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The Bipolar Teen
What You Can Do to Help Your Child and Your Family
By David J. Miklowitz, Elizabeth L. George
The Guilford Press Copyright © 2008 The Guilford Press
All rights reserved.
"What's Happening to My Teenager?"
Emilia, a 44-year-old single parent who worked as a waitress during the day and managed a health care supply business at night, was getting increasingly concerned about her son, Carlos, age 14. For the last 2 weeks Carlos had been "wired" and "snapping at everyone." He would explode into tirades when the Internet went down for even a few minutes, if his sister took too long in the bathroom in the morning, or if the dog wanted his attention when he was busy. Emilia suspected he had been staying up most nights well after she had gone to bed and on at least two occasions had not gone to sleep at all. She felt nervous and fearful about an odd stare he had developed and about his unusual ideas about religion, death, burial, and the afterlife. Carlos said he believed in reincarnation, which was not in itself unusual, but he also believed he could communicate with his former soul via email. He had become more irritable and disrespectful of her since he had turned 13 (for example, by swearing and occasionally shoving her out of his way), but this new behavior was a big change for him. She wondered whether she had been in denial about the milder odd behaviors that she had been seeing in her son for a long time.
Emilia decided she was not spending enough time with her son or her 12-year-old daughter, Yolanda. One Saturday, Carlos awoke at noon as usual after having been up until 4:00 A.M. the night before "doing experiments in instant messaging." Because Yolanda was at a birthday party, Emilia suggested that they see a movie with one of his friends. Although she was initially delighted that he wanted to go, she felt hurt and frustrated when an innocent conversation about which movie to see turned into a shouting match.
After the movie, Carlos said good-bye to his friend and they headed home. Carlos took his soft drink into the car and began sloshing the ice around loudly in his mouth. Suddenly, he angrily turned to her and said, "I want to go to Pizza Hut." She explained calmly that she had defrosted a steak and didn't want it to go to waste and that they had already spent $25 on the movie, popcorn, and other snacks. Carlos started yelling that he was hungry and that she'd better turn the car around and go back to Pizza Hut "or else." Emilia couldn't believe her son was demanding that she now take him out for dinner and said sharply, "You know I never give in to you when you get like this."
Carlos dumped his soft drink in her lap and then picked up a stray auto map binder that had fallen out of her glove compartment and hit his mother on the head with it. She stomped on the brakes and the car swerved. She pulled over, and they began a screaming match during which he scratched her. She felt angry, hurt, and at the same time feared for her physical safety. To escape a situation that had escalated beyond her control, she finally agreed, against her better judgment, to take Carlos to Pizza Hut.
He ordered his food and ate it quickly. They got back in the car. They were silent for the rest of the evening. When she got home, Emilia poured herself a stiff drink and drank it alone in her bedroom. She heard a knock on her door. "Mom, can I come in?," Carlos said in a plaintive voice. She let him in. He sat on the edge of her bed shaking, with the empty stare she had seen earlier that week that had made her shudder. He said, "Mom, what happens when you die? If you kill yourself, does that mean you'll go to hell?"
Emilia was devastated. What had made her son act this way? Was he just going through a strange teenage phase? Was she a bad parent, and should she have seen this coming years ago? Where could she get help? And what would happen to her and her daughter while they were trying to deal with this overwhelming problem? Would they be able to stay together as a family? Emilia desperately wanted answers, but scanning websites and reading brochures didn't give her nearly enough information.
Having a teenager who is developing or has developed bipolar disorder is extremely upsetting, frustrating, even heartbreaking. The ups and downs of adolescent bipolar disorder are difficult to manage, and its rippling effects on the family can exhaust your energies. Whether your teen is having mood problems but hasn't received a diagnosis, has already been diagnosed but is just starting treatment, or has been in treatment for some time, you'll benefit from knowing as much as possible about the adolescent form of this disorder. Knowing how to recognize episodes of the illness before they build, how to get your teenager the most up-to-date treatments, and how best to respond so that your teen's condition is more likely to stabilize will boost your confidence and energy.
Knowing the facts about adolescent bipolar disorder will help you accept and learn to cope with it, and, in turn, help your teen and other family members come to terms with the illness. Each of the following chapters describes the problems you and your teen and family are probably facing, and provides a set of solutions we've found effective in our work with families like yours. If your son or daughter was diagnosed with bipolar disorder as a child, you may already have a pretty firm grasp of the fundamentals and prefer to go straight to the chapters of current interest. But chances are that you'll find some new information on the fundamentals. Everything in this book is based on up-to-date research findings as well as clinical wisdom from our own practices and those of our colleagues.
"What Is Bipolar Disorder?"
If you're not yet familiar with the full list of bipolar symptoms and how the disorder is diagnosed, you'll find complete explanations in Chapters 2 and 3. But essentially bipolar disorder is an illness involving extreme fluctuations in mood, usually from the highest of highs to the lowest of lows, like what Carlos was experiencing. The highs are called mania and the lows depression, which is why the disorder once was and sometimes still is called manic-depression.
