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Bipolar Disorder and Adolescents

Symptoms of bipolar disorder in children and adolescents may look like other disorders

Traditionally bipolar disorder has been thought to first show in early adulthood – and more often in females.  Bipolar disorder was considered to be quite rare as few as 20 years ago, to be more exact. The first emergence came in the early 20s, mainly in females. But, our knowledge about bipolar disorder has grown rapidly in the last 20 years.

Instead of the single manic-depressive diagnosis – which included diagnostic criteria of both depressive periods, alternating with manic periods – described as “euphoria”?

Those who did not have clearly rhythmic, alternating periods of a “happy” and frantic manic phase with a classic depression period were mishandled, misdiagnosed, mistreated, or dismissed.

Bipolar ChildrenIn addition, it wasn’t really known that bipolar disorder could start in adolescence or even childhood, or that there are different types of bipolar disorder.  Today, it still isn’t “officially” recognized in the “psychiatric bible” – the Diagnostic Statistical Manual of Mental Disorders (DSM), but at least more practitioners do know that it exists.

Today, we don’t exactly know what causes bipolar disorder (only that there is a genetic link of some kind, and often some past trauma). But, we can at least identify adolescent and childhood bipolar illness.  We also recognize a variety of different types of bipolar disorder (Such as mixed manic episodes, rapid cyclers, people without a depressive phase, hypomania, dysphoria rather than euphoria and cyclothymia). We also have a “catch-all” type – Bipolar NOS or “not-otherwise-specified”.

Adolescent or childhood bipolar disorder is official known as: “early onset bipolar disorder”.  In fact, childhood bipolar disorder can be more serious than a similar disease in adults and may have slightly different symptoms.

Symptoms of bipolar illness in children can often be more severe, and the cycling period may be more frequent.  Children also have more mixed episodes.  Children also have slightly different symptoms – so even the depression phase of the cycle may not be obvious.

Pediatric patients (children and adolescents) with bipolar disorder may have:

Bipolar Disorder in Children•    Abrupt mood swings
•    Periods of hyperactivity followed by lethargy
•    Intense temper tantrums
•    Frustration
•    Defiant behavior
•    Chronic irritability

These symptoms have to appear in more than one setting (school and home) and cause “distress”.

The problem is that many of these symptoms may look like other disorders.  They might be disorders such as ADHD, childhood depression, anxiety disorder, obsessive compulsive disorder, conduct disorder, premenstrual syndrome, oppositional defiant disorder and others. The danger might come from a misdiagnosis and improper treatment.

Bipolar disorder is treated with anti-manic agents (lithium), anti-convulsants (Depakote, lamotrigine) or atypical antipsychotics (Abilify, Risperdal).  In many cases, anti-depressant won’t be needed.  Treatment for other disorders like ADHD or depression may make bipolar disorder worse. Childhood bipolar disorder is something that desperately needs treatment as the distress caused to the patient, and the family can predispose the youngster to

•    Drug or alcohol abuse
•    Stealing
•    Involvement with law enforcement
•    Poor social integration
•    Poor academic performance
•    Suicidal tendencies
•    Premature sexual behavior

The Balanced Mind has a good self-check list of symptoms that can help a parent or a teen decide if bipolar disorder might be an issue.  Self-testing is not always accurate and should be discussed with a doctor, (preferably with test results in hand).  Not all doctors accept pediatric bipolar disorder. Parents may have to seek advice from more than one mental health professional and be aware that insurance may not cover the illness.

Melissa Lind

What Type of Bipolar Disorder Is It?

Each bipolar disorder illness is unique!

Uniqueness of Bipolar DisorderWhen nearly anyone thinks about bipolar disorder, they think of the symptoms of “regular” bipolar disorder.  Not that any person with bipolar disorder is “regular” (and most would not want to be), but there are several different subtypes of bipolar disorder.

