Teen Bipolar Disorder and the Abnormal Brain: Making Sense of New Research
Mad in America; Claudia Gold, MD, 7/21/2015
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Two glaring omissions stand out in the recent widely publicized Yale study titled, in the听Yale News,听“.” Using MRI to compare a group of teens with the diagnosis of bipolar disorder according to DSM criteria with a group that did not have this disorder, they found volume decrease in the area of the brain cortex known to be involved in emotional regulation.
The first omission is any mention of the possible effects of medication. While the newsletter does not even mention medication,听听does say that the teens carrying the bipolar were on medication but that “medication was not systematically studied.” The long-term effects of psychiatric medication are unknown. A听听in the听Archives of General Psychiatry suggested that one of group of drugs, the atypical antipsychotics, which are often used to treat bipolar disorder, might themselves be linked to decreased brain volume.
But perhaps the more glaring omission is anything about the early history, or life story, of these teenagers.
听by Harvard psychiatrist Martin Teicher and colleagues demonstrates that mental illness in the setting of what they term 鈥渕altreatment鈥 is a very different entity, in terms of course of illness, response to stress, brain structure and gene expression, than the same DSM named 鈥渄isorders鈥 in the absence of these experiences.
Maltreatment is broadly defined as being 鈥渃haracterized by sustained or repeated exposure to events that usually involve a betrayal of trust.鈥
It includes not only physical and sexual abuse, but also emotional abuse, including exposure to domestic violence, humiliation and shaming, as well as emotional and physical neglect. The incidence of childhood maltreatment ranges from about 14% in one-year prevalence to 42% in retrospective reviews covering the full 18 years of childhood.
The way maltreatment is defined has great significance in the way we think about the connection between childhood experiences and adult mental illness. The word 鈥渢rauma鈥 itself may convey a kind of 鈥渘ot me鈥 response, but when the term is defined in this way, we see that these experiences are, in fact, ubiquitous.
This research shows that it is meaningless to talk about mental health disorders, as defined by the DSM system, without knowledge of this early life experience.
But perhaps more importantly, the language we use has great implication for treatment. The Yale study authors recognize that the brain is 鈥減lastic鈥 so prevention is possible. But without recognizing the role of early life experience in development of the brain abnormalities, the treatment might very well end up being a drug. 听Broadening our understanding of the cause of the brain abnormalities, as Teicher鈥檚 work demonstrates, shows that true prevention lies in supporting young families, and intervening early in families where children are at risk for experiencing maltreatment.
Teicher recommends starting with the way we name these disorders:
听We propose using the term ecophenotype to delineate these psychiatric conditions. We specifically recommend, as a first step, adding the specifier 鈥渨ith maltreatment history鈥 or 鈥渨ith early life stress鈥 to the disorders discussed here so that these populations can be studied separately or stratified within samples. This will lead to a richer understanding of differences in clinical presentation, genetic underpinnings, biological correlates, treatment response, and outcomes.
The Yale study, tellingly published in the journal 鈥Biological Psychiatry鈥 gives the impression that these 鈥渄isorders鈥 are biological in the way that, to use a frequent comparison, diabetes is. This view is a disservice to our humanity; to the way our lives have meaning because of our relationships with others and the stories we tell. The first and critical step in prevention of 鈥渂ipolar disorder鈥 is to recognize that these stories exist, and to make space and time to hear them.