 28, 2007, at 0:05:32
Emme I did so does that make me borderline? Love Phillipa
Posted by Phillipa on January 28, 2007, at 17:54:50
In reply to Re: I'm a lot better these days, but why still DSH? » Deneb, posted by madeline on January 28, 2007, at 6:54:41
Maddie will BPD be removed from the axis II in the DSM? Isn't a new one due to be released? Love Phillipa
Posted by sunnydays on January 28, 2007, at 18:54:35
In reply to Re: I'm a lot better these days, but why still DSH? » tofuemmy, posted by Phillipa on January 28, 2007, at 17:48:51
No, it's just a risk factor for borderline. You still have to meet the DSM criteria for the disorder to have it.
sunnydays
Posted by Phillipa on January 28, 2007, at 19:20:30
In reply to Re: I'm a lot better these days, but why still DSH? » Phillipa, posted by sunnydays on January 28, 2007, at 18:54:35
Thanks sunndays as I don't meet the criteria for it. Love Phillipa such helpful people here.
Posted by Kath on January 28, 2007, at 19:22:50
In reply to Re: I'm a lot better these days, but why still DSH? » Kath, posted by Larry Hoover on January 28, 2007, at 13:52:14
Thanks Larry,
I admire you & Nikki & anyone else who has chronic pain. I am so very fortunate not to have physical pain. I'm so sorry that you & Nikki do & anyone else too.
Kath
Posted by Deneb on January 29, 2007, at 11:17:55
In reply to Re: I'm a lot better these days, but why still DSH?, posted by Deneb on January 27, 2007, at 18:24:04
> Do I have a borderline personality disorder? Is it a mental illness? Is it serious?
>
> Opinions?
>
> Am I just a bad and lazy person? What's wrong with me?
>
> Deneb*I definitely have a borderline personality disorder. My pdoc encouraged me to read books on borderline personality disorder.
Is it serious? Is considered a "mental illness"? or is it a psychological disorder? Or is there no difference between the two?
Should I be treated by a psychologist or a psychiatrist?
Deneb*
Posted by sunnydays on January 29, 2007, at 11:26:34
In reply to I have a BPD, posted by Deneb on January 29, 2007, at 11:17:55
> > Do I have a borderline personality disorder? Is it a mental illness? Is it serious?
**** I think it is considered a mental illness. But that means that it's not your fault, Deneb. Just as depression is an illness, and diabetes is an illness, and heart disease is an illness, I think it can also be considered an illness. You learn to manage it like any other illness.
or is it a psychological disorder? Or is there no difference between the two?
**** I don't think there's a difference between the two in the way they are commonly used. But again, having a mental illness doesn't reflect anything about you as a person.
>
> Should I be treated by a psychologist or a psychiatrist?
>
> Deneb***** I think ideally both, but either/or could very well be adequate. Also, in the US there are social workers and other types of therapists that can help too, they don't have to have a Ph.D. It's up to you to find treatment that you feel works for you.
(((((Deneb))))
sunnydays
Posted by Dinah on January 29, 2007, at 11:45:41
In reply to I have a BPD, posted by Deneb on January 29, 2007, at 11:17:55
Deneb, you're the same person you were yesterday. A diagnosis is just a name that helps clinicians understand how to help you best (ideally).
Talk to your pdoc about treatment, but since you've responded to medications, and since therapy is usually recommended for BPD, I'd imagine she'll tell you a combination is best.
DBT teaches valuable skills, and you might want to look up Marsha Linehan on Amazon or google her.
It's not so bad, Deneb, although there are some negative stigmas in the minds of some clinicians, unfortunately. Don't let that get you down. Just choose clinicians that are more empathetic and better educated. You wouldn't want the clinicians who judge people by a label anyway, would you?
Linehan sees BPD as a cluster of characteristic coping styles that people use to cope with emotional lability and a slow return to baseline (inability to regulate one's emotions). DBT is designed to help with that. I've never been diagnosed with BPD, but I have a fair number of traits. In fact some clinicians would have thrown me in that diagnosis just because I self injure. But emotional lability and slow return to baseline *definitely* describes me. What's helpful for me is a combination of meds and therapy. I wouldn't want to do without either.
Don't think of this as a bad thing, Deneb. Think of it as a way to conceptualize your difficulties and pain, and a starting point to learning to deal with them.