One big problem with bipolar disorder is that each illness is unique.  Psychiatrists may classify them into categories – but they don’t always fit.  Here are some case scenarios: (bipolar episodesbipolar groups)

•    Jennifer has episodes where she is extremely agitated and unhappy and never seems to sleep very much.  These periods seem to last for a long period of time – but can alternate with months where she is simply unhappy and doesn’t feel like doing anything.
•    Max has had periods of depression before.  A lot of times, they go away after a couple of months and then he seems normal but recently he “disappeared” for a couple of weeks after some really bizarre behavior.  His friends never knew that he was any kind of bipolar until he told them he had been at the hospital.
•    Ben has periods of depression that can last for several months but when he is not depressed, he is productive and seems quite outgoing.
•    Sandra’s mood state can switch erratically.  One day she is all about shopping and the next time you call her, she is still in bed at noon.   This is a constant issue – and you never know what you are going to get.

These are three examples of bipolar disorder that don’t seem to fit the “normal” pattern.  None of these patients seems to be “regular” bipolar.

Bipolar disorder is defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM) as:

Bipolar Disorder TypeBipolar I Disorder: manic or mixed episodes that last at least 7 days – or if manic symptoms are severe enough to need hospitalization.  This, usually, includes periods of depression that last at least two weeks.
Jennifer and Max both fit into this category.  Even though Max never had a severe manic episode, having a bipolar episode that warrants medical attention, he qualifies for the Bipolar I category.  Jennifer has mixed episodes – rather than euphoria or traditional mania – she has periods of “dysphoria” where she is agitated, irritable and irrational but with an excess of energy.

Bipolar II Disorder: depressive and hypomanic episodes in a pattern – but manic episodes are not severe.
Ben has Bipolar II disorder.  He has periods of depression that are debilitating, but his non-depressed periods are quite productive, and he doesn’t exhibit manic behavior.

Bipolar Disorder Not Otherwise Specified: (Bipolar Disorder NOS) symptoms of illness don’t meet any other group, but the symptoms are clearly not within the standard range.
Sandra has BP-NOS.  She is what is commonly called a “rapid cycler,” meaning that she switches back and forth from mania to depression much faster than other people with bipolar disorder.

There is also a very mild form of bipolar disorder known as cyclothymia.  It is a cyclical pattern of hypomania alternating with periods of mild depression.  Many people would not even realize this is a problem.

Bipolar disorder is hard to classify.  It may be easy to determine that someone has a problem – but the uniqueness of each bipolar case makes it more difficult for even a patient to identify with the diagnosis.  Each type of bipolar disorder is, usually, treated the same medically. With an anti-manic agent (Lithium), anti-epileptic (Lamictal, Depakote) or atypical antipsychotic (Abilify, Zyprexa) – and sometimes with an antidepressant.

Melissa Lind

Cutting – An Actual Mental Disorder

Non-Suicidal Self-Injury

A lot of people are shocked and horrified at the thought of self-mutilation and for many years “cutting” was categorized only as a symptom of Borderline Personality DisorderBPD, as you may know, has symptoms of unstable personal relationships, impulsivity, and extreme mood changes (different from Bipolar disorder as they can change on a dime and swing wildly).

The new issue of the American Psychiatric Association’s Diagnostic and Statistical Manual, Fifth Edition or DSM-5, includes it as a separate diagnosis of Non-Suicidal Self-Injury (NSSI).  Research has suggested that NSSI can occur independently of BPD but is also often a co-existing or co-morbid illness, occurring alongside BPD, Bipolar Disorder, one of the many anxiety disorders or with other disorders such as anorexia or bulimia.

Cutting DisorderI am the mother of pre-adolescent children – who are beginning to believe they know all about people who act “weird” or do “weird” things (their words, not mine).  My daughter has recently talked about the “EMO” kids – which as a dumb mom, I had to figure out was a social group of kids who were “emotionally dark.”  She includes in her description of an “EMO” as “you know, like kids who are cutters.”  It is stereotypical to think that they all wear black clothing and heavy eyeliner – as some may – but many do not.

Some people who have the disorder would never be suspected of such – but then we are also sometimes surprised when someone who seems to have everything commits suicide, only to find that under the polished exterior was extreme anguish.  Often, cutting will be dismissed as a “stage” and it may be a “stage” – but often it is not.  Many patients – have arms or hips full of patterned scars – proving that it is often a condition all to itself.

