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The Truth About ADHD and Bipolar

During a gathering at the beginning of 2012 the excellent Floridian psychiatrist David Keisari told me that I should be feeling validated because, more than 10 years ago, many of our colleagues thought that I was supporting “crazy ideas.” He knows that situation very well because he was the person who brought me to Florida and he was also my boss at that time.
I bring this up to introduce the subject of truths and fallacies about ADHD and Bipolar because I find it interesting that another very smart clinician, Dr. Javier Perez, said something along those lines when I was leaving Phoenix, AZ, after fighting virulent attacks from an establishment that was reluctant to consider the idea of diagnosing a child with a mood disorder. To magnify this coincidence of events, in 1996 another Medical Director (Dr. Mark Rubin) also supported my dissenting view of the prevailing psychiatric mantra in Arizona at that time:  all distracted and restless children, even those with violent behavior, has ADHD* and amphetamines will help them. The second element of their diagnostic formulation was that genetic endowment was not a matter to be considered.

One will think that after 20 years, and the American Psychiatric Association’s (APA) endorsement of pediatric bipolar spectrum as a reality, the “war” will be softening but the opposite is actually happening.  At times it looks to me as a mirror image of the fanaticism that characterizes the current political debate…an argument between two deaf and blind individuals.
The majority of psychiatrists and psychotherapists have accepted the presence of bipolar spectrum but only with one condition: it has to be accompanied by ADHD, Conduct Disorder, Autism, PTSD, Oppositional-Defiant Disorder, etc.
Very few follow the DSM (Diagnostic and Statistical Manual) guideline that indicates “the symptoms do not occur exclusively during the course of a Pervasive Developmental Disorder, Schizophrenia or other Psychotic Disorder and are not better accounted for by another mental disorder (e.g., Mood disorder, Anxiety Disorder, Dissociative Disorder, or a Personality Disorder). (Page 66 of the DSM Manual’s Handbook)”.  Any rational lay person can understand that an individual that is unable to make eye contact with his or her parents should not be considered “ADHD” because of lack of attention in class.  Still respected academics from prestigious universities support the thesis that ADHD and Autism occur in the same person.  By the same token, despite the DSM inclusion of lack of attention, hyperactivity and distractibility as essential element of manic or hypomanic episode, most doctors and psychotherapists will diagnose the child of bipolar parents as having ADHD.  Worse yet, when the symptoms don’t improve “with appropriate” treatment, the child is considered “oppositional-defiant” or Conduct Disorder which is the pediatric equivalent of Antisocial Personality.

But the picture gets gloomier.  Since 2007-08 doctors have embraced the idea of diagnosing ADHD in adults with already established diagnosis of Bipolar Disorder, PTSD -having symptoms after traumatic (s) event (s) - ignoring the warnings about the negative consequences of giving amphetamines-like drugs to a patient with elevated mood or anxiety. From the academic view, it is even more difficult to understand such position.
Returning to the DSM guideline, one of the criteria to diagnose ADHD is that symptoms must be present before the age of 7 years old.  The enthusiasm for labeling people with ADHD drive some doctors and psychotherapists to accept the statement “I always struggled with school” as an evidence of “undiagnosed ADHD” without further investigating what kind of struggle the person had.  Was it behavioral or academic?
The other major fallacy is the alleged “high co-morbidity” between ADHD and Bipolar Disorder. The most prestigious training centers in the USA still teach that many bipolar patients “started out as ADHD.” Just imagine for a second that we pose a similar statement in the field of another medical specialty?  If I play Devil’s Advocate and I say that bronchial asthma can progress to emphysema (also called Chronic Obstructive Pulmonary Disease) is it not the case then that when the most aggressive respiratory problem is diagnosed we don’t call the patient “asthmatic” any more but instead we say that he or she has COPD?

To conclude I want to say that I plan to keep this uphill fight going because every single day I see the consequences of the wrongly diagnosed ADHD as well as the common practice of prescribing antidepressants to bipolar patients.  Losing a job, ending a marriage, disaffecting from relatives and friends, getting into legal problems are some of the most common “prices” patients have to pay for their doctors and psychotherapists mislead interest in helping them.  My final advice to readers of this website:  Stay away from clinicians that give the same diagnosis to 90-95% of their patients.  Whether in psychiatry or dermatology that cannot be possible and it will be naïve to believe that it could be right to do it.

Manuel Mota-Castillo, M.D.

*On the day, I wrote this comment NBC (Dateline) presented the case of a little boy with a possible transgender disorder that was diagnosed with anxiety and later on with ADHD.  He was prescribed several medications by psychiatrists in Japan that didn’t help with his behavior.  All symptoms disappeared when the real problem was identified.

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