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Extinction of Oppositional-Defiant Symptoms Following Treatment with Mood Stabilizers:A Five Year (minimum) Case Series.

 
Manuel Mota-Castillo, M.D.
Assistant Clinical Professor St. Matthews University Medical School
(The author have no conflict of interest to disclose)

 
ABSTRACT:

 
Background:  ODD is currently recognized in the DSM-IV-TR as an independent, authentic diagnostic category.  The author herein questions the validity of ODD as an entity of its own.
Objective: This report offers new evidence that the utility and validity of ODD as an authentic diagnostic category are in serious doubt, and highlight the lack of scientific evidence to support the existence of ODD.
Method: The author studied a statistically significant number of patients, previously diagnosed with ODD, for a minimum of five years following the patient's first evaluation.
Results:  Patients with a variety of psychiatric disorders were previously misdiagnosed with ODD.
Limitations: This case series report is a combination of chart review and clinical monitoring by the author.  The only involvement by the mental health professionals that gave the initial misdiagnoses is written psychiatric evaluations.  The prototype of clinical interview supported by the American Board of Psychiatry and Neurology was used to establish diagnoses.
Conclusions: This work corroborated the clinical observation that a high percentage of patients currently receive the diagnosis of ODD, when their symptoms are better explained by other major psychiatric disorders.  It suggests too that ODD is not an authentic, independent diagnosis, but rather a symptom of many psychiatric disorders that present with and exhibit oppositional and defiant behavior.
Key Words: Oppositional-Defiant; ADHD; bipolar spectrum; DSM-V

INTRODUCTION:

A cohort of 44 children and adolescents, previously diagnosed with Oppositional-Defiant Disorder (ODD), were re-evaluated upon request from their parents. The patients were followed for a minimum of five years and good behaviors were noticed after treatment with mood stabilizers was implemented. "ODD" symptoms have not re-emerged, with the exception of brief episodes of hypomania which were controlled with modification in medications and psychotherapy.

BACKGROUND:

The validity of Oppositional-Defiant Disorder (ODD) as an authentic diagnostic category has been questioned since its inception in the DSM nomenclature, but only by a small group of psychiatrists. (Rey JM (1993; Mota-Castillo, M., 2004) The majority of child psychiatrists still support the legitimacy of "oppositional behavior" as a bona fide diagnosis. (Malone et al., 2000) This report is the result of many “wake-up calls” witnessed by the author, in a variety of settings, over the past decade. As stated in paper referenced as No. 2, during work with children on the validation of the Bipolar Spectrum Diagnostic Scale for the pediatric population, it became clear that a significant number of children presenting with mood abnormalities had been misdiagnosed with ODD.
The cases presented show that when ODD is diagnosed, the behaviors labeled as "oppositional-defiant" can be explained by other conditions that carry an obvious genetic link to the real diagnoses. The arrival at an incorrect diagnosis frequently begins when doctors interpret a symptom as a diagnosis.
Dr. Charles Huffine (Huffine, C., 2008) former President of American Association of Community Psychiatry explains it with these words: "Conduct Disorder (CD) and ODD are clearly defined and can be reliably identified according to their criteria. However they are examples of heterogeneous diagnoses whose validity should be questioned. Under the DSM criteria the patients qualify for CD or ODD, but in fact they are misdiagnosed and therefore are not seen as candidates for treatment that could help them."
In my experience, the practical result is that children with "out of control behavior" are denied hospitalization by the HMOS because, for example, a manic episode may be mislabeled as ODD.
Ironically, the fundamental theories of the psychological treatment modality that are blamed (Mota-Castillo, M., 2007) for the origin of ODD contain the strongest arguments against its validity as a diagnosis. Both Freud (Freud, S.& Gay, P., 1995)  and Erikson (Erikson, E., 1963) postulated that by five years of age a child has achieved a sense of morality and respect for rules. They identified this milestone as Superego (Freud, S., Strachey, J. and Gay, P., 1990) and the "mastering of initiative versus guilt.” (Erikson, E.; 1963) Thus, a child who already understands the concept of hierarchy in the home environment and the classroom will not suddenly decide to become disrespectful and defiant for the sole purpose of receiving punishment. More often children show defiance because during periods of elevated and/or grandiose moods, impulsivity is magnified and judgment is impaired. In other cases, obsessive-compulsive inflexibility, or the unwillingness of a child with Social Anxiety Disorders to attend school, are interpreted as defiance to adults.

