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19 March 2010
Can small children get bipolar disorder?By Zarathustra of the Mental Nurse blog
Recently I heard something via a friend that alarmed me. An American schoolteacher commented on a 5 year old child in his class who was nodding off into his schoolwork due to being prescribed a combination of quetiapine and risperidone - two atypical antipsychotics. This was because a child psychiatrist had diagnosed him with "pediatric bipolar disorder", or PBD.
The idea of of young children having bipolar disorder runs against the traditional view that bipolar disorder emerges in somebody's teens at the very earliest. PBD isn't a recognised category in either the DSM-IV or the ICD-10, the two main classification systems for psychiatric diagnoses. Despite this, recent years have seen rapid growth in the number of children being diagnosed with PBD in the United States. Glossy websites claim that many of the children currently being diagnosed with conditons such as ADHD actually have bipolar.
Among my colleagues in Child and Adolescent Mental Health Services (CAMHS), professionals are taking sides. You know those arguments people have about ADHD? The ones where one side says, "You're drugging up our kids, you sickos!" and the other side exclaims, "These children need help, and we're giving to them!" Well, the pediatric bipolar debate is roughly similar, except with more shouting and the occasional item of hurled furniture. Some of my colleagues reckon it's the new big thing.Others insist it's a load of cobblers dreamed up by a vocal clique of American shrinks sucking at the teat of Big Pharma. So far, the "load of cobblers" contingent appear to be be gaining ground.
British child psychiatrists tend to have a different outlook to their American counterparts, making more use of psychosocial interventions (counselling, CBT, parent training, family therapy etc) and less use of medication. Antipsychotics are used comparatively rarely, and the use of more than one antipsychotic in a single child is rarer still. For a five year old who is functioning enough to be in a mainstream classroom (as in the ancedote above) to be prescribed multiple antipsychotics is almost unheard of in Britain.
Diagnoses of PBD are also extremely rare over here. Among the kids being seen by CAMHS in my area, I can't think of a single one who was diagnosed with bipolar any younger than 13. We do, however, have a girl on our caseload who was diagnosed with ADHD in Britain and prescribed methylphenidate. The parents then took her to America where she was promptly diagnosed with PBD and prescribed mood stabilisers and antipsychotics. On their return to Britain, she was re-assessed by CAMHS, found not to have signs or symptoms of bipolar, and switched back to methylphenidate.
It's not just Britain where PBD is virtually undiagnosed. PBD diagnoses are almost exclusively an American phenomenon. Almost all of the research comes out of America too. There isn't a single published study of the prevalence of PBD in Britian. That said, I'm aware of a so far unpublished study in which 200 British children with ADHD were assessed for signs and symptoms of bipolar disorder. Of the 200, only one was felt to show evidence of PBD.
Even in America, concerns are being raised about the extent of the diagnoses. The draft of the fifth edition of the DSM contains a proposed diagnostic category of "Temper Dysregulation Disorder with Dysphoria". According to the LA Times, this has been introduced in order to reduce the number of children being diagnosed with PBD, which the authors insist is given too frequently to children who turn out not to have bipolar disorder when they grow into adulthood. It's good that they've recognised these concerns, but it seems odd that they seem to need to slap a medical label onto excessive temper tantrums in order to do so.
So, what's the truth of it? Given the recent explosion in PBD diagnoses in the States, it'll probably be a few years before we have large scale studies tracking how many of them actually develop bipolar disorder as adults. Personally, I'm strongly skeptical that PBD is anything other than a very rare illness, and I suspect that in many cases it will turn out to be a misdiagnosis of other problems. Either way, I'm of the view that we shouldn't be prescribing powerful (and dangerous) antipsychotics to small children without a clear rationale and an evidence base. Right now we don't have either.Zarathustra
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24 February 2010
Eating disorders are not a lifestyle choiceA guest post by Ilona Burton, who blogs in the Independent Minds community and campaigns for greater awareness of eating disorders.
At the age of just seven, my new year’s resolution was to lose weight. I began to hide food, throw it away, stuff it in my mouth and spit it out, and give it away to other people. Not a particularly conscious decision, not the result of bullying or a reaction to an obvious trigger – just something that very gradually, inexplicably became habitual and horribly addictive, an illness that ended up affecting over three quarters of my life.Contrary to popular belief, the development of my eating disorder, as with the majority of sufferers, was not a vain attempt to lose weight in order to resemble skinny models or celebrities. This was a time when the Spice Girls were a picture of health, nobody knew who Nicole Richie or her stylist Rachel Zoe (later blamed for the size zero epidemic) were, and I was shopping at Tammy Girl, completely unaware of size zero, size 6 or any fad diets.
