Childhood Conduct Disorder and Oppositional .Defiant Disorder Are Common Manifestations of Bipolar Disorder
The Journal of Bipolar Disorders, 2004
Vol. 3 Number 4
Manuel Mota-Castillo, MD
Medical Research Group of Central Florida
Grange City, Florida.
(Dr. Mota-Castillo is a member of the speakers' bureaus of AstraZeneca Pharmaceuticals, ClaxoSmithKiine, Eli Lilly and Company, and Pfizer Inc.)
After reading this article, physicians should be able to state that behind a presenting complaint of oppositional-defiant behavior lies a diagnosis to be identified.
Over the past 10 years, many colleagues have come to realize that this statement is supported by thousands of their files, in which the stories of so many children are the best testimony of how frequently bipolar disorder (BP) is misidentified as· oppositional-defiant disorder (ODD) or conduct disorder (CD). I can affirm, without hesitation, that this is the case in most of the patients I have treated in the past 8 years of my practice. Only in a very small number of patients labeled as "ODD" or "CD" will the actual condition be something different from BP, like obsessive-compulsive disorder, social anxiety disorder, psychotic disorders, and depression. For all practical purposes, in the presence of a child with overtly defiant behavior, it is better to think first of a mood disorder.1,2 I support those who believe that conceptualizing oppositional-defiant behavior as a symptom, rather than as a diagnosis, helps to determine the real nature of the patient's problem. Among this idea's pioneers we find prominent names like Andres Pumariega, Rakesh Jain, Ronald Pies, Paul Genova, and Charles Huffine.3,6
In contrast, the circularity of accepting ODD as a separate diagnostic entity can be discerned in the following scenario:"Doctor, I am here because my son displays oppositional and defiant behavior." The doctor evaluates the child: investigates family history, previous treatment interventions, possible substance abuse, and medical conditions; runs psychological tests; and applies behavioral scales. After that thorough assessment, the doctor says: "My conclusion is that your son has oppositional-defiant disorder."
In spite of how unhelpful that physician might sound, he or she still would be right, in that such a conclusion is supported by the DSM-IV.7 This is one of the reasons why Huffine, Pumariega, and I have been advocating the elimination of ODD and CD as accepted diagnoses.8
Before elaborating, I should clarify that I respect all the well known scholars who delineated these diagnoses.9 Some of these clinicians no longer support the validity of ODD and CD, or are at least willing to question it. Nevertheless, to be fair to them, we have to put the ODD and CD categories in an historical perspective. It is my impression that ODD and CD were viable alternatives at a time when the psychiatric establishment refused to label a child as bipolar. However, the designations "ODD" and "CD" should be used in psychiatry as infrequently as "Fever of Unknown Origin" is diagnosed by infectious disease specialists. Just as such specialists can now determine the origin of most fevers, psychiatrists must make every effort to identify the origin of so-called "oppositional defiant" behavior.
Indeed, now that specialists in child psychiatry acknowledge that BP occurs in children, we need to reformulate ODD and CD in that light. If we examine the DSM-IV list of symptoms for ODD and compare it with the symptoms reflected in the Bipolar Spectrum Diagnostic Scale for Children* (BSDS), 10 we find that every DSM-IV symptom corresponds to one or two from the Scale (see table below).
In regard to CD, many clinicians use it as "the next level of severity" when the so-called treatment fails to control the ODD. In my experience, the usual scenario is "co-morbidity" with ADHD and the prescription of a Ritalin-type medication. Such psychostimulants only worsen the dysphoria of the underlying mood disorder.
Psychiatrists can understand this formulation, but I have my doubts when it comes to primary care physicians. They are familiar with the DSM-IV, but they may not read psychiatric journals and can be out of touch with recent developments in the psychiatric field. We should remember that in 1999, the Journal of Clinical Psychiatry published a report from the APA showing that 60% of psychiatric services in the U.S. are provided by primary care physicians.
One oversight that can be blamed on mental health professionals is neglecting to consider family history in the diagnostic formulation. I have changed diagnoses of hundreds of children who were misdiagnosed with ADHD plus ODD or CD whose parents, grandparents, and uncles were afflicted by bipolar spectrum disorders or schizophrenia.11
It is time for psychiatrists to stop repeating the words parents use in describing their children-oppositional and defiant and to begin diagnosing the underlying mood disorder.
