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Comments and Controversies


Overlooked diagnoses

Vol. 10, No. 04 / April 2011

Not all mood swings are bipolar disorder” (Current Psychiatry, February 2011, p. 38-52) is a highly relevant and helpful article with a glaring omission. There is no mention of the emotional lability and behavioral dyscontrol associated with abuse, trauma, and invalidation. “Mood swing” symptoms are prominent in developmental trauma disorder and complex posttraumatic stress disorder, although these diagnoses are not yet in the DSM. Unfortunately, the effects of abuse, trauma, and invalidation often are unrecognized in the differential diagnoses of these children and too often the “kneejerk” diagnoses of bipolar disorder, oppositional defiant disorder, and attention-deficit/hyperactivity disorder are inappropriately assigned, delaying the implementation of trauma theory-informed therapy.

Bradford B. Schwartz, MD
Private Practice
York, PA

The authors respond

We thank Dr. Schwartz for his comments regarding emotional lability and behavioral dyscontrol associated with children who have experienced trauma, abuse, and invalidation. An assessment for possible trauma always is part of the initial assessment of each child referred to our program. None of the patients discussed in our article had a history of abuse or trauma. Referrals to our pediatric mood disorders program initially are screened through the Cincinnati Children’s Hospital Psychiatric Intake and Response Center, which functions as triage, gathering psychiatric history, including assessing trauma, and children with a history of abuse and trauma are referred to other clinicians specializing in this area. But Dr. Schwartz’s point is well taken—trauma or abuse always should be part of the differential diagnosis of children and adolescents referred for mood swings.

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

Erin Monroe, CNS
Clinical Nurse Specialist
Division of Psychiatry

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

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