It's Nobody's Fault

by Harold Koplewicz

  Another way in which parent counseling can be useful is to help parents redefine and come to terms with their special role as the mother and father of a child with major depressive disorder. Being the parent of a child or adolescent with MDD isn’t easy, to say the least. There are all sorts of unexpected questions that may arise, especially as a child moves through adolescence to adulthood.

  “I never know how much slack to cut her,” said the mother of a 15-year-old girl diagnosed with MDD. “I know I have a right to expect things from her, but it takes so much effort for her to do the easiest things. I don’t want to ask her to do too much and put a lot of unnecessary pressure on her. On the other hand, I don’t want to let her off the hook about everything just because she’s sick.” This mother makes an excellent point. Sooner or later her daughter will have to take her place out in the world, and it’s her parents’ job to prepare her for that day. Parent counseling will bring these issues out into the open.

  Even when a teenager is diagnosed with MDD, parents have to learn to let go a little and encourage a child to be independent. Allowing a child to make his own decisions is difficult for any parent; when a child’s decision-making abilities are impaired by major depressive disorder, it can be nearly impossible.

  “I’ve always been a little overprotective; I admit it,” said one mother. “My older daughter is 21 years old and perfectly normal, and I still interfere in her life too much. My 19-year-old is the one who’s depressed, and I have to remind myself constantly not to take over her life. I’m tempted to ask her every day if she’s taking her medication and to call the doctor to see if she’s showing up for her appointments, but I don’t. I know that would be wrong.”

  Yes, that would be wrong, but the impulse is perfectly understandable. Knowing when to get involved and when to step back and let it happen is a real skill for any parent. Here’s how yet another mother, whose 22-year-old clinically depressed son has just moved into his own apartment for the first time, expresses the conflict: “Part of me wants to let him go completely—say, ‘It’s your life and your problem.’ But then I think, ’Wait. If my son had a broken leg, I wouldn’t just point to the stairs and wish him the best of luck getting to the top. I’d get him a crutch or let him lean on me. Together we’d work out a way for him to get to the second floor.’”

  CHAPTER 15

  Bipolar Disorder/Manic Depressive Illness

  According to his parents, Leo, nearly 14 years old, had been perfectly normal until about a year before he came to my office for the first time. At the age of 13 the boy had been doing well in school, and he’d had a full social life as well, with plenty of friends and activities. But then things started to change. Leo became rambunctious and difficult to deal with. He was very sad at times, becoming tearful and even crying quite often, and his judgment was poorer than it used to be. He dyed his hair bright red and then streaked it with purple. Then he got himself a small tattoo. Mom and Dad thought it was a rebellious teenager phase at first. Then Leo’s behavior became even more worrisome. He overslept often and virtually had to be forced to go to school. He complained of headaches, neck discomfort, and other assorted pains. He was totally enervated one day and so energetic the next that he claimed he didn’t need sleep. Instead he’d stay up all night practicing the guitar. When I talked to Leo about his music, he told me, in the most matter-of-fact way, that he needed to practice. He was going to be a huge rock star.

  For the last few months Molly had been talking to herself a great deal, but her mother figured that her daughter was just rehearsing for the school play. At 16, Molly was quite passionate about acting. For the three weeks before I met Molly, the girl had been “blue,” as her mother put it—withdrawn and isolated from her friends and family, unable to concentrate on her studies. Then, two days before Molly came to see me, she came out of her funk with a vengeance. She was yelling and screaming incoherently and talking nonstop even when no one was around. She would eat only when forced to do so and hardly slept at all. By the time I saw Molly—and checked her into the hospital for a short stay—she was out of control, talking incessantly (mostly about Madonna) and singing songs from The Sound of Music. Her first night in the hospital she took off all her clothes and danced in the bathroom. The nurses said that Molly appeared to be having the time of her life.

  HIGHS AND LOWS

  Adolescents are moody. That’s an indisputable fact, like the sun rising in the east. Parents of teenagers expect erratic behavior from their kids, and so they should. Adolescence is a time for change of all sorts, and hormones tell only part of the story. Kids also go through some important developmental stages at this point in their lives, the most significant of which are separating from Mom and Dad and coming to grips with their sexuality. Normal, healthy teenagers will accomplish these tasks without too many casualties, although there will probably be some serious power struggles along the way. Rebellion and moodiness come with the territory.

  The territory occupied by bipolar disorder—also called manic-depressive illness—is characterized by a very different, much more serious brand of moodiness. This disorder involves intense, persistent moods that are clearly different from and much more intense than the child’s usual demeanor and are extremely inappropriate to the event and the environment. The mood swings must be severe enough to cause distress and dysfunction.