I thank Dr. Ronald Pies, who read and made suggestions on the manuscript.
Mota-Castillo M. Psychiatric Times 2003;20:39--40.
Pies R, Genova P. Multiple papers in Psychiatric Times and personal communications. American Psychiatric Association.
Diagnostic and Statistical Manual of Mental Disorders: DSM-IV. 4th ed. Washington, D.C.: American Psychiatric Press, Inc.; 1994.
Mota-Castillo M. Psychiatric Times 2004;21(2):3.
Rey JM. Am] Psychiatry 1993;150:1769-1778.
Ghaemi SN, et al. Sensitivity and specificity of a new bipolar spectrum diagnostic scale.] Affect Disord. In press.
Mota-Castillo M. Psychiatric Times 2004;21:21-22.
Hans Steiner, MD
Professor of Psychiatry and Behavioral Sciences.
Child Psychiatry and Child Development
Co- director, Center for Psychiatry and the Law Department of Psychiatry and Behavioral Sciences Stanford University of Medicine. Stanford, California
(Dr Steiner has disclosed that he has no significant relationships with, or financial interests in, any commercial companies pertaining to this educational activity)
After reading this article, physicians should be able to identify maladaptive aggression in juvenile bipolar disorder and to apply the optimal interventions from a developmental perspective.
Several studies report associations between bipolar disorder (BP) and oppositional defiant disorder (ODD) and conduct disorder (CD), 1,4 with rates as high as 69%. This overlap also exists in symptomatic bipolar offspring. 4 At first glance, it is hard to argue that these disorders are not related, but there are several counterpoints to be considered.
First, the co-occurrence of these diagnoses could be definitional and hence spurious or trivial. There is a definitional overlap between disruptive behavior and bipolar symptoms. 5 ODD contains the criteria "loses temper, touchy and easily annoyed, angry, resentful, spiteful, and vindictive"; CD the criteria "bullies, threatens and intimidates others, initiates physical fights, is physically cruel to people."
Mania contains the criteria "irritability, distractibility, psychomotor agitation." These criteria are sufficiently similar to produce confounds. In the absence of completely objective criteria, "irritability" and "touchy and easily annoyed" may be simply different observer interpretations of the same phenomenon.
One study has examined this issue regarding the overlap between BP and disruptive
behavior disorders (DBD),6 reporting that after eliminating the overlap, two separate disorders remain. Still, the issue has not been definitively laid to rest and may drive the observed relation.
There is much dissatisfaction in child and adolescent psychiatry with the poorness of fit between an ad ult-derived and down ward extended taxonomy and clinical realities in youth. The overlap between DBD and BP is a good case in point.4
Secondly, another source of significant associations could derive from the fact that children with BP are more likely to come from psychopathological parents, and that such families exhibit characteristics that will lead to poor socialization of aggressive behaviors. 7,8
Indeed, families of bipolar offspring are characterized by high levels of conflict and parental control.8 Family disorganization is evident early in life.9 Studies report 2-year-old children of bipolar parents to show "heightened distress and preoccupation with the conflicts and suffering of others,"9 increasing problems socializing with peers, and aggression toward both peers and adults. A longitudinal study following offspring for 3 years 10 noted that significantly more offspring of affectively ill parents had developed depressive and behavioral problems. Bipolar patients produce bipolar offspring and dysfunctional family environments. A priori, it is an open question which main effects and/or interactions produce maladaptively aggressive outcome.
Most interestingly and importantly, the association between these disorders could be spurious, because their co-existence really is the developmental psychopathological expression of the same deficit. BP is definitely characterized by heightened aggression. 11,12 From the view of developmental psychopathology, this association represents the invasion of disordered mood regulation into other domains of functioning. This seems to be common in prepubertal onset BP. 3
Why should this be so?
