THERE鈥橲 a children鈥檚 picture book in the US called Brandon and the Bipolar Bear. Brandon and his bear sometimes fly into unprovoked rages. Sometimes they鈥檙e silly and overexcited. A nice doctor tells them they are ill, and gives them medicine that makes them feel much better.
The thing is, if Brandon were a real child, he would have just been misdiagnosed with bipolar disorder.
Also known as manic depression, this serious condition, involving dramatic mood swings, is increasingly being recorded in American children. And a vast number of them are being medicated for it.
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The problem is, this apparent epidemic isn鈥檛 real. 鈥淏ipolar emerges from late adolescence,鈥 says Ian Goodyer, a professor in the department of psychiatry at the University of Cambridge who studies child and adolescent depression. 鈥淚t is very, very unlikely indeed that you鈥檒l find it in children under 7 years.鈥
How did this strange, sweeping misdiagnosis come to pass? How did it all start? These were some of the questions I explored when researching The Psychopath Test, my new book about the odder corners of the 鈥渕adness industry鈥.
Freudian slip
The answer to the second question turned out to be strikingly simple. It was really all because of one man: Robert Spitzer.
I met Spitzer in his large, airy house in Princeton, New Jersey. In his eighties now, he remembered his childhood camping trips to upstate New York. 鈥淚鈥檇 sit in the tent, looking out, writing notes about the lady campers,鈥 he said. 鈥淭heir attributes.鈥 He smiled. 鈥淚鈥檝e always liked to classify people.鈥
The trips were respite from Spitzer鈥檚 鈥渧ery unhappy mother鈥. In the 1940s, the only help on offer was psychoanalysis, the Freudian-based approach of exploring the patient鈥檚 unconscious. 鈥淪he went from one psychoanalyst to another,鈥 said Spitzer. He watched the psychoanalysts flailing uselessly. She never got better.
Spitzer grew up to be a psychiatrist at Columbia University, New York, his dislike of psychoanalysis remaining undimmed. And then, in 1973, an opportunity to change everything presented itself. There was a job going editing the next edition of a little-known spiral-bound booklet called DSM 鈥 the Diagnostic and Statistical Manual of Mental Disorders.
DSM is simply a list of all the officially recognised mental illnesses and their symptoms. Back then it was a tiny book that reflected the Freudian thinking predominant in the 1960s. It had very few pages, and very few readers.
What nobody knew when they offered Spitzer the job was that he had a plan: to try to remove human judgement from psychiatry. He would create a whole new DSM that would eradicate all that crass sleuthing around the unconscious; it hadn鈥檛 helped his mother. Instead it would be all about checklists. Any psychiatrist could pick up the manual, and if the patient鈥檚 symptoms tallied with the checklist for a particular disorder, that would be the diagnosis.
For six years Spitzer held editorial meetings at Columbia. They were chaos. The psychiatrists would yell out the names of potential new mental disorders and the checklists of their symptoms. There would be a cacophony of voices in assent or dissent 鈥 the loudest voices getting listened to the most. If Spitzer agreed with those proposing a new diagnosis, which he almost always did, he鈥檇 hammer it out instantly on an old typewriter. And there it would be, set in stone.
That鈥檚 how practically every disorder you鈥檝e ever heard of or been diagnosed with came to be defined. 鈥淧ost-traumatic stress disorder,鈥 said Spitzer, 鈥渁ttention-deficit disorder, autism, anorexia nervosa, bulimia, panic disorder鈥︹ each with its own checklist of symptoms. Bipolar disorder was another of the newcomers. The previous edition of the DSM had been 134 pages, but when Spitzer鈥檚 DSM-III appeared in 1980 it ran to 494 pages.
鈥淲ere there any proposals for mental disorders you rejected?鈥 I asked Spitzer. 鈥淵es,鈥 he said, 鈥渁typical child syndrome. The problem came when we tried to find out how to characterise it. I said, 鈥榃hat are the symptoms?鈥 The man proposing it replied: 鈥楾hat鈥檚 hard to say because the children are very atypical鈥.鈥
He paused. 鈥淎nd we were going to include masochistic personality disorder.鈥 He meant battered wives who stayed with their husbands. 鈥淏ut there were some violently opposed feminists who thought it was labelling the victim. We changed the name to self-defeating personality disorder and put it into the appendix.鈥
DSM-III was a sensation. It sold over a million copies 鈥 many more copies than there were psychiatrists. Millions of people began using the checklists to diagnose themselves. For many it was a godsend. Something was categorically wrong with them and finally their suffering had a name. It was truly a revolution in psychiatry.