Posted by one woman cine on January 29, 2007, at 11:48:09
In reply to I have a BPD, posted by Deneb on January 29, 2007, at 11:17:55
Isn't this on psychology?
Can be there 2 threads on the same subject? I'm just wondering if this should be re-directed -
Posted by Deneb on January 29, 2007, at 15:35:59
In reply to Re: I have a BPD » Deneb, posted by Dinah on January 29, 2007, at 11:45:41
My pdoc told me I had a BPD a while ago. I thought I outgrew it, but I haven't. I still have it. I'm not upset about having it because I already knew I had it for a long time.
Deneb*
Posted by Kath on January 29, 2007, at 19:34:19
In reply to Re: I have a BPD » Deneb, posted by Dinah on January 29, 2007, at 11:45:41
What's 'lability' mean?
K
Posted by Phillipa on January 29, 2007, at 21:31:10
In reply to Re: I have a BPD » Dinah, posted by Kath on January 29, 2007, at 19:34:19
Kath I think moods change rapidly. Love Phillipa
Posted by laima on January 31, 2007, at 7:57:56
In reply to Re: I have a BPD, posted by Deneb on January 29, 2007, at 15:35:59
I agree with the people who have written here that a label like 'borderline...' doesn't mean much, if anything at all, about you as a person. A lot of psychiatric labels are most useful for quickly describing symptom clusters for doctors, and especially for insurance companies. A lot of experts are questioning the usefulness of such labels at all- and a lot of experts will assign a different label to the very same patient because they will group the very same symptoms into different clusters! There was a story in the New York Times about just that late last fall. I wouldn't dwell too much on it if I were you.
Deneb, a good therapy program, like DBT, can still help solidify your improvements. You can think of it as mentorship, if that is a nicer way to think of it. In the group section, you can share your successes with others in the group, inspire them, celebrate what you've accomplished. In your private sessions, you can identify if there are any shadowy areas that you'd still like to work on. I know you've recently written about thinking occcasionally about hurting yourself. I hope you can move away from that, for your own peace of mind. That one day, such thoughts are distant, distant fuzzy memories. It sounds like things are moving along for you, you are making choices, like about school, and I trust you are considering the positive and constructive aspects of what is changing. I hope that continues to be true. Please continue framing what happens for you in positive ways- that's helped me personally tons. Ie, not "I almost flunked my classes", but, "I am reconsidering what I want out of my academic career, and am taking a breather so I can sort it out. I dropped the classes which weren't right for me and my concerns, so that I can use the time and energy to focus better on working out what I want in the greater picture." Yay Deneb! I hope you see the kind concern of your mom regarding the lion blanket, and can see some compassionate humour in it. If you wrote a book, that could be a funny little chapter. I hope you continue to feel better, and think of your better moments when your mood isn't up to snuff.
Something I like out of DBT is the notion of "self-soothing"- finding ways to soothe yourself in healthy ways when things aren't feeling so well- bubble bath, walk in nature- whatever makes you feel nicer. Mine include excersise with peppy music, bath with nice smelly stuff, guormet hot chocolate, walk to favorite lunch spot for a treat, movie at the theater. Develop an "arsenal" of helpful self-soothing methods that you can dip in to when needed. Distraction rather than dwelling, and doing opposite to how one feels sometimes. Ie- feel like curling up in bed in middle of day? Force a walk outside. Mood usually follows.
> My pdoc told me I had a BPD a while ago. I thought I outgrew it, but I haven't. I still have it. I'm not upset about having it because I already knew I had it for a long time.
>
> Deneb*
Posted by laima on February 6, 2007, at 7:40:33
In reply to Re: I have a BPD » Deneb, posted by laima on January 31, 2007, at 7:57:56
Deneb, and others, this is from New York Times. The article focuses mostly on childhood "bipolar", which I realize isn't what we are talking about here- and no one here is a child- but it does get across that even respected experts don't all agree about diagnostic labels, that there is considerable fuzziness and disagreement about how to group symptoms and characteristics together into official disorders. How politics of drug marketing affect psychiatry, a bit of the history of childhood diagnosises, things like that. If you go to the actual link, they have some charts and multimedia stuff, as well as links to other articles in this series. Interesting- might be worth a look.