Basic emotion (fear, sadness, anger) circuits13 are controlled by neuroarchitectures that operate in close proximity in the amygdala, an area of dysfunction that has been implicated in BP. 14 Dysfunction in the basic threat detection and mood regulation circuitry readily expresses itself in maladaptive impulsive aggression. 15 An immature central nervous system is unable to contain disorders in distinct circuits and symptom domains. Thus, when disorders have an early onset, more domains of functioning are affected. While the exact mechanism for this spread of dysregulation is presently unknown, cogent models exist-such as the kindling model proposed by Post et al.16 To diagnose separate disorders would miss this point. Treatments in psychiatry are becoming increasingly specific, making it important to commit to principal disorders. We expect that treating the BP as specifically as possible (e.g., with mood stabilizers) will reduce secondary disturbances , such as disruptive behavior, and there is some evidence supporting this contention.12
Finally, the developmental model of psychopathology has profound theoretical implications. The model looks beyond symptoms at developmental trajectories and pathogenetic pathways.17 Disorders arise out of constitutional/genetic and environmental factors interacting over time to produce outcomes such as BP.
Early manifestations of disorders are less defined and affect a wider range of domains because of deficient differentiation. Developmentally, we do not assume that when disorders are present they will persist in their present form into adulthood. They may change character or disappear altogether.
Continuity is an empirical question to be examined in longitudinal studies. When disorders have later onset, or as they "mature" over time, they breed true, exhibiting core deficits, and crystallize into distinct diagnoses. Simple lists of comorbid conditions do not reflect this progression. Many authors17 have argued that the DSM comorbidity approach leaves us with too many ambiguities in the care of our young patients. In youth, comorbidity is the rule. Having a discrete disorder is seen as a developmental "achievement." But we can reduce confusion by adopting a developmental stance that looks for principal disorders, however difficult this may be at the present time. In this view, maladaptive aggression in juvenile BP is part and parcel of the core problem.
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Chang KD, et al. Bipolar Disord 2001;3:73-78.
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Blair J, et al. (Stanford/Howard/AACAP Workgroup on Juvenile Impulsivity and Aggression). Juvenile Maladaptive Aggre ssion: The Neuroscience of Maladaptive Aggression. 2004.
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Steiner H. Handbook of Mental Health Interventions in Children and Adolescents: An Integrated Developmental Approach. San Francisco, CA:Jossey-Bass; 2004.
Rebuttal to the Article by Dr. Steiner
By Manuel Mota-Castillo, MD
There is nothing to argue about the scientific part of Dr. Steiner's article. The thorough explanation of the developmental, sociological, and biochemical components of the mental disorders being discussed in this debate has the signature of an outstanding academic, as should be expected from Dr. Steiner. Nonetheless, I have several questions that have to do with the politics behind DSM-IV.
I believe that oppositional-defiant disorder (ODD) and conduct disorder (CD) are remnants of an era when to diagnose a child as bipolar was a sacrilege. The acceptance of this diagnosis in the pediatric population has brought a better quality of life to many families but also a serious headache to psychiatric researchers: What to do with a huge amount of data tainted with two artifacts, ODD and CD ?
This question seems to be a Pandora's Box that no one is willing to open . This could render highly regarded studies, such as the Multimodal Treatment Study of Children with Attention Deficit/Hyperactivity Disorder (ADHD), also known as MTA, useless.
Another compounding factor is the respect that most professionals in this field have for the many researchers who have contributed to the understanding of mental illnesses. They may feel hurt even though we know that a significant part of most studies is in the hands of doctors in training, who follow the misleading DSM-IV parameters. This could explain why the MTA study diagnosed children with ODD and CD instead of bipolar spectrum disorders.
Possibly, too, why some of my current patients were diagnosed with a comorbidity of ADHD and ODD at famous children's clinics in Boston, Philadelphia, Minneapolis, and New Haven, CT, to mention just a few.
Even Dr. Steiner falls into the trap of referring to "a definitional overlap between disruptive behavior and bipolar symptoms." I don't believe there is an "overlap," but, in fact, disruptive behavior is part of the bipolar spectrum. I believe ODD and CD are part of one diagnosis! that can present with multiple features under a rather wide umbrella: bipolar spectrum disorders. As a mat ter of fact, one of Dr. Steiner's statements seems to validate my theory: "Studies report 2-year-old children of bipolar parents to show 'heightened distress and preoccupation with the conflicts and suffering of others,' increasing problems socializing with peers, and aggression toward both peers and adults ." Two-year-old children of bipolar parents with this type of behavior are diagnosed by me as bipolar, 2 as reported in the Journal of Affective Disorders. The 25-month-old boy mentioned in that article is now 7 years old and is still bipolar, as his parents are.