Although bipolar disorder is difficult to deal with at any age, in our experience it is particularly challenging for teenagers and their families. For example, the shifts from high to low or low to high can occur even more quickly in teens than in adults. As Emilia observed in her son, teens can quickly change from elated, happy, and highly energized to angry, irritable, or morose, with suicidal despair. Some teens even experience mania and depression simultaneously. When manic, teens, like children and adults, experience euphoria, intense irritability, an inflated sense of self (grandiosity), increased energy and activity, rapid speech and thinking, distractibility, impulsive and reckless behavior, and a decreased need for sleep. When depressed, they feel intensely sad, lose interest in life, feel fatigued, slowed down, guilty, hopeless, and suicidal; they cannot sleep or they sleep way too much. For kids who are already undergoing huge developmental changes, these symptoms create an enormous burden in their young lives.
It's hard to say how many teens actually have bipolar disorder at any one time because so much depends on accurate diagnosis. Many people are not diagnosed until years after the symptoms appear—or at all. We know that about one in 25 adults (4% of the population) has bipolar disorder and that about half of these develop bipolar disorder in their childhood or teen years. The average age at first onset of bipolar disorder is between 15 and 19. This means that there is a good chance your teen is not the only one in his high school class who is suffering the mood swings of bipolar disorder.
Whoever they may be, teens with bipolar disorder usually have significant difficulties in school, not just at home. People with the disorder—young and old—have trouble managing their work, relationships, and family life. They are often codiagnosed with disorders like attention-deficit/hyperactivity disorder (ADHD; as in Carlos's case). Others have anxiety disorders, substance (drug or alcohol) abuse, or learning disabilities, all of which can complicate the process of getting an accurate diagnosis and appropriate treatment.
Fortunately, though, we're learning more and more about how to help teens with bipolar disorder, both with medication and with coping methods that pick up where medicine leaves off. Sharing them with you is the goal of this book.
In Part I you'll find up-to-date information about the symptoms, causes, and course of bipolar disorder over time. What does the disorder look like, and how is it experienced by the bipolar teen (Chapter 2)? How is it diagnosed (Chapter 3)? How will you experience it as a parent, and how will it look to other members of your family, like siblings (Chapter 4)? How does the disorder look at different stages of development? What happens to bipolar teens as they enter adulthood?
"Why Is It So Hard for Anyone to Tell Me What's Wrong?"
Emilia took Carlos back to see the psychiatrist who had evaluated him when he turned 13. That's when he was diagnosed with ADHD, a diagnosis that had also been suggested by an elementary-school teacher. The physician met with Emilia and listened sympathetically, but seemed uninterested in her recounting of the increasingly hostile interactions she had been having with Carlos. He met briefly with Carlos, who said little other than "I just get pissed off sometimes."
Carlos's psychiatrist told Emilia that he still believed Carlos had ADHD. He renewed Carlos's prescription for Adderall, a stimulant medication, and recommended he start taking Zoloft, an antidepressant, for his morose mood.
The parents we work with have usually been told many different things about what is wrong with their teen. Most have been told at one point or another that their teen has ADHD. Often this is true, although not always. Many are told that the teen is just depressed, anxious, or going through the ups and downs of growing up. You may have gone through numerous lengthy evaluations where the same questions were asked again and again, only to be told that your teen was going through "growing pains" or "a phase." The truth is that the distinction between bipolar disorder in teens and other disorders—and even between bipolar disorder and normal teenage development—is very hard to make (see Chapter 4). Professionals are not always reliable in making this distinction.
Securing an accurate and reliable diagnosis is the first step toward obtaining proper treatment for your child. Fortunately, there are things you can do to maximize your chances of getting an accurate diagnosis, but this process is still fraught with the potential for trial and error. Some studies have found that the lag time between the onset of bipolar disorder and getting first treatment for it can average 8–9 years! This typically happens, as it did with Carlos, when the child is repeatedly treated for the wrong conditions because he has never had the benefit of a proper diagnostic evaluation.
If you've had this experience, you, like Emilia, may feel frustrated and angry at the mental health system. But you may be able to resolve your doubts and answer nagging questions by reading Chapter 3, where you'll learn how doctors diagnose bipolar disorder in teens and how they distinguish it from ADHD, oppositional defiant disorder, and a host of other mental health complications. You'll learn how to get a proper referral for a diagnostic evaluation, what questions you should ask of the mental health provider who performs it, and what you can do if you're not satisfied with the results.
You'll become familiar with the term comorbidity, which means the codiagnosis of two or more disorders in the same person (for example, bipolar disorder in conjunction with ADHD). Knowing about illness comorbidities will help you select among the various treatment alternatives for your teen because the medications recommended for comorbid illnesses are often quite different. Hopefully, you will feel less isolated by knowing that many other parents have gone through the long and often frustrating process of finding the right diagnosis for their teens.
