I needed an intellectual oasis to deal with the anguish and frustration triggered by the monumental amount of misleading information that was included in the well-written article “Not all mood swings are bipolar disorder” (Current Psychiatry, February 2011, p. 38-52). Fortunately, a commentary by Dr. Irene Abramovich (“Breaking the box,” Comments & 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. Kowatch 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 was my position in a debate titled “Childhood conduct disorder and oppositional-defiant disorders are common manifestations of bipolar disorder” in which I argued that ODD and CD are behavioral expressions of genuine diagnoses.¹ Besides bipolar disorder, I also have seen obsessive-compulsive disorder, social anxiety disorder, and even sexual abuse labeled as “ODD” because the child refuses to be around people (such as a classroom) or is distracted by intrusive thoughts or flashbacks and turns hostile when reproached in front of the class.

In my view, Dr. Kowatch and colleagues give undeserved credit to the behavioral scales (the “cookbooks” of psychiatry) to make diagnoses and seem to miss warning signs in patients’ family history, ie, “history of depression and anxiety” (many times this translates as agitated/dysphoric mania) and “drinking problems, “ which frequently is found in undiagnosed bipolar spectrum patients who use alcohol to “shoot down” racing thoughts that interfere with normal sleep.

From January 2010 to February 2011, I reviewed charts and interviewed patients and families of 1, 654 patients with diagnoses of attention-deficit/hyperactivity disorder co-morbid with ODD, bipolar disorder, generalized anxiety disorder, and even 2 diagnoses that are not allowed by DSM rules: autism and mental retardation. The data from this study, which covers 12 counties that represent the 5 geographical areas of Florida, are being analyzed. In the meantime, I refer readers to my poster presentation from the 2010 U. S. Psychiatric and Mental Health Congress “Extinction of oppositional-defiant symptoms following treatment with mood stabilizers. “² In this study 44 patients were followed for at least 5 years (10 patients were observed for 7 years and a similar number for 6) and none had “oppositional” behavior after the diagnoses were treated. One caveat is that I placed antipsychotics in the same category as conventional mood stabilizers because 5 patients considered to be “inattentive” and “oppositional” actually had schizophrenia.

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 consider all diagnostic possibilities and obtain a thorough family history, which usually includes alcoholism, cannabis abuse, moodiness, suicide completion, unstable lifestyle, etc.

Manuel Mota-Castillo, MD
Assistant Clinical Professor
St. Matthews University
Voluntary Faculty
University of Central Florida
Lake Mary, FL

References

1. Mota-Castillo M, Steiner H. Childhood conduct disorder and oppositional-defiant disorder are common manifestations of bipolar disorder pro and con. Journal of Bipolar Disorders: Reviews and Commentaries. 2005;3:3,15-17.

2. Mota-Castillo M. Extinction of oppositional-defiant symptoms following treatment with mood stabilizers. Poster presented at: 23rd Annual U.S. Psychiatric and Mental Health Congress; November 20 2010; Orlando, FL.

The authors respond

We never suggested that clinicians use “cookbook medicine. “ The “behavioral scales” we recommended in our article are well-validated and reliable tools that allow a clinician to effectively elicit a great deal of useful information from patients and their parents about presenting problems and symptoms. This information can be used with other clinical information to make an accurate diagnosis and subsequent treatment plan.

The purpose of our article was to share our experiences in the differential diagnosis of mood swings in children and adolescents and to suggest that there are other diagnoses that cause mood swings besides bipolar disorder. Although a family history of mood disorders is important, it is also important to recognize that a recent, state-of-the-art study by Birmaher et al¹ reported that 10% of children of parents with bipolar disorder had a bipolar spectrum disorder. That means that 90% did not have bipolar disorder. It is important to remember this when evaluating children of parents with bipolar disorder. Although these children’s risk for developing bipolar disorder is increased compared with the general population, it is more likely that they will not develop bipolar disorder.

Robert A. Kowatch, MD, PhD
Professor of Psychiatry and Pediatrics

Erin Monroe, CNS
Clinical Nurse Specialist
Division of Psychiatry

Sergio V. Delgado, MD
Associate Professor of Psychiatry
and Pediatrics
Cincinnati Children’s Hospital Medical Center
Cincinnati, OH

Mood swings and ODD