Mota-Castillo M. Psychiatric Times 200 4; 21( 2):3.
Mota-Castillo M, et al.J. Affect Disord 2001;67:193 -197.
Rebuttal to the Article by Dr. Mota-Castillo
By Hans Steiner, MD
I agree with Dr. Mota's central arguments, which are complimentary rather than contra to my position. He approaches the disruptive behavior disorder (DBD)/bipolar disorder (BP) overlap from a different vantage point, i.e., clinical experience. Juvenile bipolar illness is indeed very often complicated by maladaptive aggression, as is a whole host of other psychopathology in youths. This is supported by data that we have reported.1,3 This conclusion was also reached by a National Consensus Panel in Washington, DC.4 It is also very important to alert primary care doctors to the possibility of overdiagnosis of attention-deficit/hyperactivity disorder (ADHD), as we have reason to believe that the treatment of each is becoming increasingly specific.
Our opinions diverge where Dr. Mota asserts that maladaptive aggression in bipolar disorder is frequently misidentified as oppositional-defiant disorder (ODD) or conduct disorder (CD). As we have pointed out, the core problem with the current descriptive taxonomy is that it does not refer to pathogenic pathways and process es. It is impossible to know what any symptom "really" is, because descriptive symptoms are often a final common pathway: Affectively charged aggression can appear in the context of psychiatric trauma, mental retardation, pervasive developmental disorder, ADHD, and BP, to name a fews,6 To therefore suggest that "for all practical purposes, in the presence of a child with overtly defiant behavior, it is better to think first of a mood disorder" is overreaching. Clinical experience may reflect bias in selection, observation, or treatment, or all three. In a randomly selected cohort of 840 severely maladaptively aggressive youths, bipolar disorder was diagnosed in only 1% of boys and 3%of girls.2 The bulk of the youths suffered from other diagnoses, such as substance use disorders (80% ), anxiety and depression (32%) , ADHD(12% ), etc. It seems best to re-emphasize the main points of agreement:(1) that maladaptive aggression is commonly found in all kinds of internalizing and externalizing disorders, and (2) it is perhaps best understood as "fever" is in the rest of medicine .
The argument that ODD and CD should not be separate diagnoses is tangential to this debate. There are good reasons to think that by modifying them appropriately, new and useful taxa can be designed that are valid, discriminate, and lead to specific interventions.
The Stanford/Howard Workgroup on Juvenile Aggression has summarized the neuroscientific advances that should inform such changes: How these would result in new diagnostic entities and how such entities can best be treated. 5,6 Details of these discussions are beyond the scope of this reply.
Steiner H , Redlich A. Child psychiatry and juvenile justice. In: Lewis M, ed. ChilLi and Adolescent Psychiatry: A Comprehensive Textbook. Philadelphia: Lip pincott Williams & Wilkins; 2002:1417-1425.
Steiner H, et al. The Assessment of the Mental Health System of the California Youth Authority. Report to Governor Gray Davis. December 31, 2001
Steiner H , Karnik N. Child or adolescent antisocial behavior. In :Sadock BJ , Sadock VA, e ds . Kaplan & Sadock's Comprehensive Textbook of Psychiatry. Vol. 2. 8th ed. Philadelphia, PA: Li ppincott Williams & Wilkins; 2004.
Carlson GA, et al. Scientific Proceedings Of The Annual Meeting Of The American Academy Of Child And Adolescent Psychiatry. 2004;20:54.
Steiner H, et al. Scientific Proceedings Of The Annual Meeting Of The American Academy Of Child And Adolescent Psychiatry. 2004;20:35.
Steiner H. Scientific Proceedings Of The Annual Meeting Of Th e American Academy Of Child And Adolescent Psychiatry. 2004;20:35.
Oppositional-Defiant and Conduct Disorders: Alternative Expressions or Complications of Bipolar Disorder in Childhood?
By Hagop S. Akiskal, MD,
(Dr. Akiskal is a consultant for, and is a member of the speakers' bureaus of, AstraZeneca Pharmaceuticals, Bristol-Myers Squibb Company, GlaxoSmithKline, Eli Lilly and Compan y, Pfizer Inc., and Sanofi-Aventis.)
