W WP PA A
From “madness” to “mental health problems”:137
reflections on the evolving target of psychiatry
OFFICIAL JOURNAL OF THE WORLD PSYCHIATRIC ASSOCIATION (WPA)
Volume 11, Number 3 October 2012
NEW IMPACT FACTOR: 6.233
Actions to alleviate the mental health impact
of the economic crisis
K. WAHLBECK, D. MCDAID
Differential diagnosis of bipolar disorder
in children and adolescents
Investigating schizophrenia in a “dish”:
possibilities, potential and limitations
N.J. BRAY, S. KAPUR, J. PRICE
FORUM - CONSUMER MODELS OF RECOVERY:
ISSUES AND PERSPECTIVES
Issues and developments on the consumer
A.S. BELLACK, A. DRAPALSKI
Recovery from schizophrenia: form follows
Recovery research: the empirical evidence
A stigma perspective on recovery
M.C. ANGERMEYER, G. SCHOMERUS
Agency: its nature and role in recovery from
severe mental illness
P.H. LYSAKER, B.L. LEONHARDT
Consumer models of recovery: can they survive
Recovery: is consensus possible?
The vicissitudes of the recovery construct;
or, the challenge of taking “subjective experience”
Consumer perceptions of recovery: an Indian
Consumer recovery: a call for partnership
between researchers and consumers
An empirically derived approach to the
classification and diagnosis of mood disorders
D. WESTEN, J.C. MALONE, J.A. DEFIFE
Assessing the diagnostic validity of a structured
psychiatric interview in a first-admission
J. NORDGAARD, R. REVSBECH, D. SÆBYE, J. PARNAS
MENTAL HEALTH POLICY PAPERS
Lessons learned in developing community
mental health care in East and South East Asia
H. ITO, Y. SETOYA, Y. SUZUKI
Lessons learned in developing community
mental health care in Latin American and
D. RAZZOUK, G. GREGÓRIO, R. ANTUNES,
J. DE JESUS MARI
Mobile technologies in psychiatry: providing
new perspectives from biology to culture
J. SWENDSEN, R. SALAMON
Promises and limitations of telepsychiatry
in rural adult mental health care
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2. McRae TW. The impact of computers on accounting.
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3. Fraeijs de Veubeke B. Displacement and equilibrium models
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There was a time when the target of the psychiatric profes-
sion was very clear and widely accepted. It was “madness”,
that is, a few patterns of behaviour and experience which
were obviously beyond the range of normality.
In the perception of part of the public opinion, of several
colleagues of other medical disciplines, and paradoxically of
some fervent critics of old asylums, this traditional target of
psychiatry has remained unchanged: psychiatry deals with
people who are “mad”.
But the actual target of the psychiatric profession has
changed dramatically in the past decades. It has become a
range of mental disorders (or of “mental health problems”,
according to some official documents of international orga-
nizations), including several conditions which are obviously
on a continuum with normality. Fixing a boundary between
what is normal and what is pathological has consequently
become problematic. This boundary is often determined on
pragmatic grounds, or on the basis of “clinical utility” (i.e.,
prediction of clinical outcome and response to treatment),
although this pragmatism may involve some tautology (in
fact, requiring that a diagnostic threshold be predictive of
response to treatment seems to imply that a condition be-
comes a mental disorder when there is an effective treatment
available for it).
In this new scenario, psychiatry has become the focus of
On the one hand, the profession is being accused to un-
duly pathologize ordinary life difficulties in order to expand
its influence (e.g., 1,2). This criticism becomes harsher when
the above-mentioned evolution of the target of psychiatry
from “madness” to “mental health problems” is, in good or
bad faith, ignored: pathologizing ordinary life difficulties be-
comes “making us crazy” (3). Of course, the argument is pre-
sented with greater emphasis when the perceived unduly
“pathologization” occurs in children or adolescents, or when
it is considered to be a consequence of an alliance between
psychiatry and the pharmaceutical industry.
On the other hand, the psychiatric profession is being
pressured to go beyond the diagnosis and management of
mental disorders, acting towards the promotion of mental
health in the general population (e.g., 4,5). Within this frame,
especially in those countries in which community mental
health services are most developed and psychiatrists are lead-
ing those services, there is a call for dealing with “mental
health problems” which are not proper mental disorders,
such as the serious psychological distress occurring as a con-
sequence of a natural disaster or of the ongoing economic
From “madness” to “mental health problems”:
reflections on the evolving target of psychiatry
Department of Psychiatry, University of Naples SUN, Naples, Italy
crisis. Furthermore, psychiatrists are being pressured to di-
agnose and manage proper mental disorders as early as
possible, which means dealing with a variety of conditions
that may be “precursors” or “prodromes” of those disor-
ders, but more frequently are not, with the unavoidable risk
to, again, pathologize situations that are within the range
The two Special Articles which appear in this issue of the
journal (6,7) are both relevant to the above debate.
Indeed, the ongoing economic crisis is having a significant
impact on the mental health of the population in many coun-
tries, especially where scarce social protection is available for
people who become unemployed, indebted or poor due to
the crisis. Mental health services are often called to inter-
vene, in a situation of uncertainty and confusion about roles
A couple of recent episodes from my country, Italy, are
emblematic in this respect. Last spring, a group of widows of
entrepreneurs who had committed suicide, allegedly as a
consequence of economic ruin, marched in an Italian town
under the slogan “Our husbands were not crazy”. “It was
despair, not mental illness, which brought my husband to do
that”, one of them said (8). In the same period, in another
Italian town, the widow of an entrepreneur who had com-
mitted suicide blamed the professionals of a mental health
service because they had not hospitalized him compulsorily.
They had found him worried about his economic problems,
but they had thought he did not have a mental pathology.
“He was depressed. They should have hospitalized him”, the
widow said (9).
So, psychiatry is being blamed on the one hand for un-
duly pathologizing and stigmatizing understandable psycho-
logical distress, and on the other for not pathologizing that
same distress and not managing it as if it were proper mental
Equally emblematic is the ongoing discussion on “attenu-
ated psychosis syndrome” and “juvenile bipolar disorder”
(the former proposed for inclusion in the DSM-5; the latter
never included in the DSM, despite considerable lobbying).