It was also a gold rush for drug companies, which suddenly had 83 new disorders they could invent medications for. 鈥淭he pharmaceuticals were delighted with DSM,鈥 Spitzer told me, and this in turn delighted him: 鈥淚 love to hear parents who say, 鈥業t was impossible to live with him until we gave him medication and then it was night and day鈥.鈥
Spitzer鈥檚 successor, a psychiatrist named Allen Frances, continued the tradition of welcoming new mental disorders, with their corresponding checklists, into the fold. His DSM-IV came in at a mammoth 886 pages, with an extra 32 mental disorders.
Now Frances told me over the phone he felt he had made some terrible mistakes. 鈥淧sychiatric diagnoses are getting closer and closer to the boundary of normal,鈥 he said.
聯Psychiatric diagnoses are getting closer and closer to the boundary of normal聰
鈥淲hy?鈥 I asked. 鈥淭here鈥檚 a societal push for conformity in all ways,鈥 he said. 鈥淭here鈥檚 less tolerance of difference. Maybe for some people having a label confers a sense of hope 鈥 previously I was laughed at but now I can talk to fellow sufferers on the internet.鈥
Part of the problem is the pharmaceutical industry. 鈥淚t鈥檚 very easy to set off a false epidemic in psychiatry,鈥 said Frances. 鈥淭he drug companies have tremendous influence.鈥
One condition that Frances considers a mistake is childhood bipolar disorder. 鈥淜ids with extreme temper tantrums are being called bipolar,鈥 he said. 鈥淐hildhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child.鈥
鈥淪o maybe the diagnosis is good?鈥
鈥淣o,鈥 Frances said. 鈥淎nd there are very good reasons why not.鈥 His main concern is that children whose behaviour only superficially matches the bipolar checklist get treated with antipsychotic drugs, which can succeed in calming them down, even if the diagnosis is wrong. These drugs can have unpleasant and sometimes dangerous side effects.
Knife edge
The drug companies aren鈥檛 the only ones responsible for propagating this false epidemic. Patient advocacy groups can be very fiery too. The author of Brandon and the Bipolar Bear, Tracy Anglada, is head of a childhood bipolar advocacy group called BP Children. She emailed me that she wished me all the best with my project but she didn鈥檛 want to be interviewed. If, however, I wanted to submit a completed manuscript to her, she added, she鈥檇 be happy to consider it for review.
Anglada鈥檚 friend Bryna Hebert has also written a children鈥檚 book: My Bipolar, Roller Coaster, Feelings Book. 鈥淢att! Will you take your medicines please?鈥 she called across the kitchen when I visited her at home in Barrington, Rhode Island. The medicines were lined up on the kitchen table. Her son Matt, 14 years old, took them straight away.
The family鈥檚 nickname for baby Matt had been Mister Manic Depressive. 鈥淏ecause his mood would change so fast. He鈥檇 be sitting in his high chair, happy as a clam; 2 seconds later he鈥檇 be throwing things across the room. When he was 3 he鈥檇 hit and not be sorry that he hit. He was obsessed with vampires. He鈥檇 cut out bits of paper and put them into his teeth like vampire teeth and go up to strangers. Hiss hiss hiss. It was a little weird.鈥
鈥淲ere you getting nervous?鈥 I asked. 鈥淵eah,鈥 said Hebert. 鈥淥ne day he wanted some pretzels before lunch, and I told him no. He grabbed a butcher knife and threatened me.鈥
鈥淗ow old was he?鈥
鈥淔our. That was the only time he鈥檚 ever done anything that extreme,鈥 she said. 鈥淥h, he鈥檚 hit his sister Jessica in the head and kicked her in the stomach.鈥
鈥淪he鈥檚 the one who punched me in the head,鈥 called Matt from across the room.
