08 June 2011 by Jon Ronson
The New Scientist Magazine
There's a children's picture book in the US called Brandon and the Bipolar Bear. Brandon and his bear sometimes fly into unprovoked rages. Sometimes they're silly and overexcited. A nice doctor tells them they are ill, and gives them medicine that makes them feel much better.
The thing is, if Brandon were a real child, he would have just been misdiagnosed with bipolar disorder.
Also known as manic depression, this serious condition, involving dramatic mood swings, is increasingly being recorded in American children. And a vast number of them are being medicated for it.
The problem is, this apparent epidemic isn't real. "Bipolar emerges from late adolescence," says Ian Goodyer, a professor in the department of psychiatry at the University of Cambridge who studies child and adolescent depression. "It is very, very unlikely indeed that you'll find it in children under 7 years."
How did this strange, sweeping misdiagnosis come to pass? How did it all start? These were some of the questions I explored when researching The Psychopath Test, my new book about the odder corners of the "madness industry".
The answer to the second question turned out to be strikingly simple. It was really all because of one man: Robert Spitzer.
I met Spitzer in his large, airy house in Princeton, New Jersey. In his eighties now, he remembered his childhood camping trips to upstate New York. "I'd sit in the tent, looking out, writing notes about the lady campers," he said. "Their attributes." He smiled. "I've always liked to classify people."
The trips were respite from Spitzer's "very unhappy mother". In the 1940s, the only help on offer was psychoanalysis, the Freudian-based approach of exploring the patient's unconscious. "She went from one psychoanalyst to another," said Spitzer. He watched the psychoanalysts flailing uselessly. She never got better.
Spitzer grew up to be a psychiatrist at Columbia University, New York, his dislike of psychoanalysis remaining undimmed. And then, in 1973, an opportunity to change everything presented itself. There was a job going editing the next edition of a little-known spiral-bound booklet called DSM - the Diagnostic and Statistical Manual of Mental Disorders.
DSM is simply a list of all the officially recognised mental illnesses and their symptoms. Back then it was a tiny book that reflected the Freudian thinking predominant in the 1960s. It had very few pages, and very few readers.
What nobody knew when they offered Spitzer the job was that he had a plan: to try to remove human judgement from psychiatry. He would create a whole new DSM that would eradicate all that crass sleuthing around the unconscious; it hadn't helped his mother. Instead it would be all about checklists. Any psychiatrist could pick up the manual, and if the patient's symptoms tallied with the checklist for a particular disorder, that would be the diagnosis.
For six years Spitzer held editorial meetings at Columbia. They were chaos. The psychiatrists would yell out the names of potential new mental disorders and the checklists of their symptoms. There would be a cacophony of voices in assent or dissent - the loudest voices getting listened to the most. If Spitzer agreed with those proposing a new diagnosis, which he almost always did, he'd hammer it out instantly on an old typewriter. And there it would be, set in stone.
That's how practically every disorder you've ever heard of or been diagnosed with came to be defined. "Post-traumatic stress disorder," said Spitzer, "attention-deficit disorder, autism, anorexia nervosa, bulimia, panic disorder..." each with its own checklist of symptoms. Bipolar disorder was another of the newcomers. The previous edition of the DSM had been 134 pages, but when Spitzer's DSM-III appeared in 1980 it ran to 494 pages.
"Were there any proposals for mental disorders you rejected?" I asked Spitzer. "Yes," he said, "atypical child syndrome. The problem came when we tried to find out how to characterise it. I said, 'What are the symptoms?' The man proposing it replied: 'That's hard to say because the children are very atypical'."
He paused. "And we were going to include masochistic personality disorder." He meant battered wives who stayed with their husbands. "But there were some violently opposed feminists who thought it was labelling the victim. We changed the name to self-defeating personality disorder and put it into the appendix."
DSM-III was a sensation. It sold over a million copies - many more copies than there were psychiatrists. Millions of people began using the checklists to diagnose themselves. For many it was a godsend. Something was categorically wrong with them and finally their suffering had a name. It was truly a revolution in psychiatry.
It was also a gold rush for drug companies, which suddenly had 83 new disorders they could invent medications for. "The pharmaceuticals were delighted with DSM," Spitzer told me, and this in turn delighted him: "I love to hear parents who say, 'It was impossible to live with him until we gave him medication and then it was night and day'."
Spitzer's successor, a psychiatrist named Allen Frances, continued the tradition of welcoming new mental disorders, with their corresponding checklists, into the fold. His DSM-IV came in at a mammoth 886 pages, with an extra 32 mental disorders.
Now Frances told me over the phone he felt he had made some terrible mistakes. "Psychiatric diagnoses are getting closer and closer to the boundary of normal," he said.
"Why?" I asked. "There's a societal push for conformity in all ways," he said. "There's less tolerance of difference. Maybe for some people having a label confers a sense of hope - previously I was laughed at but now I can talk to fellow sufferers on the internet."
Part of the problem is the pharmaceutical industry. "It's very easy to set off a false epidemic in psychiatry," said Frances. "The drug companies have tremendous influence."
One condition that Frances considers a mistake is childhood bipolar disorder. "Kids with extreme temper tantrums are being called bipolar," he said. "Childhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child."
"So maybe the diagnosis is good?"