On the one hand, the need is emphasized to diagnose and
manage schizophrenia and bipolar disorder as early as pos-
sible, even before the typical clinical picture becomes mani-
fest, in order to improve the outcome of those disorders; on
the other, concern is expressed about the risks involved in
false-positive diagnoses, especially in terms of societal stigma
and self-stigmatization and of misuse of medications (e.g.,
World Psychiatry 11:3 - October 2012
This uncertainty and confusion is likely to persist for sev-
eral years. In this situation, what the psychiatric profession
mostly seems to need is a refinement of its diagnostic (espe-
cially differential diagnostic) skills. The detailed description
of proper mental disorders provided by current diagnostic
systems may not be sufficient, especially for psychiatrists
working in a community setting. First, we may also need a
description of ordinary responses to major stressors (such as
bereavement, economic ruin, exposure to disaster or war,
disruption of family by divorce or separation) as well as to
life-cycle transitions (e.g., adolescent emotional turmoil).
The current attempt, within the development of DSM-5, to
describe “normal” grief as opposed to bereavement-associat-
ed depression, in order to guide differential diagnosis, is a
first step in this direction. Second, we may need a character-
ization of the more serious responses to the above stressors
which can come to the attention of mental health services
although not fulfilling the criteria for any mental disorder.
The serious and potentially life-threatening psychological
distress related to economic ruin, in which shame and de-
spair are the most prominent features and the diagnostic cri-
teria for depression are often not fulfilled, is a good example.
The current delineation of “adjustment disorders” in both the
ICD-10 and DSM-IV is too generic and ambiguous to be
useful for differential diagnostic purposes and as a guide for
Of course, other mental health professionals (and perhaps
other professionals outside the health field) will have to col-
laborate with psychiatrists or even take the lead in those
characterizations. This may hopefully contribute to the con-
struction of a transdisciplinary, clinically relevant, body of
knowledge in the mental health field, whose existence is at
The characterization of the above “mental health prob-
lems” could guide the development of adequate interven-
tions and community resources. On the one hand, in fact,
there is the risk of an inappropriate extension of interventions
used for proper mental disorders to the new emerging condi-
tions (e.g., use of antidepressant medications for the under-
standable psychological distress related to economic ruin);
on the other, there is the risk to reduce the intervention to the
provision of practical advice (which in some contexts is like-
ly to be entrusted to untrained volunteers) while differential
diagnosis and professional management are also needed.
Proving that effective interventions are available for these
emerging mental health problems will not, however, be suf-
ficient. We will also need to convince the public opinion that
there is an acceptable balance between the benefits provided
by those interventions and the risks (in terms of societal
stigma and self-stigmatization) of any mental health referral
(12). This calls for a real integration of mental health care in
the community (including active partnership with primary
care workers, social services and relevant stakeholders) in
parallel to the development of effective interventions. One or
the other of these two elements is often emphasized, while in
reality both of them are essential.
Finally, it cannot be ignored that, just as a consequence of
the ongoing economic crisis, the human and financial re-
sources of mental health services are being significantly cut
down in many countries. These services may be unable to
implement further activities at a time when they have difficul-
ties to carry out their traditional ones. This argument was
indeed put forward initially in some countries recently struck
by natural disasters, such as Sri Lanka and Indonesia. But
mental health professionals in those countries have been able
to turn the emergency into an opportunity to convince ad-
ministrators of the importance of mental health care for the
society, so that the final outcome has been a growth as well
as a better integration of mental health services. One could
argue that the current economic crisis may represent in sev-
eral countries an analogous opportunity to show how essen-
tial mental health care is for communities, and how flexible
mental health services can be in addressing the emerging
needs of those communities, if appropriately supported.
1. Horwitz AV, Wakefield JC. The loss of sadness. How psychiatry
transformed normal sorrow into depressive disorder. Oxford: Ox-
ford University Press, 2007.
2. Stein R. Revision to the bible of psychiatry, DSM, could introduce
new mental disorders. Washington Post, February 10, 2010.
3. Kutchins H, Kirk SA. Making us crazy. DSM: the psychiatric bible
and the creation of mental disorders. New York: Free Press, 1997.
4. World Health Organization. The world health report 2001. Mental
health: new understanding, new hope. Geneva: World Health Or-
5. World Health Organization Regional Office for Europe. Mental
health: facing the challenges, building solutions. Report from the
WHO European Ministerial Conference, 2005. Copenhagen: World
Health Organization Regional Office for Europe, 2005.
6. Wahlbeck K, McDaid D. Actions to alleviate the mental health im-
pact of the economic crisis. World Psychiatry 2012;11:139-45.
7. Carlson GA. Differential diagnosis of bipolar disorder in children
and adolescents. World Psychiatry 2012;11:146-52.
8. Alberti F. Le vedove della crisi in corteo: i nostri mariti non erano
pazzi. Corriere della Sera, May 5, 2012.
9. Di Costanzo A. Imprenditore suicida, la moglie accusa. La Repub-
blica, April 26, 2012.
10. Corcoran CM, First MB, Cornblatt B. The psychosis risk syndrome
and its proposed inclusion in the DSM-V: a risk-benefit analysis.
Schizophr Res 2010;120:16-22.
11. Parens E, Johnston J, Carlson GA. Pediatric mental health care dys-
function disorder? N Engl J Med 2010;362:1853-5.
12. Bolton D. What is mental disorder? An essay in philosophy, science
and values. Oxford: Oxford University Press, 2008.
The financial turmoil that began in 2007 has developed
into a full-blown economic crisis in many countries. This
crisis is likely to have a negative impact on health, espe-
cially mental health. The full health impact of the crisis re-
mains to be seen, but reports of negative mental health ef-
fects have already emerged. For instance, an increase in
suicide attempts has been reported in Greece (1), and in-
creases in the rate of suicides following the onset of the re-
cession have been observed in Ireland (2) and England (3).
However, the outlook does not have to be so bleak. A recent
World Health Organization (WHO) publication points out
that the association between economic crises and many
negative mental health outcomes is avoidable (4).
Societies can be more or less resistant to stressors, which
can include both economic upturns as well as crises. The
latter can destabilize public service budgets, with many con-
sequences, including some on education, social welfare and
health care systems. Policy choices can influence the impact
of any economic recession on mental health outcomes. Un-
wise austerity measures in public services for children, fam-
ilies and young people may result in long-lasting and costly
mental (and physical) health damages, and create an obstacle
to economic recovery. Conversely, measures to ensure that
social safety nets and supports are in place can increase the
resilience of communities to economic shocks and mitigate
the mental health impacts of fear of job loss, unemployment,
loss of social status and the stress-related consequences of
economic downturns (5).
