I needed an intellectual oasis to deal with the anguish and frustration triggered by the monumental amount of misleading information included in the well-written article “Not all Mood Swings are Bipolar Disorder” (Current Psychiatry, February 2011, p. 38-52). Fortunately, a commentary by the superb psychiatrist Irene Abramovich (Breaking the Box, Comment & Controversies, Current Psychiatry, February 2011, p. 59) appeared as a therapeutic elixir. I believe that the “mood swings” article is filled with examples of how dangerous “Cookbook” medicine can be. Dr. Kowarth and colleagues use an expression that can be applied to the so-called diagnoses, Oppositional-Defiant Disorder (ODD) and Conduct Disorder (CD): “Mood swings are analogous to a fever in pediatrics-they indicate something potentially is wrong with the patient, but they are not diagnostic as an isolated symptom.” A similar concept but using other words was my position in a debate titled "Childhood Conduct Disorder and Oppositional-Defiant Disorders Are Common Manifestations of Bipolar Disorder” in which Professor Hans Steiner supported the “con” view while I argued that ODD and CD are behavioral expressions of genuine diagnoses. Besides bipolar disorder I have also seen Obsessive-Compulsive Disorder, Social Anxiety Disorder and even Sexual Abuse of a Child labeled as “ODD” because the child refuses to be around people (like in a classroom) or get distracted by intrusive thoughts or flashback and turns hostile when reproached in front of the class.
In my view, Dr. Kowatch and associates give undeserved credit to the behavioral scales (the “cookbooks” of psychiatry) to make diagnoses and seem to miss warning signs in the family history of patients, i.e. “history of depression and anxiety” (many times translates as agitated/dysphoric mania) and “drinking problems” which is frequently found in non-diagnosed bipolar spectrum patients who use alcohol to “shot down” racing thoughts that interfere with normal sleep. Finally, they quote a sample population in the hundreds and I want to answer with one of thousands.
From January of 2010 until February of 2011 I reviewed the charts and interviewed patients and families of 1654 patients with diagnoses of ADHD comorbid with ODD, bipolar disorder, generalized anxiety disorder and even two diagnoses that are not allowed by DSM rules: autism and mental retardation. The data from this study, that covered 12 counties representatives of the 5 geographic areas in which the state of Florida is divided, is been analyzed. In the meantime, I can refer readers to another one already published. It was my Poster Presentation in the last US Psychiatric Congress “Extinction of Oppositional-Defiant Symptoms Following Treatment with Mood Stabilizers: A Five-Years (minimum) Case Series.” In this study 44 patients were followed for at least 5 years (10 patients were observed for 7 years and similar number for six) and none of them had “oppositional” behavior after the real diagnoses where treated correctly. One caveat is that I placed antipsychotic in the same category of the conventional mood stabilizers because 5 of my patients actually had schizophrenia when they were considered to be “inattentive” and “oppositional.”
I oppose the authors’ assertion that “it can be difficult to differentiate the mood swings and symptoms of ODD from those of pediatric BD.” My experience is that it is simple if we maintain an open mind to consider all diagnostic possibilities and we obtain a thorough family history, which usually included alcoholism, cannabis abuse, moodiness, complete suicide, unstable life style, etc.
Manuel Mota-Castillo, M.D.
Assistant Clinical Professor
St Matthews University
Lake Mary, Florida
Assistant Clinical Professor St. Matthews University And Voluntary Faculty at University of Central Florida