Cutting Disorder - Mental IllnessSelf-mutilation most often starts in the early teen years when adolescent emotions are at their height – but often extends well into adulthood.  The majority of “cutters” are female – but not all.  There is often a co-existing mental illness and may have a family history component – but also often occurs following events of abuse – including sexual, physical or emotional abuse.  Sudden life changes such as unemployment or divorce – and isolation may trigger an occurrence.

People who “cut” often express a desire to “feel” as if they cannot truly attach to their own emotions.  Others will say they “cut” to kill the pain – this is because the act of producing pain also causes the body to release endorphins (the body’s natural painkiller) that makes them feel better.  Unfortunately, even though the action may induce temporary euphoria – it is often followed by guilt and a return of the negative feelings.

NSSI is defined as:

• 5 or more days of intentional self-inflicted damage to the surface of the body without suicidal intent – in the past year.
Patients must be intending to:
o Seek relief from negative feelings or thoughts and/or
o Resolve interpersonal problems and/or
o Induce a positive emotional state
• The behavior must be associated with 1 of:
o Interpersonal problems
o Negative thoughts or feelings
o Premeditation
o Ruminating on injury (obsession)

NSSI includes not only “cutting” but also burning, hitting or punching, head banging, biting, non-aesthetic piercing or carving of skin (tattoos and body piercing don’t apply), pulling out hair or other “topical” mutilation.  If a patient has expressed suicidal thoughts or shows suicidal tendencies – it is not classified as NSSI as the intent of a person with NSSI is not to commit suicide.
NSSI should be first viewed as a serious medical condition that truly requires treatment.  It may be resolved by treating an existing co-morbid psychiatric condition – but likely it will also require psychotherapy to resolve some of the underlying issues.

Definition of Self-injury/cutting (Mayo Clinic)

Cutting and Self-Harm: Warning Signs and Treatment (WebMD)

If you see signs of NSSI or “cutting” in a child, teen, or adult that you know – encourage them to seek help.

Melissa Lind (WriterMelle)

An Actual Mental Disorder – Cutting

Bipolar Disorder – Euphoria vs. Dysphoria or Mixed Episode

Most symptoms of Manic Episodes appear to be positive

Manic-depression or Bipolar disorder is usually perceived on of two ways – a person who alternates between depression and euphoria – or a person who alternates between depression and craziness.

Often a person who is told that they are bipolar will identify one of those two states – and will object based on the fact that they have never been “euphoric“, and they have never been actually psychotic or “crazy”.

Bipolar disorder or Manic-Depression is defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) – “the Bible” of psychiatric disorders – as “…clinical course that is characterized by the occurrence of one or more Manic Episodes…”

7 “points” retrieved from: DSM IV Criteria for Manic Episode – Food and Drug Administration

A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least one week. With three or more of:

1. Inflated self-esteem or grandiosity
2. Decreased need for sleep (e.g., feels rested after only three hours of sleep)
3. More talkative than usual or pressure to keep talking
4. Flight of ideas, or subjective experience that thoughts are racing
5. Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. Increase in goal-directed activity (either socially, at work or school or sexually) or psychomotor agitation
7. Excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

There is another specifier – “The symptoms do not meet criteria for a Mixed Episode” which is left out in a lot of thought processes.

Bipolar - EuphoricOne problem that is often encountered when diagnosing Bipolar disorder – or when trying to convince someone who has Bipolar disorder that they do, indeed have the illness – is that most of the “symptoms” of a Manic Episode appear to be “positive” or “happy.”  If you examine the wording – it looks on the surface and is often described as periods of “Euphoria” or extreme happiness.

In truth, many people with Bipolar disorder don’t have periods of “euphoria,” they don’t have what is perceived as “inflated self-esteem or grandiosity“, and they don’t seek out “excessive involvement in pleasurable activities.”  They may have “dysphoria,” they may believe that they have to do everything themselves, they may experience psychomotor agitation…they may be in a really active bad mood.

