The first paragraph of Jennifer Egan’s article on bipolar disorder in the current New York Times Magazine is striking:
When Claire, a pixie-faced 6-year-old in a school uniform, heard her older brother, James, enter the family’s Manhattan apartment, she shut her bedroom door and began barricading it so swiftly and methodically that at first I didn’t understand what she was doing. She slid a basket of toys in front of the closed door, then added a wagon and a stroller laden with dolls. She hugged a small stuffed Pegasus to her chest. “Pega always protects me,” she said softly. “Pega, guard the door.”
Claire, of course, is not the patient. Her brother James, age 10, is. And one of the underappreciated ravages of pediatric bipolar is the effect these children have on their younger siblings, who learn to do what they can to protect themselves from unpredictable rages.
Egan is a journalist and a novelist who spent several months following different families with children who have received the bipolar diagnosis. While acknowledging that the diagnosis is over-used, she makes it abundantly clear that these children are not normal, and tend to be “wildly, explosively angry.” For example, 7 year old Joe’s mother describes a tantrum at Walmart, when she refused to buy him a video game, that “resulted in her having to sit on Joe in an aisle until store employees could help her wrestle him into the car… A recent rampage at school concluded with a 20-minute physical fight with a police officer….”
In describing some of the children’s evaluations at the University of Pittsburgh bipolar clinic, we are reminded how difficult it is to tease out ADHD from bipolar disorder, since three of the seven criteria for mania are also criteria for ADHD: distractibility, activity increase and talkativeness. Egan interviews Gabrielle Carlson, the director of child and adolescent psychiatry at the Stony Brook University School of Medicine, who uses the apt phrase “diagnostically homeless,” to describe these extremely troubled kids who don’t quite fit known categories. She believes that that it’s crucial to come up with a clear diagnosis, although it’s not clear to me that she makes a strong case. Regardless of the diagnosis, out of control kids end up getting the same meds to protect themselves and others around them.
The article is long but keeps your interest. You’ll get a family’s eye view of what it’s like to live with these children, and you’ll understand why these kids end up rotating through a laundry list of medications.
In her concluding comments, Egan focuses too much on the kindling theory of bipolar disorder, a worn-out hypothesis which I put in the category of wishful thinking. Yes, it would be nice if bipolar disorder turned out to be a kind of epilepsy of psychiatry, preventable with early anticonvulsant meds. But the evidence is indirect and inconsistent, which even the father of the kindling theory, Robert Post, acknowledges.
I can’t blame her—it’s best to end an article on a hopeful note. Unfortunately, the science is still in its infancy, and we have to muddle through, guessing as we go, hoping that we’ll fall into an answer someday.