This is because mental health depends upon a variety of
socioeconomic and environmental factors (6). High frequen-
cies of common mental disorders and suicide are associated
Actions to alleviate the mental health impact
of the economic crisis
Kristian WahlbecK1, DaviD McDaiD2
1Finnish Association for Mental Health, Maistraatinportti 4 A, FI-00240 Helsinki, Finland; 2LSE Health and Social Care and European Observatory on Health Systems
and Policies, London School of Economics and Political Science, London, UK
The current global economic crisis is expected to produce adverse mental health effects that may increase suicide and alcohol-related
death rates in affected countries. In nations with greater social safety nets, the health impacts of the economic downturn may be less
pronounced. Research indicates that the mental health impact of the economic crisis can be offset by various policy measures. This paper
aims to outline how countries can safeguard and support mental health in times of economic downturn. It indicates that good mental
health cannot be achieved by the health sector alone. The determinants of mental health often lie outside of the remits of the health sys-
tem, and all sectors of society have to be involved in the promotion of mental health. Accessible and responsive primary care services
support people at risk and can prevent mental health consequences. Any austerity measures imposed on mental health services need to
be geared to support the modernization of mental health care provision. Social welfare supports and active labour market programmes
aiming at helping people retain or re-gain jobs can counteract the mental health effects of the economic crisis. Family support programmes
can also make a difference. Alcohol pricing and restrictions of alcohol availability reduce alcohol harms and save lives. Support to
tackle unmanageable debt will also help to reduce the mental health impact of the crisis. While the current economic crisis may have a
major impact on mental health and increase mortality due to suicides and alcohol-related disorders, it is also a window of opportunity
to reform mental health care and promote a mentally healthy lifestyle.
Key words: Mental health, economic crisis, suicide prevention, social policy
(World Psychiatry 2012;11:139-145)
with poverty, poor education, material disadvantage, social
fragmentation and deprivation, and unemployment (7-9).
Recessions can widen income inequalities in societies, which
in turn increases the risk of poor mental health (10).
As people move down the socio-economic ladder due to
loss of jobs and income, their health is at risk of being ad-
versely affected (11). The number of households in high
debt, repossession of houses and evictions is at risk of in-
creasing as a result of the economic crisis. Protective factors
will be weakened and risk factors will be strengthened.
MentAl heAlth risKs
in econoMic downturns
A substantial body of research signposts that additional
mental health risks emerge in times of economic change. We
know that people who experience unemployment and im-
poverishment have a significantly greater risk of mental
health problems, such as depression, alcohol use disorders
and suicide, than their unaffected counterparts (12,13).
Men, in particular, are at increased risk of mental health
problems (14) and death due to suicide (15) or alcohol use
(16) during times of economic adversity.
There is evidence that debts, financial difficulties and
housing payment problems lead to mental health problems
(17-19). The more debts people have, the higher the risk of
many common mental disorders (20,21).
Increases in national and regional unemployment rates
are associated with increases in suicide rates (3,5,22). The
least well educated are those at greatest risk of ill health after
World Psychiatry 11:3 - October 2012
job loss (23). Pooled evidence calls for protective interven-
tions targeting both newly and long-term unemployed, espe-
cially men with low educational attainment (23).
During recessions, social inequalities in health can widen
(24). It is the poor – and those made poor through loss of
income or housing – that will be hardest hit by the eco-
nomic crisis (23). The crisis is likely to increase the social
exclusion of vulnerable groups, the poor and people living
near the poverty line (25). Vulnerable groups include chil-
dren, young people, single parent families, the unemployed,
ethnic minorities, migrants, and older people. Work from
South Korea reported increasing income-related inequali-
ties in suicide and depression over a 10-year period follow-
ing an economic crisis, strengthening the argument for tar-
geted investment in social protection supports (26).
economic crises put families at risk
Families as a whole also feel the effects of economic crisis.
Poor families are especially hurt by cuts in health and educa-
tion budgets. Family strain may lead to increases in family
violence and child neglect. Children may also find themselves
having to provide care and support for other family members.
The foundations of good mental health are laid during
pregnancy, infancy and childhood (27). Mental health is
promoted by a nurturing upbringing and a holistic prepara-
tion for life in pre-schools and schools by providing social
and emotional learning opportunities (28). Cuts in pre-
school support and the educational system may have life-
long consequences on psychological well-being.
Economic stress, through its influence on parental mental
health, marital interaction and parenting, impacts on the
mental health of children and adolescents (29,30). The im-
pact of extreme poverty on children may include deficits in
cognitive, emotional and physical development, and the
consequences on health and well-being may be life-long
(31). Nation-wide population follow-up data from Finland,
which experienced a severe economic recession in the be-
ginning of the 1990s, reveals gloomy figures: at age 21 one
in four of those born in 1987 had committed a criminal of-
fence and one in five had received psychiatric care (32).
Alcohol-related harms increase during downturns
In many countries, alcohol consumption is negatively as-
sociated with population mental health. For example, in
Eastern Europe, alcohol consumption plays a considerable
role in the suicide rate, especially in men (33).
In Russia, the societal changes seen after the collapse of
the Soviet Union in 1991, as well as the breakdown of the
rouble in 1998, were followed by increases in alcohol-relat-
ed deaths (34). Likewise, high rises in unemployment have
been linked to a 28% rise in deaths from alcohol use in the
European Union (5).
Binge drinking and alcohol-related deaths tend to in-
crease in many countries during economic downturns
(35,36), creating a need for governments to upgrade alcohol
MentAl heAlth risKs cAn be MitigAted
Countries with strong social safety nets see smaller changes
in the mental health of the population related to economic
downturns (37). European data indicates that, in countries
with good formal social protection, health inequalities do not
necessarily widen during a recession (5). For instance, in Fin-
land and Sweden, over a period of deep economic recession
and a large increase in unemployment, health inequalities re-
mained broadly unchanged and suicide rates diminished, pos-
sibly because social benefits and services broadly remained
and buffered against the structural pressures towards widen-
ing health inequalities (38-40). These European findings are
echoed by US data linking increased suicide rates with reduc-
tions in state welfare spending (41).