November 11, 2006
Troubled Children
What’s Wrong With a Child? Psychiatrists Often DisagreeBy BENEDICT CAREY
Paul Williams, 13, has had almost as many psychiatric diagnoses as birthdays.The first psychiatrist he saw, at age 7, decided after a 20-minute visit that the boy was suffering from depression.
A grave looking child, quiet and instinctively suspicious of others, he looked depressed, said his mother, Kasan Williams. Yet it soon became clear that the boy was too restless, too explosive, to be suffering from chronic depression.
Paul was a gifted reader, curious, independent. But in fourth grade, after a screaming match with a school counselor, he walked out of the building and disappeared, riding the F train for most of the night through Brooklyn, alone, while his family searched frantically.
It was the second time in two years that he had disappeared for the night, and his mother was determined to find some answers, some guidance.
What followed was a string of office visits with psychologists, social workers and psychiatrists. Each had an idea about what was wrong, and a specific diagnosis: “Compulsive tendencies,” one said. “Oppositional defiant disorder,” another concluded. Others said “pervasive developmental disorder,” or some combination.
Each diagnosis was accompanied by a different regimen of drug treatments.
By the time the boy turned 11, Ms. Williams said, the medical record had taken still another turn — to bipolar disorder — and with it a whole new set of drug prescriptions.
“Basically, they keep throwing things at us,” she said, “and nothing is really sticking.”
At a time when increasing numbers of children are being treated for psychiatric problems, naming those problems remains more an art than a science. Doctors often disagree about what is wrong.
A child’s problems are now routinely given two or more diagnoses at the same time, like attention deficit and bipolar disorders. And parents of disruptive children in particular — those who once might have been called delinquents, or simply “problem children” — say they hear an alphabet soup of labels that seem to change as often as a child’s shoe size.
The confusion is due in part to the patchwork nature of the health care system, experts say. Child psychiatrists are in desperately short supply, and family doctors, pediatricians, psychologists and social workers, each with their own biases, routinely hand out diagnoses.
But there are also deep uncertainties in the field itself. Psychiatrists have no blood tests or brain scans to diagnose mental disorders. They have to make judgments, based on interviews and checklists of symptoms. And unlike most adults, young children are often unable or unwilling to talk about their symptoms, leaving doctors to rely on observation and information from parents and teachers.
Children can develop so fast that what looks like attention deficit disorder in the fall may look like anxiety or nothing at all in the summer. And the field is fiercely divided over some fundamental questions, most notably about bipolar disorder, a disease classically defined by moods that zigzag between periods of exuberance or increased energy and despair. Some experts say that bipolar disorder is being overdiagnosed, but others say it is too often missed.
“Psychiatry has made great strides in helping kids manage mental illness, particularly moderate conditions, but the system of diagnosis is still 200 to 300 years behind other branches of medicine,” said Dr. E. Jane Costello, a professor of psychiatry and behavioral sciences at Duke University. “On an individual level, for many parents and families, the experience can be a disaster; we must say that.”
For these families, Dr. Costello and other experts say, the search for a diagnosis is best seen as a process of trial and error that may not end with a definitive answer.
If a family can find some combination of treatments that help a child improve, she said, “then the diagnosis may not matter much at all.”
A Kaleidoscope of DiagnosesThe most commonly diagnosed mental disorders in younger children include attention deficit hyperactivity disorder, or A.D.H.D., depression and anxiety, and oppositional defiant disorder.
All these labels are based primarily on symptom checklists. According to the American Psychiatric Association’s diagnostic manual, for instance, childhood problems qualify as oppositional defiant disorder if the child exhibits at least four of eight behavior patterns, including “often loses temper,” “often argues with adults,” “is often touchy or easily annoyed by others” and “is often spiteful or vindictive.”
At least six million American children have difficulties that are diagnosed as serious mental disorders, according to government surveys — a number that has tripled since the early 1990s. But there is little convincing evidence that the rates of illness have increased in the past few decades. Rather, many experts say it is the frequency of diagnosis that is going up, in part because doctors are more willing to attribute behavior problems to mental illness, and in part because the public is more aware of childhood mental disorders.
At the playground, in the gym, standing in line at the grocery store, parents swap horror stories about diagnoses, medications or special education classes. Their children are often as fluent in psychiatric jargon as their mothers and fathers are.