This is a state of “dysphoria.”  It is also called a “mixed state” where the Manic Episode and the Depressive Episode occur at the same time.  Features may include the racing thoughts, irritability, lack of sleep, psychomotor agitation of a Manic Episode but also include anhedonia or lack of enjoyment, inappropriate guilt, or suicidal thoughts which are symptoms of depression.

Unfortunately, this disconnects in presentation, and lack of awareness of mixed states (in both the patient and some professionals) often gives the bipolar patient an “easy out” in acceptance of the diagnosis.

Melissa Lind

Mixed Episode or Manic Episode with Mixed Features is given too little attention!

Curse of the Ferrari Brain: the Other Side of Bipolar Disorder

Manic Episode: Another Side of Bipolar Disorder.

Welcome back, my friends!

My apologies for the extended absence. I’ve been very busy with other projects, which I’ll have to return to soon. Also, I wanted to make sure this article was perfect, because this one’s a little tricky.

So far, most of my articles have focused on depression. As someone with type II bipolar disorder, that’s the side I know best. Also, it’s the side that’s easiest for a person who doesn’t have bipolar disorder to understand. Everyone has been bummed at some point. Wanna understand bipolar depression? Take your depression, magnify by about a jillion, and there ya go. Pretty easy to understand, right? The other side of the coin isn’t as straightforward. A good metaphor, I hope, will make it easier to understand.

Let’s say that the average human brain is like a Volvo.The Volvo gets great mileage and is one of the safest, most dependable cars on the road. You wanna get to work on time, day after day and with very little fuss and worry? A Volvo is the car for you.Average human brain - Volvo

The bipolar brain is more like a Ferrari.

Bipolar brain - like a Ferrai

“Farrah”

The Ferrari is fast and flashy. Its sleek, predatory looks practically demand that you drive it at dangerous speeds. You want to make it to work in forty seconds flat? Then the Ferrari is the car for you. Unfortunately, it guzzles gas like your Aunt Janie guzzles gin and tends to spend more time in the shop than on the road. The insurance premiums are astronomical and you are almost guaranteed to wrap it around a tree someday.

Now then… bipolar depression is like the times when the Ferrari is in the shop. It’s up on the lift, and you’re going nowhere. You can’t even show it off by rolling it into your driveway. Not only that, but you gotta walk to work while all the Volvo drivers practically blaze by at 35 mph. In your mind’s eye, they laugh at you as it starts to rain. Your anxiety tells you they are ALL aiming for puddles near you, and the occasional sociopath WILL soak you for his or her amusement.

But then the shop owner calls. Your chariot awaits! You go down to the shop, pay the exorbitant bill, and fire up that 16-cylinder Italian ego trip.

“I’ve missed you, Farrah,” you say, not caring about the look the shop owner gives you. If HE had a Ferrari, he’d name her Farrah, too. Your foot barely taps her gas pedal and she purrs delightedly. She’s missed you, too.

“Good girl,” you say, then ease Farrah’s shifter into first, the action so smooth that instinct alone tells you that she’s out of neutral. You pull out of the shop’s parking lot and into traffic. At first, she’s just glad to be off of that horrible rack and back on the road where she belongs, but every red light, every school zone is an irritant, and sand only makes pearls in oysters. Sand in an engine is death, but Farrah complies and stays below the speed limit… for now.

As you pull into the parking lot at work, all eyes turn to you and your beautiful machine. You pull into your space and reach for the key to kill her ignition, but you stop short.

“It’s been so long. Just once,” she begs. “Pretty please?”

You know this is how it starts, but you’re still in control. Just once won’t hurt anything, right? It’s not like you’re doing anything dangerous. Besides, what’s the point in owning a car like Farrah if you can’t show her off?

With Farrah’s gears in neutral, your foot presses hard on her accelerator and her engine screams ecstatically. Those who weren’t looking before certainly are now. Many are impressed. Many others are jealous. And Farrah, at long last, feels warm and tingly.

“Mmm… baby,” she purrs. “You’re the only one who knows how to touch me right. Again. Please.”

“Sorry, babe,” you say, a little defeated. “I gotta go to work now.”