This is the second debate on the boundaries of pediatric bipolar disorder, the previous one having been dedicated to the prevalence of bipolarity in childhood and its discrimination from attention-deficit/hyperactivity disorder (ADHD)1The reason for featuring prepubertal bipolar disorder in two consecutive issues is based on the request of readers of this CME journal.
In some ways, the present debate between Drs. Mota-Castillo and Steiner is reminiscent of that between Drs. Faedda and Carlson 1 in one fundamental respect: Clinicians who have to treat patients on the basis of a diagnosis generally avoid vague conditions for which treatment implications are uncertain, whereas academic psychiatrists thrive on such uncertainty. Scientists are skeptical-clinicians cannot afford such a stance.
Dr. Mota-Castillo makes an excellent case why oppositional-defiant disorder (ODD) and conduct disorder (CD) should often be treated as putative expressions of bipolar disorder, especially in the presence of bipolar family history. He concludes his debate with a quotable quote: Psychiatrists should "stop repeating the words parents use in describing their children-oppositional and defiant and to begin diagnosing the underlying mood disorder." Professor Steiner eloquently argues that despite partial overlap in symptoms, behavior, and clinical express ion, ODD, CD, and pediatric bipolar disorder are distinct disorders, which, nonetheless, might represent developmental alternatives for a partially shared genetic diathesis, involving dysregulation of emotional and aggressive behavior.
Although he doesn't say so, he probably would not disagree that clinicians must treat conduct disorders on the basis of pragmatic considerations: Given bipolar familial background, and partially shared manifestations with bipolar disorder, ODD and CD could benefit from mood-stabilizing agents. This is not only reasonable practice, but also important for public health.
The position espoused by Professor Steiner is one that will eventually reshape DSM-X! It will obviously take a long time to get there. What today we call "comorbidity" in both child and adult psychiatry will one day be understood on the basis of putative shared molecular mechanisms of genetic origin; non-shared genes and environments would account for the phenotypic variability. In adult psychiatry, in the bipolar arena, we have a situation not much different from its pediatric counterpart: If externalizing disorders such as ADHD, ODD, and CD are the bugaboos of the child psychiatrist, impulse control disorders, substance and alcohol disorders, and borderline personality disorder are their counterparts for the adult psychiatrist.2 Therefore , I do not agree with those who believe that pediatric bipolar disorder is "special" because it is confounded by comorbidity; adult bipolar disorder is certainly no less comorbid.3
It is becoming increasingly accepted that anxiety disorders commonly co-occur with adult bipolar disorder,4 and the same is now being reported for pediatric bipolar disorder.5"Comorbidity" may not be the best term to describe the co-occurrence of anxious and bipolar manifestations. The dysregulation of bipolar disorder is not just limited to mood, but certainly involves broader affective states, such as anxiety, phobia, post-traumatic stress disorder, and obsessive-compulsive disorder. It probably also involves dysregulation of circadian rhythms, activity cycles, drives, and impulses. This is an emerging spectrum perspective in ad ult bipolarity. 6 It is relevant in this context that in a collaborative research report with Dr. Masi, we hypothesized that anxious-phobic behavior is a precursor of bipolar disorder in children, whereas CD can be regarded as a complication.7
In another report with P. Dr. Dilsaver 8 severe conduct disorder (meeting the threshold of referral to the juvenile justice system) in destitute Hispanic youth appeared to be the expression of a bipolar depressive mixed state. The latter is in line with the position of Dr. Mota-Castillo. But Professor Steiner's position is not really in disagreement; it is rather a methodologically and theoretically enriched discussion of the same clinical phenomenology.
Akiskal HS. Prevalence of bipolar disorder in prepubertal children. J. Bipolar Disorder 2004;3(3):16-17.
Akiskal HS. Demysrifyin g borde rline perso nality: Critique of the concept and unorthodox reflections on its natural kinship with the bipolar spectrum. Acta Psychiatr Scand 2004; 110:401-407.
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Akiska l HS. Primary Psychiatry 2004;11(9) :30 -3 5.
Masi G, et al. Compr Psychiatry 2003;44:184-189 .
Dilsaver S, Benazzi F, Akiska l HS. Psychopat hology. In press.