THEREâS a childrenâs picture book in the US called Brandon and the Bipolar Bear. Brandon and his bear sometimes fly into unprovoked rages. Sometimes theyâre 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 isnât real. âBipolar emerges from late adolescence,â says Ian Goodyer, a professor in the department of psychiatry at the University of Cambridge who studies child and adolescent depression. âIt is very, very unlikely indeed that youâll find it in children under 7 years.â
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 âmadness industryâ.
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. âIâd sit in the tent, looking out, writing notes about the lady campers,â he said. âTheir attributes.â He smiled. âIâve always liked to classify people.â
The trips were respite from Spitzerâs âvery unhappy motherâ. In the 1940s, the only help on offer was psychoanalysis, the Freudian-based approach of exploring the patientâs unconscious. âShe went from one psychoanalyst to another,â 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 â 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 hadnât helped his mother. Instead it would be all about checklists. Any psychiatrist could pick up the manual, and if the patientâs 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 â the loudest voices getting listened to the most. If Spitzer agreed with those proposing a new diagnosis, which he almost always did, heâd hammer it out instantly on an old typewriter. And there it would be, set in stone.
Thatâs how practically every disorder youâve ever heard of or been diagnosed with came to be defined. âPost-traumatic stress disorder,â said Spitzer, âattention-deficit disorder, autism, anorexia nervosa, bulimia, panic disorderâŚâ 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 Spitzerâs DSM-III appeared in 1980 it ran to 494 pages.
âWere there any proposals for mental disorders you rejected?â I asked Spitzer. âYes,â he said, âatypical child syndrome. The problem came when we tried to find out how to characterise it. I said, âWhat are the symptoms?â The man proposing it replied: âThatâs hard to say because the children are very atypicalâ.â
He paused. âAnd we were going to include masochistic personality disorder.â He meant battered wives who stayed with their husbands. âBut 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.â
DSM-III was a sensation. It sold over a million copies â 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. âThe pharmaceuticals were delighted with DSM,â Spitzer told me, and this in turn delighted him: âI love to hear parents who say, âIt was impossible to live with him until we gave him medication and then it was night and dayâ.â
Spitzerâs 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. âPsychiatric diagnoses are getting closer and closer to the boundary of normal,â he said.
ÂPsychiatric diagnoses are getting closer and closer to the boundary of normalÂ
âWhy?â I asked. âThereâs a societal push for conformity in all ways,â he said. âThereâs less tolerance of difference. Maybe for some people having a label confers a sense of hope â previously I was laughed at but now I can talk to fellow sufferers on the internet.â
Part of the problem is the pharmaceutical industry. âItâs very easy to set off a false epidemic in psychiatry,â said Frances. âThe drug companies have tremendous influence.â
One condition that Frances considers a mistake is childhood bipolar disorder. âKids with extreme temper tantrums are being called bipolar,â he said. âChildhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child.â
âSo maybe the diagnosis is good?â
âNo,â Frances said. âAnd there are very good reasons why not.â 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 arenât 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 didnât want to be interviewed. If, however, I wanted to submit a completed manuscript to her, she added, sheâd be happy to consider it for review.
Angladaâs friend Bryna Hebert has also written a childrenâs book: My Bipolar, Roller Coaster, Feelings Book. âMatt! Will you take your medicines please?â 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 familyâs nickname for baby Matt had been Mister Manic Depressive. âBecause his mood would change so fast. Heâd be sitting in his high chair, happy as a clam; 2 seconds later heâd be throwing things across the room. When he was 3 heâd hit and not be sorry that he hit. He was obsessed with vampires. Heâd 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.â
âWere you getting nervous?â I asked. âYeah,â said Hebert. âOne day he wanted some pretzels before lunch, and I told him no. He grabbed a butcher knife and threatened me.â
âHow old was he?â
âFour. That was the only time heâs ever done anything that extreme,â she said. âOh, heâs hit his sister Jessica in the head and kicked her in the stomach.â
âSheâs the one who punched me in the head,â 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, âBiedermanâs influence is so great that when he merely mentions a drug during a presentation, tens of thousands of children will end up taking it.â Biederman has said bipolar disorder can start, âfrom the moment the child opens his eyesâ.
âWhen they were testing Matt he was under the table, he was on top of the table,â said Hebert. âWe went through all these checklists. One of Dr Biedermanâs colleagues said, âWe really think Matt meets the criteria in the DSM for bipolar disorder.â
That was 10 years ago and Matt has been medicated ever since. So has his sister Jessica, who was also diagnosed by Biedermanâs people as bipolar. âWeâve been through a million medications,â said Hebert. âThereâs weight gain. Tics. Irritability. Sedation. They work for a couple of years then they stop working.â
Hebert was convinced her children were bipolar, and I wasnât going to swoop into a strangerâs 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, âThese kids can be very oppositional, powerful kids who can take years off your happy life. But they arenât bipolar.â
âSo what are they?â
âAttention-deficit disorder?â he said. âOften with an ADD kid you think: âMy God, theyâre just like a manic adult.â But they donât grow up manic. And manic adults werenât ADD when they were children. But theyâre being labelled bipolar.
âThatâs an enormous label thatâs going to stay with you for the rest of your life. Youâre being told you have a condition which is going to make you unreliable, prone to terrible depressions and suicide.â
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 âmove forward the commercial goals of Johnson & Johnsonâ, 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 shouldnât 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 couldnât 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 Rebeccaâs 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 Rebeccaâs murder.
ÂRebeccaâs parents had got into the habit of feeding her the medicines to shut her up when she was being annoyingÂ
Rebecca had been diagnosed as bipolar at 2-and-a-half, and given medication by an upstanding psychiatrist who was a fan of Biedermanâs 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 CBSâs 60 Minutes show by Katie Couric:
KC: Do you think Rebecca really had bipolar disorder?
CR: Probably not.            Â
KC: What do you think was wrong with her now?
CR: I donât know. Maybe she was just hyper for her age.