METHOD:

The author studied a statistically significant number of patients, previously diagnosed with ODD, for a minimum of five years following the patient's first evaluation. Forty four patients in treatment until December 2009 were selected using the following criteria:
  • They have been monitored by for a minimum of five years following the first evaluation.
  • A diagnosis of Oppositional-Defiant Disorder was given by a licensed practitioner before the initial evaluation conducted the author.
  • A family history of mental illness was documented and corroborated.

It is noteworthy that the author could have presented a larger number of cases, but decided to select those who still remain under his direct care. Other patients had moved to different geographical locations or were forced to change to a different practice because of insurance restrictions. Still, based on the opinion of a well-known expert in statistics, (Gibbons, R., 2008) who postulates: "Multiple repeated measures can greatly reduce the needed sample size," the author believe the number of cases presented is sufficient to support the conclusions here in.
In the cases of these youths "multiple repeated measures" have been applied by way of follow up appointments and, in a few cases, brief hospitalizations. The majority of these 44 patients were diagnosed during their pre-teen years, but a few of them were in the pre-school stage when first seen.  A small group (four patients) is comprised of young adults who were 12 or 13 year-olds when the initial evaluation took place.

This report is statistically sound because of the following reasons:
  • The subjects represent the usual population of most pediatric psychiatric practices in terms of age and presenting symptoms.
  • The length of the observational period is such that eliminates the possibility of an observed outcome could have happened by chance. In simple terms, the absence of symptoms reappearance after five years of treatment is solid evidence to support the tested hypothesis: what we call ODD is not a real diagnosis but the manifestation of multiple diagnoses

Unfortunately, this report does not include information about several traumatic events that were omitted from some of the cases to protect patient's anonymity. This is a typical example: Two-year old found wandering in the streets, wearing a dirty diaper.  This child was placed in state custody because a STD was detected but, despite what the family background could reveal about the patient's parents, 3 years later the child was diagnosed with ADHD, ODD and Reactive Attachment Disorder.  No mention of an obvious diagnosis, Sexual Abuse of a Child, could be found in the medical record.
Of note:  The codes 296.60 and 296.40 (from DSM-IV-TR) are included several times instead of the actual name of diagnoses, bipolar disorder, mixed and bipolar disorder, hypomanic) to save space.

RESULTS:

The author could not find one single patient whose "ODD symptoms" persisted after diagnosis was refined and medications adjusted. Instead, a statistically significant correlation between parental mental illness and the possibility of receiving a co-morbid ADHD/ODD diagnosis was found.

CONCLUSION:

The findings of this report are consistent across sociological, ethnic and geographical boundaries; misdiagnosis was encountered regardless of the family's socioeconomic status, race or educational background. Evidence of perfunctory assessment was suspected in those patients with persistent auditory hallucinations who stated that they were never asked about "hearing voices."  

Additional flaws in the diagnostic practices identified by this report include the lack of attention paid to the patients' family history, and the neglect by practitioners to follow DSM-IV-TR guidelines related to exclusionary criteria. For example, when it comes to ODD the diagnostic manual bans the diagnosis of ODD in the presence of Conduct Disorder. This forbidden comorbidity was recorded in several patients who arrived with diagnoses of both ODD and CD. Furthermore, DSM-IV-TR establishes that ADHD should not be diagnosed if the symptoms can be better explained by another condition such as a developmental disorder, a psychotic disorder, or a mood disorder, etc. However, some of the children evaluated in this study had been diagnosed by one or two clinicians with Autism, Obsessive-Compulsive Disorder, Post-Traumatic Stress Disorder, Social Anxiety Disorder and bipolar spectrum disorders. Curiously, none of children had been given a single diagnosis but instead "comorbid" ADHD and ODD. Presumably, the prior clinicians noticed the symptoms of hyperactivity and inattention, which were secondary to anxiety, psychotic or mood disorders, and decided that ADHD and ODD should be diagnosed as well.

This case series report is aimed at investigating whether the ODD diagnosis is justified, in the presence of other diagnoses that may "better account for the subjects’ psychopathology.” Hopefully, the stories of these 44 patients will gain the attention of the researchers working on the DSM-V's development. The positive response to appropriate treatment exhibited by the subjects herein presented, both in duration and scope, makes the diagnosing of ODD in our patients a very uphill task.  Furthermore, to the author's knowledge, no practitioner has ever presented a case series of ODD patients whose symptoms cannot be "better explained by another condition" as the DSM wisely asserts.