“The change in attitude is enormous,” said Christina Hoven, a psychiatric epidemiologist at Columbia University. “Not long ago people did all they could to hide problems like these.” Attention deficit disorder is perhaps the most straightforward diagnosis. Elementary school teachers are often the ones who first mention it as a possibility, and soon parents are answering questions from a standard checklist: Does the child have difficulty sustaining attention, following instructions, listening, organizing tasks? Does he or she fidget, squirm, impulsively interrupt, leave the classroom?
These behaviors are so common, particularly in boys, that critics question whether attention disorder is a label too often given to boys being boys. But most psychiatrists agree that while many youngsters are labeled unnecessarily, most children identified with attention problems could benefit from some form of therapy or extra help.
They are less certain about the children — perhaps a quarter of those seen for mental problems, some experts estimate — who do not fit any one diagnosis, and who often go for years before receiving a satisfactory label, if they receive one at all.
These youngsters collect labels like passport stamps, and an increasing number end up with the label Paul Williams received: bipolar disorder.
An Illness Under Dispute
Until recently, psychiatrists considered bipolar disorder to be all but nonexistent in children under 18. Today, it is the fastest growing mood disorder diagnosed in children, featured on the cover of news magazines and on daytime talk shows like “The Oprah Winfrey Show.”
The explosion of interest in bipolar disorder came after the approval of several drugs, called antipsychotics, or major tranquilizers, for the short-term treatment of mania in adults.
Beginning in the 1990s some researchers began to argue that bipolar disorder was underdiagnosed in adults. Soon, several child psychiatrists were arguing that the illness was more common than previously thought in children too.
Some experts who made those arguments had ties to manufacturers of antipsychotic drugs, financial interests disclosed in professional journals. But the message struck a chord, particularly with doctors and parents trying to manage difficult children.
Parents whose children have been given the label tend to adopt the psychiatric jargon, using terms like “cycling” and “mania” to describe their children’s behavior. Dozens of them have published books, CDs, or manuals on how to cope with children who have bipolar disorder.
A recent Yale University analysis of 1.7 million private insurance claims found that diagnosis rates for bipolar disorder more than doubled among boys ages 7 to 12 from 1995 to 2000, and experts say the rates have only gone up since then.
Katherine Finn, a 14-year-old who lives in Grand Rapids, Mich., said she was grateful for the growing awareness of the disease. Possessed by feelings of worthlessness as early as the fourth grade, Katherine said that by the sixth grade she “threw my sanity out the window.”
She became impulsive, loud, and abrasive, she said, adding, “I would blurt things out in class, I would moo like a cow, act like a little kid, just say the most random stuff.”
A psychiatrist promptly diagnosed the problem as bipolar disorder, after learning that there was a history of the disease on her mother’s side of the family. Katherine began taking drugs that blunted the extremes in her mood, and she now is doing well at a new school.
“It hit me like a Mack truck when I heard the diagnosis, but I knew right away it was correct,” said her mother, Kristen Finn, who is writing a book about her experience.
Still, many psychiatrists believe that, although childhood bipolar disorder may be real in families like the Finns, it is being wildly overdiagnosed. One of the largest continuing surveys of mental illness in children, tracking 4,500 children ages 9 to 13, found no cases of full-blown bipolar disorder and only a few children with the mild flights of excessive energy that could be considered nascent bipolar disorder — a small fraction of the 1 percent or so some psychiatrists say may suffer from the disease.
Moreover, the symptoms diagnosed as bipolar disorder in children often bear little resemblance to those in adults. Instead, the children’s moods seem to flip on and off like a stoplight throughout the day, and their upswings often look to some psychiatrists more like extreme agitation than euphoria.
“The question with these kids is whether what we’re seeing is a form of mania, or whether it’s extreme anger due to something else,” said Dr. Gregory Fritz, medical director of the Bradley Hospital, a psychiatric clinic for children in Providence, R.I.
Dr. Ellen Leibenluft, a research psychiatrist at the National Institute of Mental Health, argues that children who are receiving a diagnosis of bipolar disorder fall into two broad groups. The children in one group, a minority, have mood cycles similar to those of adults with bipolar disorder, complete with grandiose moods, and a high likelihood of having a family history of the illness. Those in the other group have severe problems regulating their moods and little family history, and may have some other psychiatric disorder instead.
