by Jon Ronson
“And then what?” I asked.
“Then they got down to it,” he said. “Why wasn’t I using their products? I said, ‘You guys are the enemy. You’ve hijacked the profession. You’re only interested in selling your products, not in treating patients.’ They all had a run at me. I held my ground. Then the bill came. We were ready to go. And then the more attractive of the two women said, ‘Oh! Would you like some Viagra samples?’”
Gary fell silent. Then he said, with some fury, “Like street pushers.”
Gary said he has nothing against checklists: “A good checklist is useful. But now we’re flooded with checklists. You can read them in Parade magazine.”
And a surfeit of checklists, coupled with unscrupulous drug reps, is, Gary said, a dreadful combination.
There is a children’s picture book, Brandon and the Bipolar Bear, written by a woman named Tracy Anglada. In it, little Brandon flies into a rage at the slightest provocation. At other times he’s silly and giddy. His mother takes him and his bear to a doctor, who tells him he has bipolar disorder. Brandon asks the doctor if he’ll ever feel better. The doctor says yes, there are now good medicines to help boys and girls with bipolar disorder and Brandon can start by taking one right away. He asks Brandon to promise that he’ll take his medicine whenever he’s told to by his mother.
Were Brandon an actual child, he would almost certainly have just been misdiagnosed with bipolar disorder.
“The USA overdiagnoses many things and childhood bipolar is the latest but perhaps the most worrying given the implications.”
Ian Goodyer is a professor of child and adolescent psychiatry at Cambridge University. He—like practically every neurologist and child psychiatrist operating outside the U.S., and a great many within the U.S.—simply doesn’t believe that childhood bipolar disorder exists.
“Epidemiological studies never find anything like the prevalence quoted by the protagonists of this view that there are bipolar children,” he told me. “It is an illness that emerges from late adolescence. It is very, very unlikely indeed that you’ll find it in children under seven years of age.”
Which is odd, given that huge numbers of American children under seven are currently being diagnosed with it.
These children may be ill, some very ill, some very troubled, Ian Goodyer said, but they are not bipolar.
When Robert Spitzer stepped down as editor of DSM-III, his position was taken by a psychiatrist named Allen Frances. He continued the Spitzer tradition of welcoming as many new mental disorders, with their corresponding checklists, into the fold as he could. DSM-IV came in at 886 pages.
Now, as he took a road trip from New York down to Florida, Dr. Frances told me over the phone he felt they’d made some terrible mistakes.
“It’s very easy to set off a false epidemic in psychiatry,” he said. “And we inadvertently contributed to three that are ongoing now.”
“Which are they?” I asked.
“Autism, attention deficit, and childhood bipolar,” he said.
“How did you do it?” I asked.
“With autism it was mostly adding Asperger’s, which was a much milder form,” he said. “The rates of diagnosis of autistic disorder in children went from less than one in two thousand to more than one in one hundred. Many kids who would have been called eccentric, different, were suddenly labeled autistic.”
I remembered my drive to Coxsackie Correctional Facility, passing that billboard near Albany—EVERY 20 SECONDS A CHILD IS DIAGNOSED WITH AUTISM.
Some parents came to wrongly believe that this sudden, startling outbreak was linked to the MMR vaccine. Doctors like Andrew Wakefield and celebrities like Jenny McCarthy and Jim Carrey promoted the view. Parents stopped giving the vaccine to their children. Some caught measles and died.
But this chaos, Allen Frances said, pales next to childhood bipolar.
“The way the diagnosis is being made in America was not something we intended,” he said. “Kids with extreme irritability and moodiness and temper tantrums are being called bipolar. The drug companies and the advocacy groups have a tremendous influence in propagating the epidemic.”
As it happens, Tracy Anglada, author of Brandon and the Bipolar Bear, is the head of a childhood bipolar advocacy group called BP Children. She e-mailed me that she wished me all the best with my project, but she didn’t want to be interviewed. If, however, I wanted to submit a completed manuscript to her, she added, she’d be happy to consider it for review.