CASE SERIES:

Allocated by the duration of their follow-up treatment: (All cases of ODD were "co-morbid" with another Axis I condition.  Two thirds of the patients are male and one third female, yet gender is not identified to protect privacy.

Seven Years Cases
  • 1st- A 16 year-old diagnosed with 296.60 (bipolar disorder, mixed) at the age of nine who belongs to a set of four siblings (next 3 cases).  They were referred for a Second Opinion after several years of worsening of symptoms.  Both parents are bipolar and one of them is also my patient.
  • 2nd- This young adult with Treatment-Resistant Paranoid Schizophrenia who failed multiple drug combinations.  Correctly diagnosed when he was 11 year-old, his treatment included a failed trial with clozapine, but molindone controlled the auditory hallucinations, which was the targeted outcome. Ironically the patient's insurance company refused to pay for this drug and offered a more expensive one, already proven ineffective for this patient.
  • 3rd- The youngest of these 4 siblings is currently stable after a recent increase in the dosage of lamotrigine the patient takes in combination with clonidine and ziprasidone.  Diagnosis: Bipolar Disorder, Most Recent Episode Mixed (296.60).
  • 4th- This patient has comorbid Obsessive-Compulsive Disorder (OCD) and BPD and has become fully manic even on small doses of sertraline, which improved his obsessions.  During the first trial with this drug 25 mg were given for a short period of time; two years later during one flare up of the obsessions, 12.5 mg was administered with a similar outcome.  The patient is unable to receive Cognitive-Behavioral Therapy (CBT) because of the restrictions imposed by the health insurance provider. Still, the patient manages to do fair in school on 4 mg of risperidone, but the OCD "drives the family insane," according to the mother's complaint.
  • 5th- This adolescent is the sibling of next case and was profiled in a Commentary published in Psychiatric Times. (Mota-Castillo, M., 2007) The mother and maternal grandmother are my patients too and all carry the same Diagnosis: 296.60
  • 6th- Similar diagnosis and misdiagnosis but patient had serious episode of mania after a brief period of cocaine abuse. Following a 3-month residential treatment stay, the patient has maintained a stable mood taking ziprasidone and lamotrigine.
  • 7th- In the case of this 13 year-old, both parents are also in treatment (diagnosed with bipolar spectrum disorders). In the past, this patient used to be a teacher's “nightmare” while medicated with methylphenidate and clonidine for ADHD and ODD. Now, as a teen, the patient is a "straight A" student.
  • 8th-14 year-old, also the child of two parents with bipolar disorder (living in another state) was adopted as a toddler. After receiving a diagnosis of ADHD at the age of five the patient go an "elevated" status when the ODD diagnosis was added a few years later. The patient's sibling is included in the five-year follow up group.
  • 9th-The story of this 17 year-old patient reinforces the relevance of the family history in formulating a diagnosis during a psychiatric evaluation. As in the preceding case, the patient was in state custody, adopted along with a sibling, because of physical abuse and neglect.  The perpetrators (biological parents) were afflicted by mental illness and substance abuse. The child was eventually adopted at age nine. My review of a Court-Ordered psychological evaluation found several scientific blunders: The child was a "Straight A" student when placed in foster care, before gaining the ADHD diagnosis. During a hospitalization prompted by a violent outburst in school, a doctor prescribed an amphetamine to control "ODD behavior," which emerged when the patient was returned by the state to the biological parents. Furthermore, the following fact could be an eye opener for those who still support the ODD diagnosis: Throughout seven years the patient has been stable on a combination of quetiapine and lamotrigine, with only small adjustments in the dosages at times when manic symptoms were reemerging.
  • 10th-  14 year-old also diagnosed with  Mood Disorder NOS who was misdiagnosed since second grade. Once again, a family history loaded with schizophrenia and mood disorders was ignored by mental health professionals. At present, there are no behavior problems at home or school because mood is stable on current medications.