Anorexia slowly became what I perceived to be the larger part of my identity, it was just what I did, what I was, who I was. During high school, despite worries raised by my friends to teachers that were passed on to my parents, I did everything I could to deny these allegations that I was ill or in danger, and as I wasn’t on death’s door, even my GP passed me off – the same story with too many other people in my position.
Not surprisingly, the situation worsened while I was at sixth form. Skipping lunch was a non-issue to me by then as it had become so normal, so I moved on to skip as many other meals I could, ever the inventive, creative excuse-giver – my intake became lower and lower, and consequently, so did my weight. Clothes hanging from my pelvic bones, I would walk an hour or so to college and back come rain or shine and despite worries and concerns from loved ones, there was little anyone could do at this stage that would stop me from being wrapped up in my anorexic behaviours.
University time – freedom, independence, but for me, a tragic waste of what should have been the best year of my life. Instead of leaving home and drinking myself into oblivion, I isolated myself and slipped quickly into a routine which involved spending most of my time wrapped in a dressing gown, weighing myself obsessively and living off an oh so fun diet of Diet Coke, celery and sugar free jelly.
While my flatmates were out socialising and dancing till dawn, as students are supposed to, I was in my room, alone, writing depressing angst-ridden poems and seeing how many stomach crunches I could possibly do – the number increasing every day. By the end of that first year, I looked like a poster girl for the line between life and death.
In the second and third year of university, I set my heart on getting a first Class degree, was the lead singer in a band, became a DJ, made an amazing group of friends and had a damn good social life – signs that things were better, especially as the previous summer I had been threatened with hospitalisation and had therefore gained enough weight to escape that.
But behind all this, my anorexia had made a little friend in bulimia – whenever I wasn’t busying myself with all the above, I was going to more dangerous lengths (vomiting, laxative abuse, diet pills which contained ephedrine, banned in most countries) to somehow feel better about myself. Of course, no matter how much weight you lose, it is never enough and it certainly never brings with it the promised state of ‘feeling better’, not even close.
It took me a three month stint in a specialised unit, a year in outpatient care and another nine months in hospital to get me to where I am now. Even after all that effort, hard work, stress and strain of fighting against an illness that clings to you, not wanting you to ever let it go, I still am at a low weight, still fighting every day to stay well enough to get by.
I am and feel a million times better and less scared, trapped and controlled by food, but I hope that my story will highlight a few of the truths behind some of the many misconceptions that are made about eating disorders.
Eating Disorders are serious mental health illnesses that affect approximately 1.6 million people – male, female, young, old, gay, straight, vain, plain – in the UK.
Eating disorders do not discriminate – they can affect anyone and anytime for any reason.
Eating disorders are not glamorous, nor are they the result of glamourisation through the worlds of fashion or celebrity – although social pressures may contribute to a disorder, they are rarely ever the cause.
Eating disorders are not a lifestyle choice or a diet gone too far.
Eating disorders CAN be beaten – though secretive in their nature and unbelievably hard to recover from, full recovery is possible. The support is there, just reach out.
Ilona Burton
Eating Disorders Awareness Week 2010 runs from 22 to 28 February. It is run by the charity Beat, which provides helplines and other support for people with eating disorders.
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7 September 2009
Battle scarredDispatches, Channel 4, Monday 7 September 8pm
Why is it that the military take the time to prepare our soldiers to fight but they don't prepare them for the battle of post traumatic stress disorder when they return from the frontline?
This evening, Channel 4's Dispatches programme looks at the emotional scars of war on soldiers when they come back from active service. David Modell's powerful documentary includes interviews with several young men who are struggling to adjust to civilian life while dealing with harrowing memories from the frontline. Many turn to alcohol to cope with the nightmares or end up lashing out in despair.
As Mind's Get it off your chest campaign shows, young men feel uncomfortable talking about their problems at the best of times, so trying to penetrate the macho culture of the armed forces and get young soldiers to open up and seek help is a difficult task. The result is that some of these men will suffer is silence with tragic consequences.
The Ministry of Defence estimates that only 4 per cent of army personnel experience post traumatic stress disorder. However, with many men keeping the problem to themselves to avoid being perceived as 'weak', and no formal monitoring of the statistics, the true figure is completely unknown. How can health services be prepared to provide adequate support in the future when they don't even know what they are dealing with?
Post traumatic stress disorder can take over a decade to surface, long after active service and when many will have lost touch with the armed forces. Civilian services and the charity sector will be left to pick up the pieces and they are not best equipped to provide the specialist support that is needed. We are sitting on an emotional timebomb which we can only be prevented from going off by acting now.
Find out more and watch excerpts on the Channel 4 website
Alison Kerry, Head of Media
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