Reforms to social welfare to maintain or strengthen safety
nets and taxation systems to reduce income inequalities po-
tentially could help protect mental health. The collated data
indicates that social protection responses are crucial in mit-
igating poor mental health in any economic crisis while high
levels of income inequality are associated with poor mental
A holistic approach to the mental health challenges of the
current economic crisis calls for interventions across several
sectors. In addition to broad social welfare measures that go
beyond mental health issues alone, the provision of mental
health services in primary care, active labour market pro-
grammes, family support and parenting programmes, alco-
hol control, promotion of social capital and debt relief pro-
grammes constitute the cornerstones of successful policies
to prevent mental health problems in the population. There
is also an emerging evidence base on the cost-effectiveness
of these actions.
Accelerating mental health care reforms
Many countries are facing pressure from the international
financial community to cut borrowing and public expenditure,
which inevitably puts strain on their health and welfare bud-
gets. Government expenditures on health are being squeezed
and falling in real terms. Data on Organisation for Economic
Co-operation and Development (OECD) countries indicate
that overall health spending grew by nearly 5% per year in
real terms between 2000 and 2009, but was followed by zero
growth in 2010 (42). Major health service cuts have recently
been seen in Greece (43). In spite of increased pressure on
mental health services (44), these services are particularly vul-
nerable to cuts, as they usually lack a strong advocacy base to
oppose them, contrary to physical illness services.
Improved responsiveness of health services to changes in
the social, employment and income status of the population,
and early recognition of mental health problems, suicidal
ideas and heavy drinking will help reduce the human toll of
recession. To meet the mental health challenges of the eco-
nomic crisis, not only is protection of spending on mental
health services required, but also restructuring of services to
meet the needs of the population. Well-developed communi-
ty-based mental health services are linked to the reduction of
suicides (45,46). An integrated care approach with a focus on
service provision in primary care will increase access to men-
tal health care, and shift the focus to prevention and early
detection of mental health problems. The mental health care
system must liaise with resilience-strengthening elements in
the community, to create a comprehensive and accessible
network. Perceived stigma is a barrier for help-seeking (47),
and support services need have high acceptability.
Due to financial constraints, governments will inevitably
have to review their welfare services. In many countries,
mental health spending is still concentrated in psychiatric
hospitals. The current financial crisis may create the urgency
and strengthen courage to eliminate the fundamental prob-
lems in hospital-dominated health care delivery and increase
access to community based services. Thus, increasing effi-
ciency of services can go hand in hand with development of
modern community-based mental health services. Sound
financial incentives are, however, needed to support the pro-
vision of high-quality community care and optimal use of
existing resources. One important challenge may be the
need to continue to fund excess inpatient services at the
same time as investing in other services during a transitional
period (48). Linking funding to accreditation systems and
provider performance assessments can help support a shift
in emphasis away from institutional care (49).
Universal coverage of mental health services is a corner-
stone in reducing the impact of the crisis, and is likely to
restrain social inequalities in health (50). The current eco-
nomic crisis provides an additional driver to review and de-
velop the funding of mental health services to ensure access
Active labour market support for unemployed people
Active labour market programmes can reduce the mental
health effects of recessions. These programmes aim at im-
proving prospects of finding gainful employment and in-
clude public employment services, labour market training,
special programmes for young people in transition from
school to work, and programmes to provide or promote em-
ployment for people with disabilities.
In European Union countries, each additional 100 USD
per head of population spending on active labour market
programmes per year reduced by 0.4% the effect of a 1% rise
in unemployment rate on suicides (5).
Active labour market programmes include group psycho-
logical support for unemployed people to promote mental
health and increase re-employment rates (51,52). Cost-ef-
fectiveness evaluations of such interventions have reported
savings for social welfare payers and employers alike,
through increased rates of employment, higher earnings and
fewer job changes (53).
Given the adverse economic impacts of unemployment
for physical and mental health, there is a case for embedding
these types of services routinely into redundancy packages
provided by employers.
Special programmes for young people in transition from
school to work and re-employment training for young peo-
ple left unemployed can be of benefit. Apprenticeship-type
training in regular educational settings offer most mental
health benefits (54).
Family and parenting support programmes
Family support programmes include support for the costs
associated with raising children, as well as expenditure re-
lated to maternity and parental leave.
In European Union countries, each 100 USD per capita
spending on family support programmes reduced by 0.2%
the effect of unemployment on suicides (5). There is also a
large body of literature indicating that investment in mea-
sures to support the well-being of parents and their children
can be protective of mental health, with long-term econom-
ic gains outweighing short-term costs (55).
control of alcohol price and availability
The most effective and cost-effective policies include con-
trols on the price and availability of alcohol (56). While
sometimes politically challenging to implement, policy ac-
tions to increase the price of alcohol will result in a reduc-
tion in consumption and associated harm across the whole
population (57). Alcohol policy, and particularly policy that
increases the price of alcohol, will reduce deaths from alco-
hol use disorders.
Control policies should be supplemented by provision of
services: heavy drinkers will benefit from delivery of brief
interventions in primary care.
debt relief programmes
It is necessary to try to prevent people from becoming
over-indebted as well as making it easier for them to pay
their fair share and be able to return to a dignified and eco-
nomically active life. This has been highlighted as a key area
for action to protect mental health in public policy (58). Tak-
ing such action results in reduced distress and socio-econom-
ic benefits (59). In Sweden, people in high debt who had
been granted debt relief had a better mental health than
World Psychiatry 11:3 - October 2012
those who had not (59). A controlled trial of access to debt
management services in England and Wales reported im-
provements in general health, anxiety and optimism (60). Use
of debt advice services have also been associated with a re-
duction in the use of health care services (61).
There is a need for national programmes to strengthen co-
operation and improve communication between health ser-
vices and debt management agencies. Debt management
advisers should be trained to refer clients to mental health
care when needed (62). On the other hand, health services
need to acknowledge the burden of over-indebtedness in
clients and provide referral links to debt advice bureaus (63).
Access to microcredit, through organizations such as credit
unions, can also help (64).
There may be scope for looking at the provisions of bank-
ruptcy laws in some countries and seeing whether they
might also be reformed to try and protect mental health.
strengthening social capital
Social capital can be defined in different ways, but in gen-
eral terms covers the resources available to individuals and
society provided by social relationships or social networks.