Six Years Cases
  • 1st- A 20 year-old with Treatment-Resistance Schizophrenia, the oldest of 5 children all of which are my patients. The children were adopted from 3 biological families but with a common background: mental illness and/or substance abuse. This is an illustration of how frequently the misdiagnoses of ADHD, ODD and Conduct Disorder (CD) is happening. This patient was hospitalized several times and took amphetamines for many years. Previous clinicians "could not understand why medications didn't work,” old record. These professionals never asked the patient about auditory hallucinations (which are constant). Medications have brightened the patient's affect and decreased the frequency and intensity of the "voices" but a fixed delusion which remains unbreakable: having several children with a very famous artist (who visits the patient during the night hours).
  • 2nd- A 16 year-old with diagnosis of bipolar disorder, mixed who also endured spurious ADHD and ODD labels until the correct diagnosis was given. Father has bipolar disorder.
  • 3rd- An almost 17 year-old with bipolar disorder, mixed and Sexual Abuse of a Child who was an "out of control child" until my first evaluation of the patient at age ten. Now the parents and teachers talk of a "perfect child" in reference to the previously "oppositional-defiant."
  • 4th- A 15 year-old with similar diagnosis as the previous one but also severe OCD, has been very difficult to keep stable possibly because of a prolonged exposure to amphetamines. According to a well-known expert in bipolar spectrum disorders, this is most detrimental to a person with bipolar disorder. (Redfield-Jamison, K., 2000)
  • 5th-  A 20 year-old with bipolar disorder and PTSD, whose response to treatment corroborates the notion that there are exceptions to every rule, and that genetic endowment and psychosocial factors are important elements in an individual’s present and future functioning. Despite a long-term exposure to amphetamines, this patient had a successful response to mood stabilizers.
  • 6th- A 13 year-old with a bipolar father and substance abuser mother, raised by a paternal grandmother.  In 2003, the patient was hospitalized because of exacerbation of persistent "ODD symptoms" while on extended release methylphenidate for alleged ADHD. In May of 2009 the patient was an Honor Roll student and still maintains stability on moderate amounts of risperidone and lamotrigine, without side effects. Diagnoses: bipolar disorder and OCD.
  • 7th- A 13 year-old with bipolar disorder, also the son of a bipolar patient, raised by a mother who re-married and has two other children without psychiatric problems. When referred for evaluation, the “past history" was as follows: "Diagnosed in school with ODD and ADHD and sent to a pediatrician with a Conners's Behavioral Scale suggestive that inattention and disruptive behaviors were present.  After multiple trials with drugs of the same type (prescribed for ODD and ADHD), behavior worsened and school performance declined." The patient's mother came only in search of a second opinion, yet refused to return to the original psychiatrist because the school and her husband were describing the patient as "this new child."
  • 8th- Another adopted child who was born positive for cocaine and later diagnosed with Fetal Alcohol Syndrome, but still diagnosed with ADHD at the age of five. Several months on methylphenidate probably contributed to a "comorbid" diagnosis of ODD when a Second Opinion was requested by a concerned adoptive mother. It took almost 3 years of medications and psychotherapy to finally achieve a stable mood and the extinction of defiant and oppositional behavior.
  • 9th- This patient was 8 year-old when a desperate single mother came asking for help because she was yelled at by a psychiatrist who said "you are a weak woman and your child is just a bad case of ODD." A drug that combines four types of amphetamines was continued despite clear evidence of a manic affect and even bizarre behavior, e.g., taking clothes off in the classroom and spreading feces at home.  After a trial with olanzapine "hyperactivity, incorrigibility and aggressiveness" were no longer present. Interesting enough the patient's father is also in treatment with olanzapine.
  • 10th- This is a case that brings back the issue of perfunctory evaluations.  By the age of 12 years several psychiatrists and counselors had interviewed this patient and nobody ever asked about auditory hallucinations.  During my first evaluation the child stated that he was afraid of reporting the "voices" because the auditory hallucinations were threatening with harm "if I say anything." Because of poor attention span and disruptive behavior, the ADHD/ODD labels were attached to this child that now is asymptomatic on ziprasidone and oxcarbazepine. Sadly, for several years methylphenidate worsened the hallucinations and the elevated mood, while the victim was blamed for "not improving despite adequate treatment."