Farrah pouts as you shut off the engine, sputtering just a little to let you know she’s put out. You promise her a full tank of premium and a stretch of deserted highway tonight followed by a loving sponge bath. You know that will make her happy, but she’s still sulking.

When five o’clock rolls around, you dash into the parking lot to find Farrah waiting. It’s a beautiful day, so you decide a little sun would be good for you both. You drop her top, fire up her engine and gun the accelerator—just a little—as you exit the parking lot. No harm done, and at last you’re out on the open road where both of you are more happy… for all of about twenty seconds.

Gridlock. No one’s going anywhere fast. The traffic jam drives you nuts, but you try to smile regardless. You’ve gotten so many “nice car, man” comments from the Volvos that your ego has slipped into overdrive. Eventually, though, it gets old. You’re sick of hearing how nice your car is. You wanna FEEL how nice she is, and in this traffic, how can you? You can’t even get out of first gear! You’ve got to MOVE!

Speed isn’t Farrah’s only good quality. She maneuvers like… well… like a gdamn Ferrari! Each time you see an opening in traffic, you seize it. At first, you make sure there’s plenty of space, but soon ANY amount of space is enough as long as it moves you forward. Other drivers stop saying “nice car” and start saying “watch it, a-hole!”

“Fuc.. them,” Farrah says. “They’re just jealous, baby.”

Finally, you come upon a stretch of open highway, just begging to be devoured. You stomp Farrah’s accelerator and instantly know that what she said is true. Who wouldn’t be jealous of this speed? This freedom?

“At last!” she screams as you tear away from the nightmare behind you. The wind whips your hair as the speedometer climbs. This is what she’s DESIGNED to do, you tell yourself. It’s just you and Farrah and all is well in the world. You drive off into the sunset, victorious, just like in the movies.

But real life isn’t the movies, and sunset only means the end of the day, not the end of the film. You pull into your garage and park Farrah for the night. You have to work in the morning, but you’re too wired to sleep. You try watching TV. You try a hot shower. Nothing works. Sleep just won’t come, not with Farrah calling to you from the garage.

“Sleep is for those Volvo people,” she says, spitting out the word Volvo as if it had the arsenic taste of bitter almonds. “You’re better than them, baby. All you need is me. Come on. Let’s go for a drive.”

But you know better. You’ve been down this road before. With the help of a few Benadryl, you ignore her voice and drift off, but your sleep isn’t like real sleep. Your body lays motionless but your mind spins like a screeching tire. Dreams and reality melt together for a few fitful hours of sleep and traffic nightmares.

You’re awake long before sunrise, but you force yourself to stay in bed until the alarm goes off, then you’re up in a flash. You sing in the shower. You skip breakfast. You rush to the garage.

“Good morning, sexy,” she says. “Ready to play?”

“Are you?” you ask, smirking as you sink into a kid leather bucket seat that fits you like a glove. You deftly slip your key in her ignition and give it a twist. As you pull on your driving gloves, the temperature gauge begins to rise. “Like that, do you?”

“Sailor baby, you get me hotter than Georgia asphalt,” she purrs.

You bet your sweet a-h I do, you think as the garage door rises to release you from your prison. Your house isn’t your home. Here with her. This is home. This is where you belong.

Now, there are two different ways this scenario can end…

END #1

The garage door is barely up before you’re skidding out of the garage and into… another fu–ing traffic jam! No! No no no no NO NO NO!!! You honk madly. Farrah’s engine growls at any Volvos who get too close. The admiration in the Volvo drivers’ eyes is gone. Today, they look upon you with fear, but you don’t give a damn. They’re just in your way, anyway, right? One Volvo tries to pull in front of you. You stomp the accelerator and he weaves out of your way just in time.

“My lane, a-hole,” you shout. “Mine!”

Your lane or not, the traffic light turns red and you’re stuck. Time stands still. You scream and rev your engine, both you and Farrah quickly reaching redline. The temperature warning light comes on, but you ignore it. It just wants to slow you down, too. You smell oil smoke, but don’t care.