In times of economic crisis, social capital can be an im-
portant protective factor. Social networks, as represented by
trade unions, religious congregations and sport clubs, seem
to constitute a safety net against the adverse effect of rapid
macroeconomic changes (65). Participation in group activi-
ties and greater levels of perceived helpfulness within com-
munities have been associated with better levels of mental
health (66). In contrast, poor levels of interpersonal trust
between individuals is associated with increased risk of de-
responsible media coverage of suicides
Evidence indicates that highly sensationalized reporting
of suicides, providing detailed descriptions of methods, can
and does lead to “copy-cat” suicides. On the other hand,
responsible reporting on suicides reduces copy-cat suicide
(68,69), especially among adolescents (70). Media guide-
lines for reporting suicides and monitoring of stigmatizing
media reports have been linked with reduced stigmatization
in press and reduction of suicides (68,70).
In economic crises, increased media coverage on possible
increases in suicides may thus have detrimental effects and
contribute to a “snowball” effect. A close collaboration be-
tween media representatives and mental health experts as
well as commonly agreed suicide reporting guidelines are
needed to prevent media-related increases in suicides during
times of economic hardship.
building the cAse For investing
in MentAl heAlth
One reason for the apparent low funding priority and ne-
glect given to mental health is the high level of stigma associ-
ated with mental health problems (71). Countering this
stigma and discrimination remains one of the most critical
challenges for improving mental health at a time of econom-
ic crisis, because this stigma may impact on the willingness
of public policy makers to invest in mental health (72). Pub-
lic surveys in some countries have indicated that mental
health can be seen as a low priority in terms of safeguarding
services in the face of budget cuts (73,74).
While economic crises may have mental health impacts,
mental health problems have an increasingly significant eco-
nomic impact in low, middle and high income countries
(75). For instance, in European Union Member States, the
economic consequences of mental health problems – main-
ly in the form of lost productivity – are conservatively esti-
mated to be on average 3-4% of gross national product (76).
Thus, mental health is an important economic factor. The
shift from a manufacturing to a knowledge-based society
emphasizes even more the importance of mental health for
sustained productivity. Good population mental health con-
tributes to economic productivity and prosperity, making it
crucial for economic growth (77).
Demonstrating that spending on mental health has eco-
nomic benefits can help governments justify new invest-
ments in mental health, as in the case of the mental health
strategy in England (78). Investing in mental health actions,
both within and external to the health care sector, provides
resources and opportunities to reduce the risk of social ex-
clusion and promote social integration. However, despite
the availability of cost-effective interventions, the priority
mental health receives in many health care systems is re-
markably low (79). This may be because many of the above-
mentioned economic benefits fall on sectors outside of the
health system. It is crucial to communicate to Ministries of
Finance that investment in mental health can have broad
benefits for the public purse as a whole (80).
every crisis is An opportunity
The current economic crisis presents an opportunity to
strengthen policies that would not only mitigate the impact of
the recession on deaths and injuries arising from suicidal ac-
tions and alcohol use disorders, but reduce the global health
and economic burden presented by impaired mental health
and alcohol use disorders in any economic cycle. It is impor-
tant to remember that investment in supports for mental
health will also have benefits in times of economic boom as
well as bust, when there will inevitably be an uneven distribu-
tion of wealth gains and not all of the population will benefit,
as was seen during the Celtic Tiger years in Ireland (81).
There are powerful public health and economic argu-
ments for universal coverage of community mental health
care, adequate social protection systems, active labour mar-
ket programmes, family and parenting support, debt relief
and effective alcohol control policy, which are strengthened
by the present economic downturn. Governments could
consider reorienting budgets to protect populations now
and in the future by budgeting for measures that keep people
employed, helping those who lose their jobs and their fami-
lies with the negative effects of unemployment, and enabling
unemployed people to regain work quickly. Business under
strain may be able to help by offering reduced working hours
or temporary sabbaticals from employment rather than
making workers redundant. Governments could also con-
sider strengthening their alcohol policies, in particular by
raising the price of alcohol, or introducing a minimum price
of alcohol. Such a policy would have a particular impact on
reducing the harm done by risky and heavy episodic pat-
terns of drinking.
Without detracting attention from the mental health risks
of the current global economic recession, it needs to be not-
ed that a recession may also contribute to positive lifestyle
changes. Fewer hours spent at work may mean more leisure
hours spent with children, family and friends. Less econom-
ic activity may contribute to a slower pace of life and
strengthen social capital by providing more opportunities
for civic participation and social networking. Iceland en-
countered a major financial and economic crisis in 2008.
Some Icelanders did see the crisis as a “blessing in disguise
for a nation that had lost its basic values to greed and narcis-
sism”, offering a chance to “recover to become a more dem-
ocratic, human and fair society” (82). Indeed, due to preser-
vation of well-developed basic social welfare in Iceland even
at the height of the crisis, reports indicate even positive im-
pacts regarding health behaviours (83).
The policy decisions taken can either worsen or strength-
en population health, and it is likely that options which pro-
mote population mental health will also support a faster
economic recovery. Population well-being, i.e. mental capi-
tal, is a crucial prerequisite for a flourishing economy with
The way out of the economic crisis is laid by the mental
health bricks of population well-being. Important bricks are
healthy families, solidarity with those struck by the crisis
and accessible and equitable community mental health care.
Well laid and cemented mental health bricks are crucial for
a return to a healthy economy.
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World Psychiatry 11:3 - October 2012
Differential diagnosis of bipolar disorder in children
Gabrielle a. Carlson
At least five issues complicate the differential diagnosis of
bipolar disorder in young people: a) the subtype of bipolar
disorder being considered (i.e., the differential diagnosis of
mania vs. that of depression; the differential diagnosis of bi-
polar I disorder vs. that of bipolar disorder not otherwise
specified (NOS)); b) the child’s age and stage of develop-
ment; c) whether one views bipolar disorder more conserva-
tively, requiring clear episodes that mark a distinct change
from premorbid levels of function, or more liberally, focusing
for instance on severe irritability/explosive outbursts as the
mood change; d) who is reporting manic symptoms, and
whether symptoms are past and must be recalled or current
and more likely to be observed; e) the utility of family history
in making a diagnosis.
Children and adolescents are not necessarily good report-
ers about events in time, or may not understand such abstract
concepts as euphoria and racing thoughts. Parents may not
be aware of or may misinterpret their child’s internal state.
Children spend almost half their waking life in school, so
that, if a child is experiencing a prevailing mood most of the
day every day, a teacher should be able to notice a behav-
ioral change, whether or not he/she recognizes symptoms as
being manic or something else (1).
This review focuses primarily on mania, and distinguishes
adolescents from children. We try to address broad vs. nar-
row approaches to diagnosis, and we discuss the implica-
tions of informant variance for diagnosis.
