All psychiatric diagnoses are suspect, insofar as they are descriptive and not explanatory. To say that an adult is having a “manic episode” is simply to provide a name for certain observable behaviors: for instance, that she is running naked down the corridors of her apartment building or staying up all night, night after night, to paint and repaint the walls of her bedroom.
That this particular naming makes sense is even less true for the “mania” that is supposedly a part of juvenile or pediatric “bipolar disorder.” There, all we might be seeing in the above behavior is an ordinary two-year-old rushing from activity to activity—practically a defining feature of being two years old. To call that behavior a “symptom of the mental disorder of juvenile bipolar disorder” is neither logical nor legitimate.
Have you ever been around a two-year-old? Don’t they sometimes melt down and have ferocious tantrums? Don’t they sometimes “suffer from excesses of energy”? Can’t they sometimes become inconsolably sad? Aren’t they sometimes willful and defiant? Yet all of these states and behaviors, as completely normal and ordinary as they are, are now deemed “symptoms of the mental disorder of juvenile bipolar disorder.” Does this make sense?
As Stuart Kaplan, author of Your Child Does Not Have Bipolar Disorder, explained in an essay in Newsweek:
“I have been a child psychiatrist for nearly five decades and have seen diagnostic fads come and go. But I have never witnessed anything like the tidal wave of unwarranted enthusiasm for the diagnosis of bipolar disorder in children that now engulfs the public and the profession. Before 1995, bipolar disorder, once known as manic-depressive illness, was rarely diagnosed in children. Today, nearly one-third of all children and adolescents discharged from child psychiatric hospitals are diagnosed with the disorder and medicated accordingly. The rise of outpatient office visits for children and adolescents with bipolar disorder increased 40-fold from 20,000 in 1994–95 to 800,000 in 2002–03. A Harvard child-psychiatry group led by Dr. Joseph Biederman, a prominent supporter of the diagnosis, recently insisted, ‘Juvenile bipolar disorder is a serious illness that is estimated to affect approximately 1 percent to 4 percent of children.’
“I believe, to the contrary, that there is no scientific evidence to support the belief that bipolar disorder surfaces in childhood. In fact, the opposite seems to be the case: the evidence against the existence of pediatric bipolar disorder is so strong that it’s difficult to imagine how it has gained the endorsement of anyone in the scientific community. And the effect of this trendy thinking can have devastating consequences. Such children are regularly prescribed medications that are not effective in kids and have unwelcome side effects.”
“Mania” in Perspective
As a therapist and creativity coach with artists for more than thirty years, I’ve frequently observed that people who are creative and who think a lot are more prone to so-called “mania” than people who do not think a lot and who aren’t creative. This fact, which is backed up by research, should alert us to the possibility that mania is not some pseudo-medical condition or brain abnormality but rather a function of the mental pressures placed on individuals who use and rely on their brains.
There is plenty of evidence to support the idea that intelligent, creative, and thoughtful people are disproportionately affected by the thing called mania. Research shows, for example, a clear linkage between “bipolar disorder” diagnoses and achieving top grades, scoring high on tests, and other, similar measures of mental accomplishment.
One study involving 700,000 adults and reported in the British Journal of Psychiatry indicated that former straight-A students were four times more likely to be “bipolar” (or “manic-depressive”) than those who had achieved lower grades.
Are these folks “more ill” than their C-average counterparts? Or are they putting their brains under relatively more pressure, thereby causing dangerous speeding accidents? Which seems more likely?
In another study, individuals who scored the highest on tests for mathematical reasoning were at 12 times greater risk for “contracting bipolar disorder.” Similar research underlines the linkage between creativity and mania, and we have thousands of years of anecdotal evidence to support the contention that smart and creative people often get manic (just think of novelist Virginia Woolf).
All this evidence suggests that enlisting your brain—say, to write a novel or to solve a riddle in theoretical physics—is a rather dangerous act, since it increases the stress on a brain already pressured by dealing with everyday matters such as financial difficulties, psychological threats, or just finding the car keys.
The current naming system used to describe “mental disorders” leads to many wrong-headed hypotheses—for example, that “because you are bipolar you are creative” or that “perhaps mania accounts for the higher test scores.” What is more likely is that the greater a person’s brain capacity and the greater their reliance on thinking long and hard, the more susceptible their revved-up brain is to racing.