 Five Years Cases
  • 1st- A 14 year-old diagnosed with ADHD and ODD in another state. The patient’s mother had to run away from a husband described as "extremely violent and with unpredictable mood changes."  Paternal grandfather killed himself, and several relatives on both maternal and paternal sides have been diagnosed with mood problems and substance abuse. Diagnosis: bipolar disorder, mixed.
  • 2nd- A 14 year-old with diagnosis of bipolar disorder, hypomanic.  Mother is bipolar and also my patient. The father's whereabouts are unknown, but he is known to have a history of substance abuse. The child was first "diagnosed" by a teacher, treated by a pediatrician, and later prescribed by two Board-Certified C&A psychiatrists who, according to the mother, conducted their "evaluation" in less than ten minutes. Patient is now stable on valproic acid.
  • 3rd- An 11 year-old diagnosed with OCD and mood disorder NOS. Father has severe OCD, and on the maternal side there are several cases of this condition. Due to obsessive behavior in the classroom (would not do as the teacher said) and decreased attention span, ODD and ADHD were the diagnoses of choice by the previous clinician.
  • 4th- This 12 year-old patient has a significant family history because both parents have OCD. This child is intolerant to SSRIs, as they trigger violent behavior and insomnia when prescribed for the OCD symptoms. Parents are able to afford out of pocket CBT for the treatment of the OCD, and quetiapine is helping with mood stabilization.
  • 5th- This other12 year-old, and the next case, are siblings with similar diagnoses: Cyclothymic Disorder and OCD. Before my evaluation they did poorly on a combination of amphetamines, risperidone and clonidine prescribed for ODD and ADHD diagnoses that did not exist.
  • 6th- As mentioned in reference to fifth case, this 10 year-old followed in the sibling's footsteps with a misdiagnosis. This patient reported taking the blame for "not getting better despite adequate treatment."
  • 7th- Another 12 year-old with a diagnosis of bipolar disorder, hypomanic and Sexual Abuse of a Child was misdiagnosed as having ADHD and ODD, probably because the previous psychiatrist did not look into a significant family history of bipolar spectrum disorders and substance abuse.
  • 8th- This case could be viewed as controversial by those who doubt the presence of mental illness in children. At the age of four the child was prescribed 100 mg of quetiapine by an inpatient psychiatrist when a hospitalization was needed while taking 50 mg of lamotrigine/day. Notwithstanding these medications, a few weeks after his release from the hospital this little child kicked the teacher in rage, frustrated over the educator's attempt to enforce classroom rules. Another doctor at the same hospital raised the dose of quetiapine to 300 mg/day and the patient was stable for almost a year.  Later on, the mother decided to increase the dose to 400 mg/day when the child’s behavior became violent again.  The patient's bipolar diagnosis is also carried by a "not in the picture" father and several paternal uncles.
  • 9th-This 16 year-old has a milder case of mood disorder than the previous case Previously, a pediatrician decided that the best treatment for disruptive behavior, defiance and irritable mood was methylphenidate, even though the father is bipolar. The patient became very aggressive and an insomniac. Currently, this youth is doing well on valproic acid and aripiprazole.
  • 10th- This 10 year-old is one of a very few with an initial diagnosis of bipolar disorder, mixed, with psychotic symptoms. The auditory hallucinations, deemed side effects from previous treatment with methylphenidate, disappeared after two months on olanzapine. The patient is still bipolar, and for the past 3 years has been on valproic acid during the day and 0.1 mg of clonidine at night.
  • 11th- Also a 10 year-old, this patient has a mild mood disorder.  Prior diagnoses of ADHD and ODD were given, regardless of a family history positive for a mother with bipolar disorder and father with substance abuse.  This case is remarkable because the mother insisted to a past psychiatrist that bipolarity should be ruled out. In 2004 the mother was told: "There is no way a child could be bipolar at such a young age.”
  • 12th- This 14 year-old diagnosed with bipolar disorder is the sibling of case number eight from the group with 7 years follow up. This patient is doing well on mood stabilizers after years of failed treatment for incorrect diagnosis of ODD.
  • 13th- Also 14 year-old and with same diagnosis as the precedent case, was diagnosed with ODD and ADHD too, despite an obvious red flag: both parents and a sibling are bipolar.
  • 14th-  This 11 year-old, the sibling of the previous case, displays severe aggressive behavior when going through a manic stage. The child used to have rapid cycling when treatment first began. At this time the cycling occurs every six to eight months and is short-lived, usually only requiring a medication adjustment. The patient’s school performance has improved even though not treatment for ADHD or ODD is prescribed.

Discussion:
These active cases seem to indicate that the prevalence of comorbid ADHD/ODD would be difficult to prove. On the other hand, I am not aware of any published study suggesting that "oppositional-defiant behavior" persisted after a treatment for the real diagnosis (OCD, Social Anxiety, psychosis, bipolar spectrum, etc.). The elimination of ODD from the incoming DMS-V would prove invaluable in clarifying some of the diagnostic confusion that exists when a clinician assesses overlapping symptoms in a patient, and then attributes multiple diagnoses to one patient when, in most cases, all symptoms could be explained by a single disease.
DSM-IV-TR clearly states that inattention, impulsivity, and restlessness can be manifestations of a long list of diagnoses ranging from ADHD to Social Anxiety Disorder, just to mention two. Apparently, many clinicians forget that ADHD is a diagnosis of exclusion, and, instead of ruling out a treatable illness (which almost always runs in the family) they make ADHD the diagnosis of choice, and prescribe medications that do worsen the actual condition and can precipitate or worsen the symptoms labeled as oppositional-defiant.
Furthermore, we should remember that psychiatry is a branch of medicine, and as such, the same approach used to diagnose "physical" diseases should be followed by mental health professionals.