Mania in post-pubertal youths
Jeffrey, who was 14 when first evaluated, was described as
an energetic, motivated, creative and gregarious adolescent,
who involved himself in multiple activities but completed
them successfully. He was conscientious and respectful, and
Department of Psychiatry and Behavioral Sciences, Stony Brook University School of Medicine, Putnam Hall-South Campus, Stony Brook, NY 11794-8790, USA
Issues complicating the differential diagnosis of bipolar disorder in young people are discussed. They include: a) the subtype of bipolar disor-
der being considered; b) the person’s age and stage of development; c) whether one views bipolar disorder more conservatively, requiring clear
episodes that mark a distinct change from premorbid levels of function, or more liberally, focusing for instance on severe irritability/explosive
outbursts as the mood change; d) who is reporting manic symptoms, and whether symptoms are past and must be recalled or current and more
likely to be observed; e) impact of family history. The diagnosis of mania/bipolar I disorder may not become clear for a number of years. This
is an impairing disorder, but so are the conditions from which it must be distinguished. Family history may increase the odds that certain
symptoms/behaviors are manifestations of bipolar disorder but it does not make the diagnosis. Until there are biomarkers that can confirm
the diagnosis, and treatments unique to the condition, it is wise to make a diagnosis of bipolar disorder in children and adolescents provision-
ally and keep an open mind to the likelihood that revisions may be necessary.
Key words: Bipolar disorder, mania, irritability, children, adolescents
(World Psychiatry 2012;11:146-152)
had many interests. Over the course of a few months, how-
ever, he developed attention problems, began using the
neighbors’ swimming pool at 2 am without their permission,
tried to call President Bush to give him advice about invading
Iraq, and became testy and oppositional with parents when
they tried to get him to get a decent night’s sleep. Following
this period, which lasted several weeks, Jeffrey became bed-
ridden with fatigue, disinterested in friends or activities, and
almost stopped eating. He felt very depressed. Further inter-
view elicited other symptoms of mania with no past history
of depression. Consultation was sought about whether this
was “adolescence” or psychopathology. Complicating mat-
ters, he had sustained a head injury playing football and, al-
though he did not lose consciousness, there was some ques-
tion about whether his behavior, which began several weeks
later, was related to the head trauma.
While Jeffrey appears to have experienced a fairly classic
manic episode, several issues need further evaluation:
•? How much do Jeffrey’s behavior encompass a clear depar-
ture from his prior “hyperthymic temperament”? (2). A
hyperthymic person is habitually upbeat and exuberant,
articulate, jocular, overoptimistic, uninhibited, carefree,
energetic and full of improvident plans, versatile with
broad interests, overinvolved and even meddlesome. That
certainly characterized Jeffrey. Had he crossed the bound-
ary into a hypomanic or manic episode? The boundary
would have been clearer had Jeffrey been a quiet, unassum-
ing character prior to going into what appeared to be his
overdrive, but his impairment and subsequent depression
were not consistent with temperament alone.
•? Was Jeffrey’s head injury relevant? There are case reports
noting the association between traumatic brain injury and
mania (3). There is also a condition called “personality
change following traumatic brain injury” (4), referring to
a disinhibited state that was called organic affective disor-
der in earlier DSMs.
•? Is there any evidence that Jeffrey is abusing substances?
New onset mood symptoms in teenagers warrant ques-
tions about drug and alcohol abuse and dependence (5).
Teens abusing marijuana, alcohol, or other drugs, may
develop psychosis and/or mood symptoms. While a posi-
tive toxicology screen helps document drug involvement,
negative drug screens do not rule out substance abuse.
Furthermore, symptoms of mania may continue for weeks
after the patient is drug free. It is often difficult to disen-
tangle whether drug abuse has precipitated a mood epi-
sode that otherwise would not have occurred, has has-
tened its onset, perpetuates a mood problem that might
otherwise have subsided, or is irrelevant (6).
Between 11% and 27% of teens hospitalized for a first
psychotic episode have a diagnosis of bipolar I disorder at
least initially (7). It is often very difficult, however, to be de-
finitive in diagnosis with the first episode, because symptoms
may be confusing or may change over time.
For instance, Dennis was 16 when, over the course of 3
days, he stopped sleeping, felt he could control the world,
wrote letters that everything had a purpose and was intercon-
nected, including the German swastika, the pyramids and
the peace symbol. He was physically restless and hyperver-
bal. He became increasingly paranoid, feeling his psychiatrist
wanted to hurt him. Over the next 6 months, with treatment
(antipsychotic and lithium), his affective symptoms remitted,
but he developed thought broadcasting and referential think-
ing which never remitted. Ten years later, he was diagnosed
with schizoaffective disorder because of his chronic thought
disorder and unremitting psychotic symptoms. His medica-
tions appeared to attenuate his mood symptoms, but not his
Although almost 70% of first episode psychotic manic
subjects retained a bipolar or probable bipolar diagnosis at
10 years following their initial episode (8), predictors of
worse outcome and change in diagnosis were Schneiderian
symptoms at baseline, and poor premorbid functioning. Oth-
er harbingers of poor outcome were depressive phenomenol-
ogy, childhood psychopathology, and younger age at first
Mania in chilDren
Mania in children before the age of 10 is more contentious
than mania in adolescents (10). In applying DSM-IV-TR bi-
polar disorder criteria to children, several modifications have
been proposed in order to fit the symptom profile of mania
to symptoms more common in younger children. Unresolved
is whether these children grow up to manifest clear episodes
of mania and depression like Jeffrey (acute onset of mania,
discrete episodes, little comorbidity) vs. ongoing dysregulat-
ed mood with depression – similar to subjects in the System-
atic Treatment Enhancement Program for Bipolar Disorder
(STEP-BD) study (11) – vs. some other outcome, including
maturity with no further episodes (12).
An insidious problem with the diagnosis of early-onset bi-
polar disorder is different interpretation of the criteria. There
is little disagreement on classic cases of mania, where onset
is clear and manic symptoms co-occur that are easily distin-
guished from other psychopathology. In other less “classic”
cases, however, there is considerably greater disagreement
(13). Reliability can be achieved easily enough within groups,
but that does not guarantee reliability across groups.
According to DSM-IV-TR, a manic episode is identified as
a “distinct period” of specific and co-occurring symptoms.
