it was announced today that the upcoming version (V) of the diagnostic and statistical manual of mental disorders will contain changes affecting the definition and diagnosis of bipolar disorder in children. the dsm-V and all the other dsms that preceded it are the bible of pathology both to the psychiatric profession and the insurance industry. the psychiatric profession uses it to categorize, qualify and codify clusters of behavior and tendency in such a way that they are legitimized as pathology, and are therefore subject to a regimen of psychiatric, and therefore, pharmacological treatment, and finally reimbursement by insurance companies. as a psychotherapist, but primarily as a human being, i am concerned by any organized mechanism that is utilized to codify pathology, and have long been skeptical of the role of the dsm in the healing sciences/arts. i am pragmatic however, and like many in my field, have yielded to the authority of this system of codification out of necessity, while not allowing it to become the sole indicator of what you actually do with clients. a person is not their diagnosis. the dsm and the attendant psychiatric paradigm are here to stay, and one must work with it in a wary, proficient, expert, and mindful manner.
that being said, i do see some possible benefit in the creation of the new diagnostic category of temper dysregulation disorder with dysphoria (TDD). this new diagnosis“ was created to capture a valid syndrome with characteristics and outcomes that are different than those of bipolar disorder. the available scientific data supports the position that the TDD syndrome is NOT simply the manifestation of bipolar disorder in childhood.”
I could bore you all with a great deal of psychobabble regarding the diagnostic conditions and indicators of the condition, but i will not. i am more interested with the sociology behind the creation of the new diagnostic category. but first let me stress that the creation of TDD does not do away with the diagnostic category of bipolar disorder for children. you will notice that i am not going into great detail explaining what bipolar is. the reason for this is…it’s not necessary for this discussion. bipolar disorder has become part of the popular culture, it’s rampant in hollywood (robin williams being one person who has come “out” regarding his bipolar), we even diagnose centuries dead people from beyond the grave, van gogh for example. although misused as a diagnosis by professionals, and mistaken for other behaviors and syndromes by laypersons, the idea of bipolar, the new “extra crazy” punctuated by manic and depressive mood shifts and swings, is conceptualized in some way by us all. there are thousands of children each year that have been diagnosed as bipolar that will be looking at a lifetime of taking mood stabilizers, anti-depressants, anti-psychotics, and anti-convulsants, depending on their symptomatology and presentation. TDD at least gives diagnosing professionals an option to make a diagnosis that can be seen more in the context of distinct behavior and as a condition that is subject to change or diminish as the person changes developmentally. it is not as hard set a diagnosis.
concerning the sociology behind the decision, it was necessary to make this change to some degree due to the rampant misuse of the bipolar diagnosis, and fears concerning the primary treatment interventions that are being used, which are largely pharmacological. there is a lack of data concerning the long term effects of the aggressive drugs that are used to manage the behaviors associated with bipolar. creating TDD effectively offered more choices that may, or may not be, less extreme. i say this due to the fact that still, in many instances, children diagnosed with TDD will be given the same medication regimen as children diagnosed with bipolar. it is only a small ray of hope.
the biggest part of the problem is the existence of the dsm in it’s current configuration at all. the medical model has dictated that negative social and personal behaviors connote illness, and illness, madness, must be treated in an environment, medically, socially and spiritually, that demands quarantine. we often do not consider the misalignments in family patterns, the malaise that exists in challenged communities, the effects of trauma, as being primary contributors to severely manic or depressive behavior. we assume that the genesis is organic, because people respond to pharmacological treatment, and by respond, we mean conform. they become more predictable, compliant and manageable, not necessarily more productive, capable, or happy. but these are not the concerns of the psychiatric social apparatus. we are in the business of control. i strongly urge a reconsideration of family based, communally based interventions such as functional family therapy to treat severe psychiatric disorders, because these types of interventions begin to address the responsivity and patterns of behavior that exist in the social environment of the affected parties, and allow for more options for change, normalization and acceptance. the mentally “ill” person is invited to become part of the process of their healing, and not a target of a process. all of this is not to excuse the pragmatic reality that there are people that are truly profoundly ill, that must be managed on strict pharmacological regimens to merely function, but they are often the exception rather than the rule. psychiatry has a tendency to hit the gnat with the hammer first, and worry about the results later.