  The word bipolar refers to the two poles of this very serious disease: mania and depression. (Chapter 14 covered major depressive disorder, or unipolar disorder.) A child with bipolar disorder will have had at least one episode of mania—or hypomania, a milder, less intense version of mania. The symptoms of mania are distractibility, irritability, grandiosity, racing thoughts, a decreased need for sleep, an increased speed of speech, poor judgment, increased risk-taking behavior, and a break in reality testing, usually characterized by delusions and hallucinations. An adolescent having a manic episode, which may last anywhere from several days to a few months, typically will feel hypersexual and expansive, will have unrealistic expectations about his performance, and will make rash decisions and spend money recklessly. A 16-year-old girl I treated once took her mother’s credit card and bought a plane ticket to Boston to see a rock concert. Another time she was caught shoplifting. “I’m a movie star,” she told the security guard. “My agent will pay for this stuff.”

  “Having Rory around is like watching an episode of Lifestyles of the Rich and Famous” said a fed-up father of a 17-year-old boy in the middle of a manic episode. “He likes only the finest things—the best watches and the best luggage and the best clothing. One day he charged a $500 ski parka, a $300 pair of alligator shoes, and two Armani sweaters and had it all sent home by Federal Express. Of course, he put everything on my credit card.”

  To be diagnosed with bipolar disorder adolescents must also have had a depressive episode, which lasts anywhere from two weeks to several months. Its symptoms are loss of concentration, sleep disturbance, change in appetite, fatigue or decreased energy, agitation, lethargy, a feeling of worthlessness, and an inability to experience pleasure.

  The incidence of bipolar disorder in children and adolescents is not known. The lifetime risk of bipolar disorder is about 1 percent among the general population—affecting men and women just about equally—but it can be much higher in families in which other members have mood disorders. The condition is very rare in children under the age of 12, although there have been reports of bipolar disorder in children as young as four.

  Bipolar disorder often starts in adolescence, but is not recognized and diagnosed until much later, when kids become older and display classic adult symptoms. A survey conducted by the National Depressive and Manic-Depressive Association found that 59 percent of those surveyed reported suffering their first symptoms of bipolar disorder during childhood or adolescence. The age of onset of bipolar disorder is most frequently between 15 and 19.

  THE SYMPTOMS

  The distress and dysfunction associated with bipolar di
sorder can vary greatly, depending on the severity of the illness and which of the two poles—mania or depression—is “in charge.” When adolescents with bipolar disorder are in the depression stage of this condition, they’re usually pretty miserable. (The elements of the “depressed triad” say it all: feelings of hopelessness, helplessness, and worthlessness.) Mania is something else again. “You don’t know what you’re missing, Doc,” one of my patients told me, describing what it’s like when he’s manic. “There’s really nothing like it. I feel great. I look handsome. I’m brilliant. There’s nothing I can’t do.” Patients in a hypomanic phase are often productive and very pleased with themselves. As long as they are in that state, their heads are filled with ideas, and they have the energy to act on them.

  Most of the kids eventually diagnosed with bipolar disorder come to my office complaining about depression. I’ve had only one patient who complained about mania, a shy, soft-spoken, extremely religious 16-year-old girl. She told me that what bothers her most about her illness is her conviction that she’s better than everybody else. “I don’t want to be better than everybody else. I don’t want to feel this way. It’s a sin,” she told me.

  Patients in the mixed state—described by some experts as being trapped between depression and mania but not quite in either one—are usually in a lot of pain. The combination of feeling sad and worthless and weighed down and, at the same time, having racing thoughts and delusions of grandeur is incredibly exhausting and upsetting to adults; it can be devastating to a child or an adolescent. Many of the patients I’ve treated say they feel out of control, all revved up but depressed and crying at the same time. It’s in this mixed state that distress and dysfunction are often most severe.

  One final term to address is rapid cycling. Officially defined as four or more distinct mood episodes in one year, rapid cycling may involve even more abrupt and frequent mood swings: up one day and down the next sometimes. Rapid cycling is relatively rare, however. Only about 20 percent of all patients with bipolar disorder have it, and most of them experience it relatively late in the illness. It is much more typical to hear the cycle described the way the mother of one of my young patients put it: “She’s not up and down, up and down, up and down. She’s down and then she’s normal. Then she has an episode where she’s really up, and we worry about her doing something dangerous and foolish. Then there’s a long period of time when things are okay again. Then she’s down again.”

  Bruce, who turned 15 just a few days before I first met him, was a classic case of rapid cycling bipolar disorder. His parents said that Bruce had been having troubles for about three months. He was withdrawn and somewhat irritable, and his sleep/wake cycle was reversed; he was sleeping in the daytime and staying awake almost all night. He would go on sleeping binges, staying in bed for days on end, and then he wouldn’t sleep for 48 to 60 hours straight. All night long he would sit at his computer, totally absorbed in the intricacies of the Internet and communicating with people all over the world. When he finally got bored with his computer bulletin boards, he turned to the Home Shopping Network and ordered hundreds of dollars worth of merchandise. When I talked to Bruce, he was sweating profusely and talking a mile a minute. The topic he liked most was himself. He couldn’t decide whether he should be president of the United States or play center for the New York Knicks.