Unfortunately, “distinct period” has not been consistently
operationalized (14). Thus, the criteria for mania will be un-
dergoing some modifications in the DSM-5 (see www.dsm5.
org). As noted in the rationale for these changes, “the ques-
tion of what constitutes an episode has been the subject of
some controversy and confusion, especially in the child psy-
chiatry literature”. In the view of the Mood Disorders Work
Group, the wording of the DSM-IV criteria for mania and
hypomania may have contributed to that confusion. The pro-
posed change is therefore a clarification whose goal would
be to ensure that diagnostic practices remain consistent with
both the intention of previous iterations of the DSM and
across the developmental spectrum. Thus, criterion A is ex-
pected to read: “a distinct period of abnormally and persis-
tently elevated, expansive, or irritable mood and abnormally
and persistently increased activity or energy, lasting at least 1
week and present most of the day, nearly every day (or any
duration if hospitalization is necessary)”.
The conceptualization of symptoms is important to the
discussion of the differential diagnosis of mania. While de-
pressive symptoms have been recognized as being different
from a depressive episode, or “clinical depression”, there has
been little appreciation that manic symptoms may occur out-
side of a manic episode. Originally highlighted in a commu-
nity study in 1988 (15), a number of studies since have con-
firmed the fact that manic symptoms occur much more fre-
quently than a manic episode, are significantly impairing, but
cut across many conditions (16,17). Without the clarification
of a distinct episode, a period with an onset and an offset that
is different from one’s “usual behavior”, and without infor-
mation in young children about what “usual behavior is”, it
is very difficult to distinguish mania from other childhood
conditions in which irritability and agitation also occur.
Attention-deficit/hyperactivity disorder (ADHD) is the
condition most often confused with mania in children (18).
There is considerable symptom overlap (both conditions
have notable distractibility, impulsivity, hyperactivity, rapid
and overproductive speech) (19). However, children with
manic symptoms have more than uncomplicated ADHD.
They invariably meet criteria for other disorders (comorbidi-
ties) and are considered more impaired (20,21). Interestingly,
when children with manic symptoms are matched with AD-
HD children with similar comorbidities, differences between
World Psychiatry 11:3 - October 2012
them evaporate (22,23). The diagnostic question becomes
whether children with manic symptoms have bipolar disor-
der and ADHD or whether they have ADHD with high levels
of emotionality and/or oppositional defiance.
Emotionality/oppositional defiance in ADHD is noted in
the DSM-III/IV text among “associated symptoms”. The
DSM-IV-TR text states that the emotionality component in-
cludes low frustration tolerance/irritability, temper outbursts,
mood lability, dysphoria and low self-esteem. These symp-
toms clearly reflect a mood dimension. The emotionality
component maps onto both inattentive and hyperactive di-
mensions of ADHD. The inattentive ADHD symptoms may
be primarily associated with breakdowns in the regulation
side, whereas hyperactivity-impulsive ADHD symptoms
may be associated with breakdown in the emotionality side
(24). What is evident is that children with either bipolar dis-
order or ADHD and emotionality are more clearly impaired
cross-sectionally and longitudinally than children with un-
complicated ADHD (20,25).
ADHD and bipolar disorder frequently co-occur. The re-
cently published Longitudinal Assessment of Manic Symp-
toms study (16) most carefully dissects the question of AD-
HD and bipolar disorder (20). The investigators compared
6-12 year old children whose parents endorsed manic symp-
toms on an instrument called the General Behavior Inven-
tory (26) (n=621) with a lower scoring group (n=86). Of the
total 707 children, the vast majority (59.5%) had ADHD
without a bipolar spectrum disorder, 6.4% had a bipolar
spectrum disorder without ADHD, 16.5% had both, and
17.5% had neither. Bipolar spectrum disorder was equally
divided into bipolar I disorder and bipolar disorder NOS
(with few having bipolar II disorder). Similar to prior studies
(1,15), most children with manic symptoms did not have bi-
polar spectrum disorder. Of the 162 children who had bipo-
lar spectrum disorder, most (72.2%) had co-occurring AD-
HD. Parent ratings revealed that this combination produced
more symptoms than either condition alone. Diagnosis was
made with the Schedule for Affective Disorders and Schizo-
phrenia for Children (K-SADS-PL, 27) and, though the au-
thors do not specify, one assumes it was based mostly on
parent information, since teachers often disagreed (20). Nev-
ertheless, considerable care was taken to distinguish chronic
symptoms from acute or fluctuating ones and it is precisely
that approach which is needed to help distinguish mania
from ADHD from the co-occurrence of the two conditions.
Apart from taking a history which establishes that an epi-
sode has taken place, further vetting of possibly overlapping
symptoms is necessary. Symptoms that lend themselves to
confusion between mania and ADHD include:
•? The silly, disinhibited behavior of a child with ADHD try-
ing to be funny and not knowing when to quit vs. someone
with an elated mood.
•? Impulsivity vs. pleasure-seeking without heeding conse-
•? Resistance to bedtime vs. a reduced need for sleep.
•? Exacerbation of subthreshold ADHD symptoms because
of increased late elementary or middle school demands vs.
the start of a mood disorder.
•? Progression of ADHD symptoms to include more opposi-
tional/explosive/conduct disordered behavior in the con-
text of family, school and/or peer difficulties.
•? Pragmatic, distracted or odd language seen in children
who have language disorders as part of ADHD or an au-
tism spectrum disorder vs. the flight of ideas/thought dis-
order of mania.
•? “Hallucinations” seen in a very anxious child vs. mood
incongruent symptoms of mania.
Children with autism spectrum disorders may be confused
with children with mania because of their emotion regulation
problems (28). Not only do these children have hyperactivity
and impulsivity, but their pragmatic language difficulties can
look like a thought disorder to clinicians who are not versed
in the difference (29). As in the case of ADHD, however, a
good history should help distinguish which symptoms are
chronic and which are manifestations of a new condition.
Interestingly, although autism and bipolar disorder (includ-
ing more classic episodic bipolar disorder) have been often
associated (30), children with known pervasive developmen-
tal disorder are almost always excluded in formal research
Lynda, described elsewhere (13), was 11 and presented
with what her parents called “mood swings”, i.e. frequent
explosive outbursts when she was frustrated over anything,
no matter how trivial. She had a history since toddlerhood
of ADHD, which never completely remitted with stimulant
medication. By 5th grade, she had become very irritable, dis-
obedient, nasty to her parents and dismissive of their con-
cerns about her poor school performance, grandiosely feel-
ing she needed no education. She viewed pornographic sites
on the computer and stayed up late at night allegedly “on line
with friends”. She was behind academically and unpopular
with classmates. She was not explosive in school, but ADHD
symptoms were evident. Her parents endorsed manic-like
symptoms during interview. Lynda herself described dyspho-
ria, irritability, trouble concentrating, low self-esteem, and
occasional suicidal ideation. In addition, there was consider-
able strife at home, though no actual domestic violence.