I hope that this contribution will:
  • Promote an open-minded view of a child with emotional symptoms at the time of formulating a diagnosis.
  • Encourage clinicians to run a thorough checklist mental list of possibilities when arriving to final diagnosis, including those that “run in the family” as it is customary in other medical specialties of the medical field,
  • Motivate clinicians to conduct a complete evaluation on every patient even if the patient present with a pre-existing diagnosis

Finally, I want to share a list of clinical entities that could present with distraction and hyperactivity:

  • ADHD
  • Nervousness, as in Social Anxiety Disorder or Generalized Anxiety
  • A medical condition (hypo or hyperthyroidism, malnutrition, parasite infestation, etc.)
  • Psychosis (hallucinations, paranoia, delusions)
  • Flashbacks from traumas (as in PTSD)
  • Obsessions and perfectionism
  • A racing mind, as in people with elevated mood
  • Explosive aggression as in Intermittent Explosive Disorder
  • Depression accompanied by anxiety
  • Low IQ
  • Learning disabilities
  • Tics (as in Tourette’s Disorder)
  • Absence seizures
  • Manic agitation misinterpreted as anxiety

By the same token, symptoms such as defiance to authority figures, refusal to go to bed at a reasonable time because of insomnia, being a "chatter box" or "the Energizer Bunny," poor frustration tolerance, impulsive behavior, "can't take a no for an answer," etc, should raise red flags to conduct a real search for a family history of mental problems. It must be remembered that on many occasions we don't get the real report of the family background until after two or three visits, when a mother feels ready to talk about "a father who was a mean drunk" or the painful memories of an abusive parent.

Acknowledgments
I thank Dr. Suzy Andrews and Dr. Ronald Pies for their review of the manuscript and suggestions.

References:
  1. Rey JM (1993), Oppositional defiant disorder. Am J Psychiatry 150(12): 1769-1778.
  2. Mota-Castillo, M., It is Really ODD?; Psychiatric Times Vol. 21, No. 3, 2004
  3. Malone et al., A Double-Blind Placebo-Controlled Study of Lithium in Hospitalized Aggressive Children and Adolescents With Conduct Disorder; Archives of General Psychiatry; Vol. 57, No. 7; July 2000.
  4. Huffine, Charles; Medical Director King County Mental Health Services; Seattle, WA. Personal communication.
  5. Mota-Castillo, M., M.D.; The Crisis of Overdiagnosed ADHD in Children; Psychiatric Times, Vol. 24, No. 6; July 2007.
  6. Redfield-Jamison, K., Monitor on Psychology (Volume 31, No. 9 October 2000) interviewed by Ken Krehbiel.
  7. Freud, S.; Structural Theory (Id, Ego, Superego); multiple books.
  8. Erikson, E.; chapter "The Eight Ages of Man", Childhood and Society, 1963; College Edition.
  9. Gibbons, R., Ph.D., guest Editorial, Psychiatric Annals, Dec. 2008 -38:12
  10. Ghaemi, S., Pies, R., Miller, C., Klugman, J., Rosenquist, J.; Sensitivity and Specificity of a New Bipolar Spectrum Diagnostic Scale; Journal of Affective Disorders, 2005; 84: 273-277.
  11. Aldea, M., Geffken, G., Jacob, M., Goodman, W. and Storch, G.; Further psychometric analysis    of the Florida Obsessive-Compulsive Inventory; Journal of Anxiety Disorders, Vol. 23, No. 1, Jan 2009.
  12. Weis, R., Toolis, E.; Cerankosky, B.; Construct Validity of the Rotter Incomplete Sentences Blank With Clinic-Referred and Nonreferred Adolescents; Journal of Personality Assessment, Vol. 90, No. 6, 2008.
  13. Hirschfield, R., The Mood Disorders Questionnaire: A Simple, Patient-Rated Screening for Bipolar Disorder; Journal of Clinical Psychiatry, Vol. 4, No. 1, 2002.

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