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Bipolar Disorder in Children, Adolescents and Adults |
Chapter 2
Gary: "The teenager from hell"
Gary was 17 when he came back to therapy. I had seen him periodically throughout his childhood and early adolescence. Like Sophie, he had mood swings and a pronounced thought disorder. He manifested distractible, pressured speech; derailment (including loose associations and flight of ideas) and sometimes 'clanging'. Clanging is speech in which the way a word sounds is more important than its meaning. The content of such speech is hard to follow as the person repeats a particularly compelling sound. Gary's main problem had always been intense rage.
Gary had been a classic "Explosive Child". Rather than getting angry and then settling down, since Gary was young his tantrums had escalated. One day when Gary was 10, I noticed his mother had bruises on her upper arm. I asked her what had happened, suspecting spousal abuse. She started to cry. "It's Gary. He pinched me so hard when I was driving him to school yesterday. I can't stand it anymore. They have a child protection agency and animal protection places. I think they need parent protection from kids like Gary. Sometimes I think he needs to be in a hospital, or a boarding school. I don't know if our family can survive."
"Marina (Gary's sister, who is three years younger than Gary) has nightmares all the time. She won't bring friends over anymore. The last time she did Gary tore all the heads off her Barbie dolls. She's only seven. What kind of mother am I that I can't protect myself or my daughter from a 10 year old boy?"
By the time he was 13, his tantrums had escalated to the point where his mother
had to call the police to help contain him. He was hospitalized in an adolescent
unit of a psychiatric hospital when he was 15. He had destroyed his room by
punching holes in the walls and tearing the door off its hinges. When the
police came, they offered to 
5150
him, realizing he was a danger to himself and his family. Gary was placed
in an involuntary 72 hour hold, which then was extended by two weeks.
He
was manic and had psychotic symptoms, so initially, it was thought that Gary
was schizophrenic. This is by no means uncommon, as explained in Treating
Adolescent Mania and Bipolar Disorder by Scott A. West, MD, Psychiatric Institute
of Florida
Mood disturbance in bipolar adolescents is primarily that of prominent irritability rather than euphoria. Furthermore, manic episodes commonly have mixed features, a state wherein patients experience co-occurring symptoms of mania and major depression. In adolescents hospitalized for the treatment of acute mania, mixed states were twice as common as pure manic states. Interestingly, 30% of patients with mixed mania in this sample had previously received antidepressant medication, compared with none in the purely manic group. This suggests that, like adults, adolescents may be quite vulnerable to the induction of mixed states and rapid cycling resulting from the use of antidepressants. Because mixed states are quite prevalent and often present with a confusing array of symptoms, diagnoses in this population are often inaccurate. The course of illness and cycle length may further distinguish early-onset mania from adult-onset mania. Children and adolescents often display a chronic and continual course, with symptoms ever present but fluctuating in intensity. They may also have relatively short mood episodes, or "affective storms," ranging from days to hours to minutes. This intense affective lability may make it difficult to sort out symptomatology into any particular diagnosis. With more limited periods of euthymia, and mood states commonly fluctuating between mixed and depressed states, it is often difficult to chart a clear pattern of distinct mood episodes. Rather, it becomes easier to conceptualize mood state and severity as a spectrum with an unlimited range of possibilities. Psychotic symptoms appear to be common in adolescents with mania, and have often resulted in the misdiagnosis of schizophrenia. Ballenger and associates reported that two thirds of their small sample of juvenile bipolar patients had psychotic symptoms. Likewise, in a group of 40 hospitalized manic adolescents, McElroy and colleagues found that 75% of the patients exhibited psychotic symptoms, most notably, delusions and hallucinations. In contrast, Wozniak and associates reported that only 16% of 43 manic children displayed psychotic symptoms. In this study, children were aged 12 years and younger and were evaluated in an outpatient setting (versus inpatient), 2 variables that may contribute to the discrepancy in the prevalence of psychosis.
It was in the hospital that Gary received the diagnosis of bipolar disorder. His parents were also seen at the hospital, and given guidance regarding parenting techniques. One helpful idea was to "pick their battles", meaning that with a child as labile and explosive as Gary, they could not be on his back every moment for every infraction. This was especially difficult for Gary's dad, who had a strong military background. Dad's inflexibility combined with Gary's mood swings and tantrumming inevitably lead to an explosion.