Still, one of the greatest difficulties associated with bipolar disorder is its effects on family life. You, and most parents coping with the illness, probably feel considerable stress and have had to make great sacrifices financially, practically, or emotionally. Emilia stopped inviting friends over for fear that she would be embarrassed by one of Carlos's "meltdowns." Chapter 4 offers a frank discussion of how bipolar disorder will affect your family. What are the various stages families go through in learning to accept the realities of the disorder? How will it affect your teen's healthy siblings? How can your family work to recognize your teen's strengths despite the disruption caused by the illness? Although your situation may differ from those described, they will give you some ideas (which will be built on later) for dealing with the stress caused by the illness.
"Why Can't I Get a Handle on What This Illness Is and Is Not?"
Before I was diagnosed, I felt like my life was a 100-piece jigsaw puzzle. Now it seems like 1,000 pieces and the first 100 don't even seem to belong to the same puzzle.
—A 17-year-old teen with bipolar disorder
Kids with bipolar disorder do all the things normal teens do: they argue with their parents, take unnecessary risks, experiment with drugs or alcohol, and have mood swings. How do you know when your child is behaving like a normal teenager and when he or she is starting to become manic or depressed? What is the teen experiencing internally, and how might that be different from what healthy teens experience?
Emilia went back and forth between believing there was something wrong with Carlos and believing he was just an annoying teen. Carlos argued this point fervently: "I don't act any different than any of my friends. It's just you who freaks out, unlike their parents."
To make matters even more complicated, once you become acquainted with the disorder, you may find yourself overly concerned that every small change in your teen's behavior heralds a new episode of illness. This is an understandable confusion, and it's easy to err in one direction or another. Even professionals, including us, sometimes mistake a normal reaction to a stressful situation for the beginning of mania—or, worse, mistake a burgeoning manic episode for normal adolescent behavior. Chapter 4 offers the wisdom regarding this tough distinction that we've collected with the help of many bipolar adolescents and their families. When you see your teen start to act angry or defiant, it helps to have some guidelines to fall back on in determining whether it's the normal assertion of independence or the extreme, unfocused irritability that is a key symptom of bipolar disorder.
"Why Is This Happening to My Child?"
In the 2 weeks immediately after Carlos started taking Adderall and Zoloft, he started getting worse. For nearly a week, he stayed up most of the night without any need to catch up on sleep during the day. He said that sleep was a waste of his time. He seemed constantly angry and on the brink of hitting Emilia. He knocked over a lamp and slammed doors. After he verbally threatened Yolanda, Emilia began to fear for her daughter's safety. He talked incessantly about a book he had obtained on occult powers and witchcraft. He started collecting odd fragments of wood and trash and used them to build a prayer altar in his room.
Things came to a head one morning when Emilia insisted Carlos get out of bed in time to get to school. He groaned and cursed at her. Later that morning, after she assumed he had already left, she found him in the bathroom with a razor, scratching "I hate you" in his arm. She called the police, and Carlos was admitted to a hospital.
Once her son was admitted, Emilia met with the inpatient attending psychiatrist, Dr. Roswell, a woman who specialized in mood disorders among teens. Dr. Roswell took a thorough history of Carlos's development, symptoms, and family history and asked questions that Emilia had never been asked before. Dr. Roswell told her that Carlos's mood and behavioral problems were probably the end result of a family history of mood disorders, although no one in the family had been diagnosed with bipolar disorder. Carlos's father had been intermittently depressed and alcoholic. Emilia herself had had several episodes of depression, one immediately following Carlos's birth and another when her husband left. Carlos's paternal grandfather had been "a ramblin', gamblin' man" (her words) who had never had a fixed address for very long.
After a week-long hospitalization, Carlos was diagnosed with bipolar disorder and started on a regimen of Depakote (a mood stabilizer) and Seroquel (an atypical antipsychotic). Dr. Roswell agreed to see him on an outpatient basis in her practice. Carlos and Emilia began a family educational program along with other families of bipolar teens, which met weekly during the evening at the hospital's outpatient clinic.
The group meetings, while highly informative, left Emilia with a combination of frustration, worry, and intense sadness. For her, the issues surrounded grieving over the loss of who she thought Carlos would be: a bright, artistically talented, and creative young man. She began to think she would spend her life taking him in and out of hospitals. These events were equally hard on Carlos, who, despite his bravado, expressed the worry that he would always be mentally ill and that he would never have a career or his own family. Privately, both Carlos and his mother agonized over the question "Why him?" How could this have happened?
Excerpted from The Bipolar Teen by David J. Miklowitz, Elizabeth L. George. Copyright © 2008 The Guilford Press. Excerpted by permission of The Guilford Press.
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