“Psychiatric diagnoses are getting closer and closer to the boundary of normal,” said Allen Frances. “That boundary is very populous. The most crowded boundary is the boundary with normal.”
“Why?” I asked.
“There’s a societal push for conformity in all ways,” he said. “There’s less tolerance of difference. And so maybe for some people having a label is better. It can confer a sense of hope and direction. ‘Previously I was laughed at, I was picked on, no one liked me, but now I can talk to fellow bipolar sufferers on the Internet and no longer feel alone.’” He paused. “In the old days some of them may have been given a more stigmatizing label like conduct disorder or personality disorder or oppositional defiant disorder. Childhood bipolar takes the edge of guilt away from parents that maybe they created an oppositional child.”
“So maybe it’s all good,” I said. “Maybe being given a diagnosis of childhood bipolar is good.”
“No,” he said. “It is definitely not good. And there’s a very good reason why it isn’t.”
Bryna Hebert, who lives two hundred miles from Robert Spitzer in Barrington, Rhode Island, was “such a high-energy child, would I have been labeled? Probably. I did all kinds of crazy things. Backflips down the stairs . . .”
But her childhood occurred before DSM-III was published, and her behavior was considered just being a child.
All that changed with her children. I was sitting with them all in her airy middle-class home. Matt, who was fourteen, wandered around playing “Smoke on the Water” on a Gibson Epiphone. Hannah worried about whether some leftover food she’d eaten was too old. Jessica wasn’t home from school. Everything seemed nice and normal to me. But then again, Matt was medicated. I visited Bryna because, like her friend Tracy Anglada, she had written a children’s book about the condition: My Bipolar, Roller Coaster, Feelings Book.
“They were always very high-energy,” said Bryna. “They were difficult kids. They had colic. They had to move. They crawled at six months. They walked at ten months. I’d pick them up from school and the teacher would say, ‘Hannah had the rice from the rice table today. She filled her mouth with rice from the rice table!’ ”
Bryna laughed and blushed. She was still a high-energy person—a fast talker, her words and thoughts tumbling out of her.
“We used to have to duct tape their diapers. They would take them off while they were sleeping. They were pretty high-end. Matt! Will you take your medicines, please?”
They were lined up on the kitchen table. He took them straightaway.
Their nickname for baby Matt was Mister Manic Depressive.
“Because his mood would change so fast. He’d be sitting in his high chair, happy as a clam, two seconds later he’d be throwing things across the room. He’s crying and he’s angry and nobody knows why. When he was three, he got a lot more challenging. Kids liked him but they were becoming afraid of him because they couldn’t predict what he’d do next. He’d hit and not be sorry that he hit. He was obsessed with vampires. He’d cut out bits of paper and put them into his teeth like vampire teeth and go around. Hiss hiss hiss. Walking down the street! Going up to strangers. It was a little weird.”
“Were you getting nervous?” I asked.
“Yeah,” said Bryna. “We’d get in the car and he’d say he could see the buildings downtown. But they’d be thirty miles away! When he played Lion King, he really was Simba. He was manic. Not too often depressed. Occasionally. He’d say he didn’t deserve to live,
but he was never suicidal. And he would have these tantrums that would last a very long time. At home one day he wanted some pretzels before lunch, and I was making lunch, and so I told him NO. I told him he couldn’t have the pretzels. And he grabbed a butcher knife and threatened me with the butcher knife. I yelled at him, ‘PUT THAT DOWN.’ ”
“How old was he?”
“Four.”
“And did he put it down?”
“Yes.”
“Was that the only time?” I asked.
“That was the only time he’s ever done anything that extreme,” said Bryna. “Oh, he’s hit Jessica in the head and kicked her in the stomach.”
“She’s the one who punched ME in the head,” Matt called from across the room.
Bryna looked furious. She calmed herself.
It was after the butcher knife incident, she said, that they took him to be tested.