“It is a mistake to lump them all together and assume they are all the same,” Dr. Leibenluft said. “It may be that the disorder has different dimensions and looks different in different kids.”
For parents with a child who is frantic and possibly dangerous, these distinctions may be academic. The medications may blunt their child’s extreme behavior, which may be all the confirmation they need.
For others, though, the uncertainties about childhood bipolar disorder loom larger. They wonder whether mania really explains what their child is going through, and if not, what it is that is being treated.
Evelyn Chase of Richmond, Va., said that a neurologist drove home his diagnosis of bipolar disorder in her 10-year-old son by pulling out “a copy of Time magazine and slamming the article in front of me.”
Ms. Chase said her son seemed to react most strongly to abrupt changes in the environment and to certain dyes and chemicals. “I used the bipolar diagnosis for school and getting services, but I don’t think it covers his behaviors,” she said.
For Paul Williams, the diagnosis simply feels like a temporary stop. In his short life, Paul has taken antidepressants like Prozac, antipsychotic drugs used to treat schizophrenia, sleeping pills and so-called mood stabilizers for bipolar disorder, in so many combinations that he has become nonchalant about them.
“Sometimes they help, sometimes they don’t,” he said. “Sometimes they make me feel like another person, like not normal.”
In recent months, his mother said, Paul seems to have improved: he visibly tries to control himself when he is upset and usually succeeds. He is an eager Mets fan who loves reading Harry Potter and the Goosebumps series. He gets out and plays baseball and football, like any 13-year-old boy.
But he has grown tired of telling his story to doctors, and neither he nor his mother expect that bipolar disorder will be the last diagnosis they hear.
In Search of Clarity
The specialists who manage children’s psychiatric disorders are trying to bring more standards and clarity to the field. Harvard researchers are completing the most comprehensive nationwide survey of mental illness in minors and hope to publish a report next year. And a recent issue of the journal Child and Adolescent Psychology was entirely devoted to the subject of basing diagnoses in hard evidence.
Given the controversies, one of the articles concludes, “we acknowledge that tackling the issue may be tantamount to taking on a 900-pound gorilla while still wrestling with a very large alligator.”
Dr. Darrel Regier of the American Psychiatric Association, who is coordinating work on the next edition of the association’s diagnostic manual for mental disorders, due out in 2011, said that researchers would focus on drawing distinctions among several childhood disorders, including bipolar disorder and attention deficit disorder.
“We wouldn’t disagree that criteria for these disorders currently overlap to some degree,” Dr. Regier wrote in an e-mail message, “and that a significant amount of research is under way to disentangle the disorders in order to support more specific treatment indications.”
Until that happens, parents with very difficult children are left to read the often conflicting signals given by doctors and other mental health professionals. If they are lucky, they may find a specialist who listens carefully and has the sensitivity to understand their child and their family.
In dozens of interviews, parents of troubled children said that they had searched for months and sometimes years to find the right therapist.
“The point is that not everything is A.D.H.D., not everything is bipolar, and it doesn’t happen like you see in the movies,” said Dr. Carolyn King, who treats children in community clinics around Detroit, and has a private practice in the nearby suburb of Grosse Pointe Farms.
“Kids often have very subtle symptoms they can mask for short periods of time,” Dr. King said, “and the most important thing is to observe them closely, and get a complete history, starting from birth and straight through every single developmental milestone.”
She added, “A speech delay can look like anxiety,” an obsessive private ritual like mania.
Or struggling children, in the end, may look only like themselves, with a unique combination of behaviors that defy any single label. Camille Evans, a mother in Brooklyn whose son’s illness was tagged with a half-dozen different diagnoses in the last several years, said she concluded, after seeing several psychiatrists, that the boy’s silences and learning difficulties were best understood as a mild form of autism.
“That’s the diagnosis that I think fits him best, and I’ve just about heard them all,” Ms. Evans said.
The label is not perfect, she said, but it is more specific than “developmental delay” — one diagnosis they heard — and does not prime him for aggressive treatment with drugs like attention deficit disorder or bipolar disorder would. He has not responded well to the drugs he has tried.
“Most important for me,” Ms. Evans said, “the diagnosis gives him access to other things, like speech therapy, occupational therapy and attention from a neurologist. And for now it seems to be moving him in the right direction.”
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