"No," Frances said. "And there are very good reasons why not." His main concern is that children whose behaviour only superficially matches the bipolar checklist get treated with antipsychotic drugs, which can succeed in calming them down, even if the diagnosis is wrong. These drugs can have unpleasant and sometimes dangerous side effects.
The drug companies aren't the only ones responsible for propagating this false epidemic. Patient advocacy groups can be very fiery too. The author of Brandon and the Bipolar Bear, Tracy Anglada, is head of a childhood bipolar advocacy group called BP Children. She emailed me that she wished me all the best with my project but she didn't want to be interviewed. If, however, I wanted to submit a completed manuscript to her, she added, she'd be happy to consider it for review.
Anglada's friend Bryna Hebert has also written a children's book: My Bipolar, Roller Coaster, Feelings Book. "Matt! Will you take your medicines please?" she called across the kitchen when I visited her at home in Barrington, Rhode Island. The medicines were lined up on the kitchen table. Her son Matt, 14 years old, took them straight away.
The family's nickname for baby Matt had been Mister Manic Depressive. "Because his mood would change so fast. He'd be sitting in his high chair, happy as a clam; 2 seconds later he'd be throwing things across the room. When he was 3 he'd hit and not be sorry that he hit. He was obsessed with vampires. He'd cut out bits of paper and put them into his teeth like vampire teeth and go up to strangers. Hiss hiss hiss. It was a little weird."
"Were you getting nervous?" I asked. "Yeah," said Hebert. "One day he wanted some pretzels before lunch, and I told him no. He grabbed a butcher knife and threatened me."
"How old was he?"
"Four. That was the only time he's ever done anything that extreme," she said. "Oh, he's hit his sister Jessica in the head and kicked her in the stomach."
"She's the one who punched me in the head," called Matt from across the room.
It was after the knife incident, Hebert said, they took him to be tested. As it happened, the paediatric unit at what was then their local hospital, Massachusetts General, was run by Joseph Biederman, the doyen of childhood bipolar disorder. According to a 2008 article in the San Francisco Chronicle, "Biederman's influence is so great that when he merely mentions a drug during a presentation, tens of thousands of children will end up taking it." Biederman has said bipolar disorder can start, "from the moment the child opens his eyes".
"When they were testing Matt he was under the table, he was on top of the table," said Hebert. "We went through all these checklists. One of Dr Biederman's colleagues said, "We really think Matt meets the criteria in the DSM for bipolar disorder."
That was 10 years ago and Matt has been medicated ever since. So has his sister Jessica, who was also diagnosed by Biederman's people as bipolar. "We've been through a million medications," said Hebert. "There's weight gain. Tics. Irritability. Sedation. They work for a couple of years then they stop working."
Hebert was convinced her children were bipolar, and I wasn't going to swoop into a stranger's home for an afternoon and tell her they were normal. That would have been incredibly patronising and offensive. Plus, as the venerable child psychiatrist David Shaffer told me when I met him in New York later that evening, "These kids can be very oppositional, powerful kids who can take years off your happy life. But they aren't bipolar."
"So what are they?"
"Attention-deficit disorder?" he said. "Often with an ADD kid you think: 'My God, they're just like a manic adult.' But they don't grow up manic. And manic adults weren't ADD when they were children. But they're being labelled bipolar.
"That's an enormous label that's going to stay with you for the rest of your life. You're being told you have a condition which is going to make you unreliable, prone to terrible depressions and suicide."
The debate around childhood bipolar is not going away. In 2008, The New York Times published excerpts from an internal hospital document in which Biederman promised to "move forward the commercial goals of Johnson & Johnson", the firm that funds his hospital unit and sells the antipsychotic drug Risperdal. Biederman has denied the allegations of conflict of interest.
Frances has called for the diagnosis of childhood bipolar to be thrown out of the next edition of DSM, which is now being drawn up by the American Psychiatric Association.
This article shouldn't be read as a polemic against psychiatry. There are a lot of unhappy and damaged people out there whose symptoms manifest themselves in odd ways. I get irritated by critics who seem to think that because psychiatry has elements of irrationality, there is essentially no such thing as mental illness. There is. Childhood bipolar, however, seems to me an example of things having gone palpably wrong.
On the night of 13 December 2006, in Boston, Massachusetts, 4-year-old Rebecca Riley had a cold and couldn't sleep. Her mother, Carolyn Riley, gave her some cold medicine, and some of her bipolar medication, and told her she could sleep on the floor next to the bed. When she tried to wake Rebecca the next morning, she discovered her daughter was dead.
The autopsy revealed that Rebecca's parents had given her an overdose of the antipsychotic drugs she had been prescribed for her bipolar disorder. They had got into the habit of feeding her the medicines to shut her up when she was being annoying. They were both convicted of Rebecca's murder.
Rebecca had been diagnosed as bipolar at 2-and-a-half, and given medication by an upstanding psychiatrist who was a fan of Biederman's research into childhood bipolar. Rebecca had scored high on the DSM checklist, even though like most toddlers she could barely string a sentence together.
Shortly before her trial, Carolyn Riley was interviewed on CBS's 60 Minutes show by Katie Couric:
KC: Do you think Rebecca really had bipolar disorder?
CR: Probably not.
KC: What do you think was wrong with her now?
CR: I don't know. Maybe she was just hyper for her age.
Jon Ronson is a writer and documentary maker living in London. He is the author of five books, including The Men Who Stare at Goats. His latest book, The Psychopath Test, is about the psychiatry industry