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Bipolar Disorder
The Diagnostic Swamp of Childhood Bipolar Disorder NOS
Bipolar Disorder NOS in Children and Adolescents Increases 18 Fold
Posted February 7, 2015
Just published in one of the world’s leading psychiatric journals is a study documenting the dramatic change in bipolar disorder NOS (not otherwise specified) diagnosed in children and adolescents aged 2 to 19 years from 1999 to 2010. The bipolar disorder NOS diagnosis in children and adolescents increased 18 fold during that time (1).
In the DSM system, patients who meet the required criteria for the diagnosis are classified as having met the full criteria (FC) for the diagnosis. Many psychiatric patients have symptoms that approximate the criteria for the diagnosis but on careful examination do not meet all of the criteria for the diagnosis. If they do not meet full criteria, they are given a not otherwise specified (NOS) diagnosis. For example, with bipolar disorder, a patient who does not meet all of the criteria for the DSM IV version of bipolar disorder I will be given a diagnosis of bipolar disorder I NOS.
An NOS diagnosis does not list the criteria that must be met to justify the NOS diagnosis. An NOS diagnosis merely states that the patient has not met all of the criteria for the stated FC diagnosis. It does not indicate which diagnostic criteria the patient did meet and does not indicate which criteria the patient did not meet. It only suggests that the patient met some but not all of the criteria for the diagnosis. There is more ambiguity to a NOS diagnosis than a FC diagnosis.
In the study discussed, data were reviewed from approximately 40,000 medical outpatient visits during three time periods: 1999-2002, 2003-2006, and 2007-2010. Approximately 16,000 of the visits were for psychiatric reasons during each time period.
The data were examined for changes in FC diagnoses and NOS diagnoses across the three time periods. By far, the greatest change in the rates of diagnosing FC and NOS diagnoses was found with bipolar I and bipolar II disorder in children and adolescents. In 1999-2002, of the children and adolescents diagnosed with bipolar I or II, over 95% received FC diagnosis and only 3.6% received NOS diagnoses. In 2007-2010, of the children and adolescents diagnosed with bipolar disorder I or II, only 28% received FC diagnoses and 72% received NOS diagnoses.
In any psychiatric disorder, there is considerable value in assigning a FC diagnosis when the patient meets the criteria. The Food and Drug Administration mostly approves medications for FC DSM diagnoses. There is almost no evidence about the pharmacological treatment of NOS diagnoses. Also, most diagnoses studied by academicians are FC, and a large amount of information about past history, family history, prognosis, and treatment of these FC disorders has been accumulated. There is relatively little information about the NOS diagnoses associated with the FC diagnoses. It is usually assumed that the NOS diagnosis is similar to the FC diagnosis in treatment response and etiology, but this may not be true.
NOS diagnoses might be considered inherent in the current categorical structure of DSM. It is inevitable that not all patients will meet full criteria for a diagnosis. Developing a spectrum approach to diagnosis was actively considered in the development of DSM-5, but, except for the diagnosis of autistic spectrum disorders, it was not implemented.
The authors of this important study do not speculate about the reason for the dramatic increase in bipolar disorder NOS in children and adolescents. One reason may be clinicians’ loss of confidence in diagnosing FC bipolar disorder in children and adolescents. The diagnosis of bipolar disorder in children has been intensely disputed. The overdiagnosis of bipolar disorder in children and adolescents is now accepted by most authorities in the field. The development of the DSM-5 diagnosis of Disruptive Mood Disregulation disorder (DMDD) to decrease the diagnosis of bipolar disorder in children and adolescents is acknowledged in the text of DSM-5. Uncertainty about making a bipolar disorder diagnosis in children and adolescents may have increased in the community samples of physicians on which this study is based. In addition to the numerous functions that an NOS diagnosis serves, it may also serve as a way of hedging a bet on the FC diagnosis. Adding NOS to the diagnosis indicates that It may be the FC diagnosis, and it may not be the FC diagnosis. With NOS, the clinician may believe that he or she can have it both ways: the clinician is both not overdiagnosing the disorder, and is not underdiagnosing it.
Some support for this speculation may be gained from the data about ADHD in this study. Over the twelve years of the study almost all children and adolescents receiving an ADHD diagnosis received a FC ADHD diagnosis. There was no variation in this over the study’s time frame; of patients receiving a diagnosis of ADHD, 99.9%, 99.7%, and 99.6% received FC diagnoses of ADHD over the three four-year periods. Contrast this with the bipolar disorder FC diagnosis over the three time periods: 96.4%, 61.6%, and 27.5%. The unvarying high rates of FC diagnoses of ADHD over the twelve years of the study contrasted with the dramatic decline in the FC diagnoses of bipolar I and bipolar II may reflect the relative simplicity of making a FC diagnosis of ADHD and an increasing clinical appreciation of the complexity and uncertainty of making an FC bipolar disorder in children and adolescents.
(1) Safer, D.J. et al., Trends in subthreshold psychiatric diagnoses for youth in community treatment. JAMA Psychiatry 2015;72:75-83.
Copyright, Stuart L. Kaplan, M.D., 2015
Stuart L. Kaplan, M.D., is the author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Diagnosis. Available at Amazon.com.
Picture credit: Hein Muck, Wikimedia Commons