All of the characteristic “symptoms of mania” that we see in adults, including high spirits, high arousal levels, high energy levels, heightened sexual appetite, sweating, pacing, and sleeplessness—and, at their severest, hallucinations, delusions of grandeur, suspiciousness, aggression and wild, self-defeating plans and schemes—make perfect sense when viewed from the perspective that a powerful pressure, likely from the existential task of making meaning in life, has supercharged a brain already feverishly racing along.
Challenging an “Epidemic”
As to what is going on in children labeled “bipolar,” we know even less. What we do know is that children already have racing brains, a feverish fantasy life, imaginary playmates, wild schemes, and all too often trauma-induced mental pressures. Doesn’t it make sense, then, to conceptualize “mania” in children (when it is something different from normal childhood curiosity and distractibility) as related to the way the mind can be pressured to race too wildly? If it is ever fair to call a child “manic,” isn’t the child’s environment the direction in which we should look?
Diagnosing children with juvenile or pediatric bipolar disorder is largely an American phenomenon. Do we actually have more “bipolar” children in the United States—or are we simply labeling more of them as such?
Peter Parry, Stephen Allison, and Tarun Bastiampillai addressed this issue in an article published in The Lancet:
“So why did the pediatric bipolar disorder diagnostic epidemic occur and remain mostly confined to the USA? Among more than a thousand, mostly American, articles about pediatric bipolar disorder, a few US psychiatrists and pediatricians have been vocal critics. They noted that diagnostic criteria for pediatric bipolar disorder deviate from strict DSM criteria, symptom-checklist approaches to diagnosis did not account for developmental and contextual factors, trauma and detachment disruption were overlooked, the pharmaceutical industry collaborated with key opinion leaders and researchers of pediatric bipolar disorder, and that the US health system often mandates more serious diagnoses in order to provide reimbursement …
“A systematic literature review of articles about pediatric bipolar disorder published from 1995 to 2010 noted almost no mention of the terms ‘attachment,’ ‘neglect,’ or ‘maltreatment,’ and very few mentions of the terms ‘trauma,’ ‘PTSD,’ ‘physical abuse,’ or ‘sexual abuse,’ and few mentions of the terms ‘verbal abuse’ or ‘emotional abuse’ in pediatric bipolar disorder research cohorts. In an era of dominant pharmaceutical industry funding and marketing, the presumption of biomedical causes for DSM disorders filled the etiological space.”
In other words, American psychiatrists seemingly intentionally overlook any explanations for troubled children’s behavior that don’t align with the assumption that the youth have a biologically based “mental illness.”
What About “Depression”?
If the “mania” part of “juvenile bipolar” is a problematic construct, so is the “depression” part. Might not any of the following cause the thing commonly called “depression”?
- A child gets a string of bad grades and begins to feel hopeless about his chances at school.
- A child is being bullied by a sibling, learns over time that she can’t come to her parents with her complaints or her pain, and feels helpless in her own home.
- A child grows up scrutinized at every turn by a stay-at-home parent who expects nothing less than perfection.
- A child is forced to live in a chaotic environment filled with marital discord, broken promises, and a lack of privacy.
- A child begins to see life as unfair and a cheat and sours on life itself.
- A child receives no permission to do any of the things that he actually enjoys doing and lives a life of rules and chores.
- A child has her efforts criticized and ridiculed in cruel and shaming ways.
- And so on…
It is dishonest to use “depression” as a pseudo-medical term under which to collect all sorts of negative states and behaviors including boredom, recklessness, irritability, anger, and so on. To say that a child is “depressed” when he is actually and obviously irritable and angry is to make a linguistic leap that is as illegitimate as an adult saying that she is “depressed” when she is irritable and angry.
Nor should the word be used as a twisted repetition of a self-reported mood or situation. But what too often happens is that a child says, “I’m depressed,” meaning something along the lines of “I’m being bullied” or “I hate life,” and his psychiatrist repeats, “You’re depressed,” but with a completely different, pseudo-medical meaning. What just happened is that the psychiatrist turned the child’s sadness, his everyday usage of the word “depressed,” into the “mental disorder of depression.”
For all these reasons and more, the construct of juvenile bipolar disorder is extremely shaky and suspicious. With some children exhibiting “manic” and “depressive” behaviors, nothing but childhood is going on. With others, something is indeed going on, but to presume that that something is medical in nature is not supported by the evidence. Pediatric bipolar disorder and other constructs of psychiatry—ADHD, ODD, and so on—are not rooted in medical science. They are labels affixed to a troublesome child or a child in trouble. The trouble may be real and genuine: but what is going on is nothing like a broken arm in need of casting.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.