Bipolar Syndrome: When Is a Disease Real?

Much frenzy about the rapid increase in diagnoses for bipolar syndrome in children. A new study in the Archives of General Psychiatry shows that there's been a 40-fold increase in diagnoses over the past decade or so, with now fully 1 percent of all children being labeled "bipolar." According to the DSM IV, the textbook for mental health and disease classification, bipolar disorder is a mood disorder characterized by manic episodes and major depressive episodes. The diagnosis is controversial because of familiar riddle of epidemiology: Either the illness was underdiagnosed for decades, and we are now identifying a previously-hidden epidemic. Or the illness is being overdiagnosed, as a condition already of flimsy status in adult populations gets extended into children. As it happens, I was speaking last week with a prominent psychiatrist who was involved in the crafting of the DSM IV. First characterized bipolar disorder in children as one of the two "major issues"* in the psychiatric community and in the crafting the new edition of the diagnostic manual. The issue is how applicable is the disorder to children, in whom mental health can be far more variable and transitory.

The big takeaway from my conversation with this psychiatrist was what he described as the "major problem" with the popular perception of the DSM. "People forget that these aren't real diseases," he said. "These are man made diseases. We're just describing symptoms, we don't really know what's going on inside."

This, of course, is a major difference between mental health diagnoses - which are efforts to describe symptoms as we see them - and pathological diagnoses - which are attempts to discern molecular and cellular processes inside the body. I wish more effort was made to make this point clear, among the menta-health community as well as among the media. This New York Times story does a nice job of referring to bipolar disorder as a "label", but it's surprising to me that there's not more of an effort to explain the relativistic nature of this label (particularly for an article that's really about the mushiness of mental health diagnoses). And as medicine starts to adopt this practice of diseases more conceptual than physical, I think this distinction must be maintained.

Interestingly, there's one major exception to the "man-made" nature of the DSM - sleep disorders, which can be understood and, more importantly, measured in physical terms

* The other being a sort-of flip side illness, Adult Attention Deficit Disorder, which represents a childhood condition being extended to adults.