They
benefited from the concepts found in the book
The Explosive Child, in particular the idea of a 'basket' system for setting
priorities. Ross Greene, the author, is quoted in an interview at the Child
and Adolescent Bipolar foundation found at:
http://www.bpkids.org/learning/reference/interviews/001.htm
The baskets are metaphors for different ways in which parents respond to their children. Basket A contains those behaviors that are important enough to have meltdowns over. Basket B contains behaviors that are important but aren't worth meltdowns; it is these behaviors on which adults are training the child how to think in the midst of frustration and how to stay calm enough to be able to do it. This is accomplished by walking the child through problem solving and working things out (sometimes by compromising). The goal is for the child, over time, to acquire the cognitive skills necessary for increased flexibility and frustration tolerance so that he can eventually handle frustrations on his own. Basket C contains those behaviors that adults are choosing to remove from the child's radar screen to reduce the child's global level of frustration. In many other approaches, Basket A is the most important basket. In this approach, Basket B is the most important, for it's the only basket in which missing cognitive skills are trained. Basket B is also very hard to do, at first.
He came back to therapy at age 17 subsequent to a manic episode fueled by not taking his medication and drinking alcohol at a party. He then took his parents' car without permission and crashed it into a tree. Fortunately, his injuries were minor. I worked with Gary's psychiatrist to adjust Gary's meds and together we educated him on the importance of compliance. As he was 17 and trying to figure out his future, Gary and I did a lot of work helping him get ready to leave his home. Our primary focus was the importance of him accepting responsibility for his behavior. He began to realize that things which had gotten him into trouble as a child could get him into prison as an adult. He began to slowly recognize his cues for states of rage building up. He learned to walk away from a situation which he realized he was clenching his jaw or making a fist. Gary worked very hard to self-regulate his rage, although certainly there were times when he resisted and regressed. This work was as much psychoeducation as psychotherapy.
Gary learned that he was most at risk when he was hungry, angry, lonely, tired, when he was irritated and at transition times. We called this HALT-IT, and he began to self regulate a little bit at a time. I think for Gary the incentive of leaving home and going off to college was a powerful motivation, and I don't believe he would have been as successful at a younger age. This round of therapy was the first in which it was just Gary, as opposed to family therapy. In particular, he learned to deal with his father's inflexibility by himself. He started out by just walking away when his dad was riding him, but then would communicate with notes. He was able finally to either do what his dad wanted him to, or to have a coherent and rational discussion about it.
Kerry and her mom
Kerry, age 16, came to therapy, irate with her mother. "She never listens to me! She never gives me any freedom. One minute she's real nice, then she is screaming at me, and grounding me. I think my mother is bipolar!" Kerry's mom had also wondered, at the time of out initial phone call, if Kerry was bipolar!
I met with Kerry and her mom together. Kerry's mom, a single parent, was clearly overwhelmed with the demands of a rebellious teenage daughter. We worked together (reluctantly.. at times I know I was dreading the screaming sessions that would evolve) for several months, on boundaries, communication, rules, chores, driving, responsibility, etc. Looking at our 'red flags' of
Grandiosity
suicidal gesture,
irritability,
decreased attention span,
and racing thoughts.
I would have to admit that both Kerry and her mother at times exhibited all of these symptoms. The issue here is degree, intensity and duration. Neither had any of these red flags for very long. I do sometimes think that all toddlers and adolescents, and their parents, should be considered temporarily in the bipolar spectrum as a consequence of NORMAL separation and individuation developmental issues.
Neither Kerry nor her mom were bipolar, nor was there any family history of BPD. The red flag behaviors were discussed and tempered as mother and daughter began to have more compassion for the stresses the other was experiencing. They developed more appropriate (or, at least, quieter, and less dramatic) ways to separate.
I had the happy task of assuring both Kerry and her mom that neither was bipolar, and that they were both perfectly normal!
In retrospect, what was interesting was the recurrence of the term 'bipolar' in both Kerry and her mother. A few years ago, teenagers would tell me that their parents were "nuts" or "insane" or "mean and unfair"; now they say they are bipolar. For parents, they used to talk about "bad" kids, and military school; then "ADD" and Ritalin, depression and Prozac, and now it is bipolar and lithium!!
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