Lynda’s differential diagnosis using DSM-IV criteria would
include ADHD and emerging oppositional defiant and pos-
sible conduct disorder, major depressive disorder, an adjust-
ment disorder secondary to increasing failure socially, aca-
demically and at home, and an episode of mixed mania.
Mood dysregulation/lability is increasingly recognized as
an important component of a number of conditions (31). The
lay public, in fact, uses the term “bipolar” to characterize
“mood swings”, i.e., abrupt changes in mood that seem inex-
??149 Download full-text
plicable to the observer. The reference is to a switch to a
negative mood, the essence of irritability. In the throes of a
manic episode, children and adults are often irritable. What
has proved controversial is the question of whether children
who become severely explosive have mania or whether this
behavior, like irritability in general, cuts across all the condi-
tions in which irritability is a prominent symptom (like de-
pression, anxiety, schizophrenia, etc.) (32).
Depressive anD anxiety DisorDers
Irritability, of course, is an important symptom not only in
mania, but also in depression (both major depressive disor-
der and dysthymia) and anxiety disorders (including post-
traumatic stress disorder, obsessive-compulsive disorder,
social phobia, separation and generalized anxiety disorders).
As with ADHD, the question is often not an “either or”, but
a “both”. The distinction between mixed mania or rapid cy-
cling and an agitated depression is especially difficult. In fact,
some consider agitated depression as part of the bipolar spec-
trum (33). Longitudinal follow-up (34) and follow-back (35)
data suggest that a predominantly depressive course in chil-
dren with bipolar spectrum disorders is more chronic and
treatment refractory than a predominantly manic course (9).
The question in the childhood group followed prospectively
will be how many either “outgrow” their manic symptoms
and remain depressed (36) or even remit (12).
Irritability and hyperarousal are also symptoms of anxiety.
Anxiety disorders are a common bipolar comorbidity in
adults and youth. In adults, anxiety symptoms decreased the
probability of recovering from a depressive episode of bipolar
disorder, increased time to recovery, and increased the likeli-
hood of relapse (37). In children, anxiety disorder usually
precedes the onset of mania, in which case, a bona fide man-
ic episode would be comorbid. Without a prior history of
anxiety, it is quite possible that the symptoms of anxiety are
part of the manic episode and not truly comorbid (38). In
children and adolescents, anxiety appears more often associ-
ated with bipolar II disorder. Those with bipolar II disorder
and anxiety had more concurrent depressive symptoms, lon-
ger and more severe depressive episodes, and a greater fam-
ily history of depression than those without comorbid anxi-
Disruptive MooD Dysregulation DisorDer
In an effort to better understand the similarities and differ-
ences between chronic, severe irritability and more classic,
episodic bipolar disorder, Leibenluft and the National Insti-
tute of Mental Health (NIMH) Intramural Program on Mood
Disorders have defined a condition called “severe mood dys-
regulation (SMD)” (32). This is characterized by chronic ir-
ritability with frequent explosive outbursts not better diag-
nosed as mania, schizophrenia or schizophrenia spectrum
disorder, pervasive developmental disorder, post-traumatic
stress disorder, substance abuse, a medical or neurological
condition. In a sample of 146 children, 75% in fact had co-
morbid ADHD and oppositional defiant disorder, and over
half (58%) had at least a lifetime anxiety disorder. Although
no actual follow-up studies of children with SMD have been
done, extrapolated data (39-41) suggest that depression un-
derlies these behaviors. It appears that the DSM-5 Mood
Disorders Work Group will use the data gathered from this
sample to add a condition to the manual as a mood disorder,
and the condition will be called disruptive mood dysregula-
tion disorder (DMDD) (see www.dsm5.org).
DMDD should be readily distinguished from mania be-
cause of the absence of episodes. In addition, the condition
is defined as starting after age 6 (to keep tempestuous tod-
dlers and preschoolers from being given the diagnosis) and
before age 10 (to indicate it is a childhood disorder). It is
chronic (i.e. symptoms have lasted for at least a year) to
hopefully keep children who are responding to acute stress-
ors, and who could be classified as having an adjustment
disorder with disturbance of conduct or mood, from getting
the DMDD diagnosis. DMDD, if the diagnosis is appropri-
ately used, is severe and disabling (31).
DMDD’s biggest diagnostic problem will be that irritabil-
ity and explosive outbursts occur with many known condi-
tions (42). Children who present with rage outbursts (regard-
less of whether or not they have chronic irritability) find their
way into emergency rooms, psychiatric and residential fa-
cilities and special education. They require a useful diagnosis
that will allow quantification, suggest a treatment alternative
and allow for insurance reimbursement. The usual diagnostic
home for children with rage outbursts has been oppositional
defiant and conduct disorder, neither of which are consid-
ered reimbursable because they are regarded as “parenting”
or “social” problems. The absence of a valid and useful way
of codifying rage outbursts has led to a misuse of the bipolar
disorder diagnosis and has prevented us from understanding
the seriousness of these outbursts (43).
There is a question of whether rage outbursts represent a
difference of degree or kind from the tantrums of younger
children (44,45). Interestingly, their structure is similar, but
the duration is longer (at least 20 minutes rather than 5 min-
utes), and what the child does during the tantrum is worse
(kicking, hitting, throwing, spitting) in part because a child
or adolescent of 7-17 is bigger and can inflict more damage
than a seriously disturbed toddler. There are no data to sug-
gest these outbursts change with diagnosis (i.e., rage out-
bursts that occur during a panic attack look similar to those
that occur during a manic episode, oppositional defiant dis-
order, depression, etc.) (46). Many clinicians are appropri-
ately concerned that this “diagnosis” will be as misused as
“bipolar disorder” (43). This could be avoided if the diagnos-
tic rules are followed, and if “explosive outbursts” were to be
used as a modifier to any condition in which they occur,
much as catatonia is being proposed to modify a variety of
disorders. For instance, a diagnosis of ADHD with explosive