It was after the knife incident, Hebert said, they took him to be tested. As it happened, the paediatric unit at what was then their local hospital, Massachusetts General, was run by Joseph Biederman, the doyen of childhood bipolar disorder. According to a 2008 article in the San Francisco Chronicle, 鈥淏iederman鈥檚 influence is so great that when he merely mentions a drug during a presentation, tens of thousands of children will end up taking it.鈥 Biederman has said bipolar disorder can start, 鈥渇rom the moment the child opens his eyes鈥.
鈥淲hen they were testing Matt he was under the table, he was on top of the table,鈥 said Hebert. 鈥淲e went through all these checklists. One of Dr Biederman鈥檚 colleagues said, 鈥淲e really think Matt meets the criteria in the DSM for bipolar disorder.鈥
That was 10 years ago and Matt has been medicated ever since. So has his sister Jessica, who was also diagnosed by Biederman鈥檚 people as bipolar. 鈥淲e鈥檝e been through a million medications,鈥 said Hebert. 鈥淭here鈥檚 weight gain. Tics. Irritability. Sedation. They work for a couple of years then they stop working.鈥
Hebert was convinced her children were bipolar, and I wasn鈥檛 going to swoop into a stranger鈥檚 home for an afternoon and tell her they were normal. That would have been incredibly patronising and offensive. Plus, as the venerable child psychiatrist David Shaffer told me when I met him in New York later that evening, 鈥淭hese kids can be very oppositional, powerful kids who can take years off your happy life. But they aren鈥檛 bipolar.鈥
鈥淪o what are they?鈥
鈥淎ttention-deficit disorder?鈥 he said. 鈥淥ften with an ADD kid you think: 鈥楳y God, they鈥檙e just like a manic adult.鈥 But they don鈥檛 grow up manic. And manic adults weren鈥檛 ADD when they were children. But they鈥檙e being labelled bipolar.
鈥淭hat鈥檚 an enormous label that鈥檚 going to stay with you for the rest of your life. You鈥檙e being told you have a condition which is going to make you unreliable, prone to terrible depressions and suicide.鈥
The debate around childhood bipolar is not going away. In 2008, The New York Times published excerpts from an internal hospital document in which Biederman promised to 鈥渕ove forward the commercial goals of Johnson & Johnson鈥, the firm that funds his hospital unit and sells the antipsychotic drug Risperdal. Biederman has denied the allegations of conflict of interest.
Frances has of the next edition of DSM, which is now being drawn up by the American Psychiatric Association.
This article shouldn鈥檛 be read as a polemic against psychiatry. There are a lot of unhappy and damaged people out there whose symptoms manifest themselves in odd ways. I get irritated by critics who seem to think that because psychiatry has elements of irrationality, there is essentially no such thing as mental illness. There is. Childhood bipolar, however, seems to me an example of things having gone palpably wrong.
On the night of 13 December 2006, in Boston, Massachusetts, 4-year-old Rebecca Riley had a cold and couldn鈥檛 sleep. Her mother, Carolyn Riley, gave her some cold medicine, and some of her bipolar medication, and told her she could sleep on the floor next to the bed. When she tried to wake Rebecca the next morning, she discovered her daughter was dead.
The autopsy revealed that Rebecca鈥檚 parents had given her an overdose of the antipsychotic drugs she had been prescribed for her bipolar disorder. They had got into the habit of feeding her the medicines to shut her up when she was being annoying. They were both convicted of Rebecca鈥檚 murder.
聯Rebecca鈥檚 parents had got into the habit of feeding her the medicines to shut her up when she was being annoying聰
Rebecca had been diagnosed as bipolar at 2-and-a-half, and given medication by an upstanding psychiatrist who was a fan of Biederman鈥檚 research into childhood bipolar. Rebecca had scored high on the DSM checklist, even though like most toddlers she could barely string a sentence together.
Shortly before her trial, Carolyn Riley was interviewed on CBS鈥檚 60 Minutes show by Katie Couric:
KC: Do you think Rebecca really had bipolar disorder?
CR: Probably not.聽聽聽聽聽聽聽聽聽聽聽聽聽
KC: What do you think was wrong with her now?
CR: I don鈥檛 know. Maybe she was just hyper for her age.