  Benjamin, 15 years old when I started treating him, had a full-blown manic episode during the two weeks he was away at camp last summer. According to the camp counselors, Benjamin was withdrawn and almost morose when he arrived at the camp, but over the course of that first week he became increasingly euphoric and irritable. He would talk very fast, sometimes so fast that no one could make sense of what he was saying. As the week wore on, he stopped sleeping and started masturbating several times a day. He also began to spend large amounts of money on inconsequential items for himself and everybody else in the cabin. He found a Bible and read it all the time, sometimes aloud to his bunkmates. I later learned that Benjamin was reading the Bible for a specific reason: he thought that he’d been chosen by God for a special purpose.

  The reason behind a symptom can often be instructive in identifying any disorder. Ann-Marie, a 16-year-old girl I treated quite recently, had a couple of symptoms with especially significant explanations. Her father brought her in because her teachers and the principal of her school told Ann-Marie’s parents that something was seriously wrong with their daughter. “I’ve been going to these parent-teacher conferences ever since she was in kindergarten,” he told me. “This is the first time I’ve ever heard any complaints.” The teacher told the father that Ann-Marie had taken to getting up in the middle of class, walking around the room, giggling, and talking back to the teacher. She was looking strange too, dirty and unkempt and often dressed in odd color combinations. Her handwriting, once so tidy and precise, had become very flamboyant. She refused to make eye contact, they said. Ann-Marie’s parents told me that her behavior at home was a little strange too. She had been talking to herself, and she became terribly upset whenever the television was on. Every time anyone turned on the set, Ann-Marie would rush to switch it off.

  I later learned that there were very specific reasons for Ann-Marie’s lack of eye contact and her hatred of the TV. Ann-Marie didn’t want to look anyone in the eye because she was convinced she had special powers. She thought that if she looked directly at anyone, she would cause that person harm. In fact, she wouldn’t even look in the mirror when she combed her hair, so frightened was she of what she might do. Her powers were so great they terrified her. She avoided the television because special messages were being broadcast to her through the TV. These facts combined with Ann-Marie’s other symptoms led me to a diagnosis of bipolar disorder.

  THE DIAGNOSIS

  “Are you sure this is manic-depressive illness?” a mother asked me.

  “Maybe I just have the world’s most obnoxious teenager.”

  Bipolar disorder is a difficult diagnosis to accept. It’s also not easy to make. There is no blood test or brain scan to aid the process. Furthermore, a lot of these troubled adolescents start medicating themselves—with alcohol, cocaine, marijuana, or Quaaludes. Drug and alcohol use clouds the diagnostic picture even more. In making a diagnosis we conduct a physical examination to rule out thyroid problems or drug abuse. Then we take a detailed history from the youngster, his parents, his teachers, and anyone else who knows him well. Along the way we look long and hard for a family history of depression, mania, schizophrenia, alcoholism, or drug addiction.

  Bipolar disorder is especially difficult to diagnose in young children. Even very young children can have sleep disturbances, loud speech, and most of the other symptoms associated with bipolar disorder, and they might also become suddenly oppositional. Of course, they’re not likely to go on spending sprees or fly off to rock concerts. Their manic phase will probably look different from that of teenagers.

  The most common symptoms of bipolar disorder in the very young are irritability, moodiness, talkativeness, hyperactivity, and distractibility —all symptoms for attention deficit hyperactivity disorder as well. A six-year-old child who is acting uncharacteristically silly or giddy may be doing so for any one of many reasons. The typical scenario is this: a first-grader who is sitting still in class, concentrating on what the teacher is saying, suddenly jumps up out of her chair and starts giggling, pulling her dress up, and talking animatedly to everybody in the class. Clearly she’s out of control. Her behavior could be interpreted as ADHD, but she may also be showing signs of bipolar disorder. Children with bipolar disorder are more moody than kids with ADHD, and their activity is more focused. Furthermore, children with bipolar disorder may have hallucinations and delusions.

  Nick, a 12-year-old boy who had been diagnosed (incorrectly) with ADHD, came to see me when his parents decided that his behavior was becoming more and more bizarre. The last straw was the hole he punched in his bedroom wall. Nick had been having problems at s
chool for some time, refusing to study and often creating problems in class. Lately he’s been agitated, unmanageable, and out of control both at school and at home. His appetite has decreased. He’s been provocative and verbally abusive to his parents. When I met Nick, he told me that he hasn’t been sleeping very well, and he’s been having some crying spells. At night when he can’t sleep he plays with a Ouija board, and he’s convinced that he has powers that make the board talk to him. I diagnosed bipolar disorder and explained to the parents why their child didn’t have ADHD. To begin with, Nick had not had any symptoms before the age of 12. The signs of ADHD must show up in early childhood.

  Even when the child has reached adolescence, the diagnosis of bipolar disorder frequently comes via a long, circuitous route. Several related disorders must be ruled out along the way. One of the possible candidates is conduct disorder (described in Chapter 18). Another is major depressive disorder, which is, of course, frequently one of the “poles” of bipolar disorder. Studies show that someone who experiences his first episode of depression in adolescence carries a 20 percent risk of developing a manic episode within three to four years. It is not uncommon to diagnose major depressive disorder and then, when the first manic episode finally occurs, to revise that diagnosis to bipolar disorder.