“Go baby,” Farrah shrieks. “Go! Go! GOOOO!”

KABLAM!

Something snaps. Thick gray smoke boils from the engine compartment. Farrah’s engine chokes and sputters as the light turns green. She’s got just enough strength to ease to the side of the road.

“This is all your fault,” she says, dying. You weep at what your anger has done.

The tow truck guy clucks his tongue as he winches Farrah’s front end into the sky. “Damn shame,” he says. “Such a nice car.”

In your mind, you finish his sentence. If only you knew how to treat it.

Welcome back to depression.

Or, it could end like this…

END #2

The garage door is barely up before you’re skidding out of the garage and onto the open road. Your floor it and Farrah jumps over the speed limit like an antelope. There’s no traffic, no cops, nothing but miles of open road. You cut each corner closer, but not because you’re out of control. You do it because you’re fucking amazing! Every move you make is the right one. The world is yours and everything is perfect…

…until you run out of gas in the middle of nowhere during a thunderstorm and have to walk to the nearest payphone (you forgot your cell in your hurry to hit the road) only to find you don’t have any change, so you have to walk all the way back to your house. Once at your house, you reach into your pocket and find that you’ve lost your keys somewhere along the way.

Welcome back to depression.

George Carlin, one of the funniest men to ever live, once said that the cliché phrase “more than happy” sounded like a medical condition.” Well, he was right. “More than happy” is called euphoria, and euphoria is sometimes a symptom of a manic episode. Sometimes, bipolar disorder feels WONDERFUL. At the beginning of the upswing, you have hypomania, and hypomania can be very, very good. It’s your chance to really shine.

Sometimes, when you’re hypomanic, you are the life of the party—charming, witty, friendly and filled with energy. Your mind becomes razor sharp, your reflexes like those of a kung fu master. You make friends easily, accomplish incredible amounts of work, and have flashes of brilliance that astound and amaze everyone around you. I LOVE it when hypomania works that way!

Sometimes, however, it doesn’t. Sometimes when you’re hypomanic, you are the total buzzkill—cranky, bitter, sullen… and yet still filled with energy. Your mind is sharp, but it’s your tongue that’s the razor. You’re nerves are so jittery you twitch. Fine silk feels like sandpaper against your skin. You still have that keen focus, but all you focus on is the neighbor’s g-damn stereo and if you had one ounce less of willpower, you’d crash right over and shove the thing straight up his a-h. But that wouldn’t fix the problem, because dammit, you’re pissed and you’re gonna stay that way. I HATE it when hypomania works that way.

Now, if you’re bipolar type II like me, hypomania is the ceiling. You hit it, stay there for anywhere from a few hours to a few weeks (depending on how rapidly you cycle) and then spiral back down into depression. If you’re type I bipolar, then hypomania is just the beginning.

Hypomania basically means “little mania,” so for a full-tilt manic episode, take my description of hypomania and magnify it exponentially: the occasional sleepless night becomes days on end without sleep; the occasional ego trip gives way to full-blown narcissism and delusions of grandeur; euphoria becomes psychosis; irritability becomes hostility and anxiety becomes outright paranoia. Some even experience hallucinations.

No matter how high the ladder goes, unless you drop dead from exhaustion (which does happen occasionally) or wrap your Ferrari around a tree (yes, those on the upswing really do tend to speed) then you’re going to find yourself right back where you started. For some, that’s a relatively normal mood. For others, it’s welcome back to depression. Hope you enjoyed the ride.

And on that note, I hope you, my readers, have enjoyed the ride. I’ll be taking a break from this blog now, but I’m sure I’ll be back I’ve got so many other stories, poems, screenplays and articles to write. I’ve got sketches to draw and music to compose. I’ve got a life without bipolar disorder… or at least a life without thinking about it all the time.

The one thing I want you to remember most of all is that NO ONE IS A DISEASE. They are a person with a disease. Their disease is not their life, at least not unless they allow it to be. Don’t do that, folks. It sucks. Be people. People are OK unless they won’t turn their g-damn stereos down.

Keep fighting, folks!

-Bruce Anderson