As it happened, the pediatric unit at their local hospital—Massachusetts General—was run by Dr. Joseph Biederman, the doyen of childhood bipolar disorder. In November 2008, Biederman was accused of conflict of interest when it was discovered that his unit had received funding from Johnson & Johnson, maker of the antipsychotic drug Risperdal, which is frequently given to children. Although the hospital denied the unit was promoting Johnson & Johnson products, The New York Times published excerpts of an internal document in which Biederman promised to try to “move forward the commercial goals of J&J.”
Biederman has said that bipolar disorder can start “from the moment the child opens his eyes.”
He has denied the allegations made against him.
The science of children’s psychiatric medications is so primitive and Biederman’s influence so great that when he merely mentions a drug during a presentation, tens of thousands of children within a year or two will end up taking that drug, or combination of drugs. This happens in the absence of a drug trial of any kind—instead, the decision is based upon word of mouth among the 7,000 child psychiatrists in America.
—LAWRENCE DILLER, San Francisco Chronicle, JULY 13, 2008
“When they were testing Matt, he was turning on the PA system,” said Bryna, “he was turning off the PA system. He was turning on the lights, he was turning off the lights. He was under the table, he was on top of the table. We went through all these checklists. He said he once had a dream that a big flying bird with rotor blades cut his sisters’ heads off. In another dream he was swallowed up by a ghost. When they heard the dreams, they really began to pay attention.”
After a while, one of Dr. Biederman’s colleagues said, “We really think Matt meets the criteria in the DSM for bipolar disorder.”
That was ten years ago, and Matt has been medicated ever since. So has his sister Jessica, who was also diagnosed by Dr. Biederman’s people as bipolar.
“We’ve been through a million medications,” said Bryna. “With the first one he got so much better but he gained ten pounds in a month. So there’s weight gain. Tics. Irritability. Sedation. They work for a couple of years then they stop working. MATT!”
Matt was playing “Smoke on the Water” quite close to us.
“Matt,” she said. “Will you do this somewhere else? Honey, can you find something to do? Go to another place.”
Bryna is convinced her children are bipolar, and I wasn’t going to swoop into a stranger’s home for an afternoon and tell them all they were normal. That would be incredibly patronizing and offensive. Plus as David Shaffer—the venerable child psychiatrist, DSM pioneer, and recently separated husband of Vogue editor Anna Wintour—told me when I met him in New York later that evening, “These kids that are getting misdiagnosed with bipolar can be very oppositional, very disturbed, they’re not normal kids. They’re very difficult to control and they terrorize and can break up a home. They are powerful kids who can take years off your happy life. But they aren’t bipolar.”
“So what are they?” I said.
“ADD?” he said. “Often when you’re with an ADD kid, you think, ‘My God, they’re just like a manic adult.’ Kids with ADD are often irritable. They’re often manic. But they don’t grow up manic. And manic adults weren’t ADD when they were children. But they’re being labeled bipolar. That’s an enormous label that’s going to stay with you for the rest of your life. If you’re a girl, you’re going to have to take medication that can induce all sorts of ovarian disorders, cause significant changes to your metabolic balance. There are the implications of you being told you have a familial genetic condition, which is going to make you unreliable, unpredictable, prone to terrible depressions, prone to suicide. . . .”
Bryna works at day care centers. “Recently one kid, a foster kid, came in,” she said. “He had been removed from his home for abuse and neglect. And because he had sexualized behaviors, and because he’d been through some moody stuff, somebody said he had bipolar disorder. He fulfilled the bipolar checklist. See? And so they gave him some pretty heavy-duty medication. It slowed him way down, to a drooling fat kid. And they declared the meds a success.”
It eventually became clear that the boy wasn’t bipolar, Bryna said. He was moody and had sexualized behavior because he had been sexually abused. But they were in thrall to the checklist. His overt symptoms tallied with the traits listed on the checklist. This was one random child in a random day care center. A million children have these past few years been diagnosed as bipolar in America.
