Bipolar 'R' Us
by Amy Johnson, M.D.

"I need something for my bipolar!" demanded the 13-year-old girl as I passed through the lunch room. "I have mood swings!"

At the girls' residential treatment center where I work, this is heard often. Another favorite is, "That medication isn't working!" One girl actually yelled, "I need 25mg more of Seroquel!" Sometimes I feel like a bartender instead of a psychiatrist.

There is a disturbing trend among these Level 4-5 seriously emotionally disturbed girls, aged 11-18. Approximately 80% of them come to residential treatment with a diagnosis of Bipolar Disorder.

Most come from psychiatric hospitals, some from other residential or group homes, and some from home. Their life stories are often very similar. On one day, I evaluated two girls, both of whom had one parent who had killed the other parent.

Recently, I saw a young teen with a history something like this: early neglect and abuse, termination of parental rights at age three, several foster homes, adoption at age six, poor bonding and behavior problems in the adoptive home, several hospitalizations, and medication trials. She presented as an intelligent, likable girl with a high level of anxiety, panic attacks, obsessive thinking, and flashbacks. She had trouble making friends. Her sleep and appetite were OK. She was not depressed, hypomanic, or psychotic.

In reviewing her chart, I noticed that she had been diagnosed with Bipolar Disorder. I told her that I was not sure if this was the problem, and she got even MORE anxious. "Have you read The Bipolar Child, by Dr. Papalose?" No, I hadn't. "Well, that's what I have. Maybe you should read the book!"

So, I haven't read the book, but I did go to Bipolarchild.com. This is a slick web site, geared to parents, whose first paragraph is, "Find out why thousands of parents wait eagerly for each issue of The Bipolar Child..." Demitri Papalose, M.D., is an associate professor at Albert Einstein. He is a geneticist, whose research deals with a physical syndrome called Velo-cardio-facial syndrome (VCFS). The research group noted a progression of behavior problems in children with VCFS; first separation anxiety, then attention difficulties, then Obsessive Compulsive Disorder, and then Bipolar Disorder. Dr. Papalose says that if DSM-IV criteria were used, only 25% of bipolar children could be diagnosed. His wife, co-author Janice Papalose, is a writer, whose first book was for performing artists, and the second book was The Virgin Homebuyer, written "after a traumatic move to the suburbs."

Linked to Bipolarchild.com is the Juvenile Bipolar Research Foundation. It describes the symptoms of Bipolar Disorder as "abrupt swings of mood and energy that occur multiple times within a day...intense outbursts of temper, low frustration tolerance, and ultra-ultra rapid cycling." This foundation invites you and your child to enroll in Bipolar research, donate money, or in the "how can you help?" section, do fund-raising, such as "host a wine tasting party."

I also looked at the web links on bipolar children. Some were written by adults with the disorder, there were many support groups for parents, book reviews, etc. It was very interesting stuff. Dr. Barbara Weller was quoted from WebM.D. as saying, "Suddenly it's like there is an epidemic of Bipolar Disorder!" This really angered some people. The topic has been on Oprah and is obviously controversial.

As I searched, I became increasingly angry. One thing was the obvious marketing to desperate parents. The other is that the entire conceptualization of the Bipolar Child is based on behavioral symptoms ONLY. Nowhere on any of these sites is a mention of possible environmental causes. There is no mention of possible parenting issues, child sexual abuse, learning/processing difficulties, medical problems, or substance abuse. There is no question about WHY these children might be so angry, moody, or labile.

Do you remember hearing in medical school what the three most important things you need for a diagnosis? History, history, history.

There is not a single girl in residential treatment who does not have a horrible story of early loss, neglect, abuse, or other psychic trauma. Most of these girls have had all kinds of trauma, and other vulnerabilities such as processing problems, substance dependence, chaotic homes, or no families. Many have a family history of psychiatric problems, and are at risk for being among the l-2% of Americans with Bipolar Disorder.

They are impulsive, angry, hopeless girls who often lash out in rage. Imagine yourself as an adolescent, or the desperate parent of a child like this, who sees an expert psychiatrist, who tells you that you have a lifelong, incurable psychiatric disorder. You will need to be on medication for the rest of your life, probably gain 40 pounds, be in and out of psychiatric hospitals, possibly be disabled, get hypothyroidism, polycystic ovaries, or a twitch. You need to think about whether you should have children, because it is genetic.

The Bipolar Girls, as I have heard them called, often view themselves as machine-like. They are empty vessels, subject to moods that do not connect to a source within themselves. Their story has no meaning in this, because they have a biologically-based disease. Rage is not connected to a cause, it just happens. Thus, self-understanding, working through pain, and learning new skills seem useless. Change comes from external sources, primarily medications and expert advice. I actually heard a girl blame the fact that she had assaulted someone, on "my bipolar."

What about the parents of a Bipolar Child? Such a diagnosis may inadvertently feed a family dynamic which requires the child to be very sick. It may take the heat off the parent to look at their own part in the problem. There may be financial compensation. It may be a relief to a parent to think it's not their fault, it's a disease.

Perhaps this one-size-fits-all diagnosis is popular because we psychiatrists are so rushed for time, perhaps can't get all the bio-psychosocial information needed and provide the complicated treatment plan required. Perhaps psychiatric residencies are becoming increasingly biological. Perhaps it is one of the few diagnoses left that is reimbursed by insurance companies.

Bipolar Disorder is a serious, tragic mental illness. We certainly will see children in practice who will be Bipolar adults. It is our responsibility to do the most thorough job we can in assessing difficult children. But I think we need to be cautious, use "rule-outs" in our thinking, develop comprehensive treatment plans, and most of all, provide hope for our patients and their family.

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