“Has anyone studied whether bipolar children still get the diagnosis when they reach adolescence?” I asked Bryna.
“Yeah,” she said. “Some do. Others outgrow it.”
“Outgrow it?” I said. “Isn’t bipolar considered to be lifelong? Isn’t that another way of saying they didn’t have it to begin with?”
Bryna shot me a sharp look. “My husband grew out of his asthma and food allergies,” she said.
When I asked Robert Spitzer about the possibility that he’d inadvertently created a world in which some ordinary behaviors were being labeled mental disorders, he fell silent. I waited for him to answer. But the silence lasted three minutes. Finally he said, “I don’t know.”
“Do you ever think about it?” I asked him.
“I guess the answer is I don’t really,” he said. “Maybe I should. But I don’t like the idea of speculating how many of the DSM-III categories are describing normal behavior.”
“Why don’t you like speculating on that?” I asked.
“Because then I’d be speculating on how much of it is a mistake,” he said.
There was another long silence.
“Some of it may be,” he said.
On the night of December 13, 2006, in Boston, Massachusetts, four-year-old Rebecca Riley had a cold and couldn’t sleep, and so she called to her mother, who brought her to her own room, gave her some cold medicine and some of her bipolar medication, and told her she could sleep on the floor next to the bed. When her mother tried to wake her the next morning, she discovered her daughter was dead.
The autopsy revealed that her parents had given her an overdose of the antipsychotic drugs she had been prescribed for her bipolar disorder, none of which had been approved for use in children. They’d got into the habit of feeding her the pills to shut her up when she was being annoying. They were both convicted of Rebecca’s murder.
Rebecca had been diagnosed as bipolar and given medication—ten pills a day—by an upstanding psychiatrist named Dr. Kayoko Kifuji, who worked at Tufts Medical Center and was a fan of Dr. Joseph Biederman’s research into childhood bipolar. Rebecca had scored high on the DSM checklist, even though at the time she was only three and could barely string a sentence together.
Shortly before her conviction, Rebecca’s mother, Carolyn, was interviewed by CBS’s Katie Couric:KATIE COURIC: Do you think Rebecca really had bipolar disorder?
CAROLYN RILEY : Probably not.
KATIE COURIC: What do you think was wrong with her now?
CAROLYN RILEY: I don’t know. Maybe she was jus
t hyper for her age.
11.
GOOD LUCK
More than a year had passed since Deborah Talmi slid her copy of that mysterious, strange, slim book across the table at the Costa Coffee. Tony from Broadmoor called. I hadn’t heard from him in months.
“Jon!” he said. He sounded excited. His excitement sounded like it was echoing down some long, empty corridor.
I was definitely pleased to hear from him, although I wasn’t sure how pleased it was appropriate for me to be. Who was Tony? Was he Toto Constant, who had struck me as the archetype Bob Hare psychopath, charming and dangerous, conforming to the checklist with an uncanny, eerie precision? Was he Al Dunlap, who had, I felt in retrospect, been a bit shoehorned by me into the checklist, even if he had himself laid claim to many of the items, seeing them as manifestations of the American Dream, the entrepreneurial spirit? Was he David Shayler, his insanity palpable but harmless to other people, reduced to a plaything for the benefit of the madness industry? Or was he Rebecca Riley or Colin Stagg, wrongly judged insane because they just weren’t what the people around them wanted them to be? They were just too difficult, just not normal enough.
“There’s going to be a tribunal,” Tony said. “I want you to come. As my guest.”
“Ah,” I said, trying to sound pleased for him.
Brian, the Scientologist from the CCHR, had told me about Tony’s various tribunals. Tony was forever pushing for them, year after year, for the many years he had now been inside Broadmoor’s Dangerous and Severe Personality Disorder unit. His optimism was tireless. He’d try to co-opt anyone he could to his side: psychiatrists, Scientologists, me, anyone. But the outcome was always the same. They’d come to nothing.