With teenagers the biggest diagnostic challenge is differentiating between bipolar disorder and schizophrenia (Chapter 16). The two illnesses have many characteristics in common. Like schizophrenia, bipolar disorder may be accompanied by psychosis. Kids with either of these diseases may lose touch with reality and have hallucinations and delusions. However, with bipolar disorder the delusion is usually a grandiose one, whereas with schizophrenia it is more likely to be simply bizarre. Debbie, a lovely, charming 17-year-old girl I treated for bipolar disorder, introduced herself at our first session as a famous supermodel and told me she had her own exercise show on television. When Debbie did her exercises in front of the mirror at home, she explained to me, her performance was transmitted through the mirror to a recording studio, which broadcast it on MTV. Schizophrenia was the first thing that came to mind when I heard Debbie’s story, but once I focused on the grandiose nature of the delusion and the “coherence” of her story, I was inclined to go the other way.
Another difference between the two diseases is that bipolar disorder has mood swings—from mania to a normal mood or depression and back again—but schizophrenia doesn’t. What’s more, people with schizophrenia don’t usually have a lot of energy or talk rapidly. Adolescents with bipolar disorder, unlike those with schizophrenia, have flight of ideas; their thoughts and comments may be rapid and seemingly all over the place, but close examination will reveal that there is a connection between one thought and the next. (The lightning-fast comic routines of Robin Williams come to mind.) The thoughts associated with schizophrenia are random and often disjointed—this is called looseness of associations. Despite all these differences, plus many more, distinguishing the two disorders is a real challenge.
THE BRAIN CHEMISTRY
Bipolar disorder is genetic. Hardly a month goes by without a report in the scientific literature that the specific gene for this disorder is about to be identified. More than half of all people diagnosed with bipolar disorder have a relative who has either bipolar disorder or depression. If an identical twin has bipolar disease, the other will also have it 65 percent of the time; this occurs only 14 percent of the time with fraternal twins. Adoption studies add support to the genetic theory behind bipolar disorder; a child whose biological mother has bipolar disorder has a 31 percent chance of having the disorder even if he is adopted at birth; if his biological mother does not have bipolar disorder but his adoptive mother does, we’re down to 2 percent.
Neuroimaging techniques have been performed on only a small number of youngsters with bipolar disorder, but preliminary findings suggest that the left and right sides of their brains are different in very specific ways. Neurotransmitter regulation is also believed to be abnormal in people with bipolar disorder. Excess dopamine and the disregulation of norepinephrine may cause manic episodes. Lithium, the medication most commonly prescribed for bipolar disorder, affects both dopamine and norepinephrine.
THE TREATMENT
There is no known cure for bipolar disorder, but there is a fairly effective treatment: medication combined with supportive psychotherapy. The medicine of choice is Lithium, a natural salt that acts as a mood stabilizer. Lithium, which is occasionally used in children to treat aggressive outbursts, works in two ways: it treats a current episode of mania or depression, and, in 70 to 80 percent of all patients, it decreases the frequency and seventy of future episodes.
For many people Lithium is an honest-to-goodness miracle drug; it gives them back their lives. Of course, not everyone responds so dramatically to Lithium. I’ve had patients with bipolar disorder who take their Lithium faithfully, never missing a dose, and still have problems once in a while. Still others do just fine for a time and then have a “breakthrough” episode—the illness basically breaks through the Lithium. When that happens, we either adjust the dose of Lithium or recommend an additional medication.
Lithium treatment requires monitoring, especially in the first few months after the medication is prescribed. It is especially important to check people on Lithium when the temperature is high; hot weather and strenuous activity lead to dehydration, which increases the concentration of Lithium in the blood and may produce unpleasant side effects. Lithium may also suppress thyroid functioning, so we check the thyroid on a regular basis with a simple blood test. If thyroid functioning is being affected, it’s easily treatable by adding a synthetic hormone. Lithium is so beneficial that most people prefer to take the additional synthetic thyroid hormone rather than discontinue the Lithium.
There are many potential side effects associated with Lithium. The most common are acne, weight gain, increased thirst, frequent urination, nausea, and hand tremor. Having witnessed the side effects of many different drugs, my colleagues and I regard these as relatively benign—we call them “nuisance” side effects—but most adolescents would disagree. I’ve been put in my place more than once by an irate teenager who told me in no uncertain terms that having bad skin or being overweight is a big deal. The hand tremor can be upsetting to these kids too, since it makes them look odd, something no child or teenager relishes. A 16-year-old patient of mine quit her job as a cashier after one day because the customers noticed that her hand was shaking as she gave them their change. All of these side effects can be minimized by adjusting the dose of Lithium, adding another medication that addresses the specific side effects, or both.
Another medication-related difficulty for teenagers is the inadvisability of drinking alcohol or taking drugs when being treated for a mood disorder. To my patients with bipolar disorder I strongly recommend moderation when it comes to alcohol and abstention from illicit drugs.
Because of the nature of Lithium—it is a mood stabilizer—kids and especially their parents often express concern about the effect the medication will have on the child’s personality. “We want our son to be well, but we don’t want to lose him,” one mother said to me. “Will he still have that spark?” They worry that a child’s emotions will be chemically regulated and that he’ll end up bland and boring. That’s not what happens. Lithium doesn’t change the personality; it just prevents those undesirable extremes—mania and depression—from happening. A child on Lithium will still be upset if something bad happens and extremely joyful when there’s something to be happy about. One of my colleagues likens the role of Lithium to regulating a thermostat. Most of the time the thermostat that controls our mood works just fine, but every now and then there’s a little glitch and we go up too high or down too low. This salt, Lithium, helps our thermostat to function better.
Lithium is not the only medication recommended for the treatment of bipolar disorder. An anticonvulsant called Tegretol, another mood stabilizer, has also been used to good effect. A patient taking Tegretol has to be monitored too; we particularly look for a drop in the white blood cells, which fight infection, and an effect on the liver. (These side effects are uncommon but serious.)
Depakote, another anticonvulsant, is also often prescribed for bipolar disorder. There are fewer side effects with this medicine than with either Lithium or Tegretol. The “nuisance” side effects are stomachache and nausea, but the major problem—which seems to occur only in very young children—is liver toxicity. Liver function should be checked regularly, particularly in the first six months a child or teenager takes the medication.
Not surprisingly, treating the two poles of this disorder—mania and depression—can be quite complicated, especially since antidepressants have been known to bring on a manic episode. That happened with a teenage girl I recently treated for major depressive disorder. The Zoloft she had been taking for her depression for nearly two years eventually brought on a manic episode. It’s very important to remember that the antidepressant didn’t cause her mania; that was there to begin with, and the episode was bound to happen some time. The medication just pushed her into the manic phase. (What’s more, the mania didn’t go away when the medication was stopped.) Some people with bipolar disorder require not just one medication but seve
ral working at once. For instance, antipsychotic agents such as Haldol may be given in conjunction with the mood stabilizer during the onset of the manic episode.
The biggest problem associated with the treatment of bipolar disorder is getting kids to take their medication. Studies show that one-third of all adolescents stopped taking their Lithium within a year of its being prescribed. Patients never run out of reasons to stop taking their medicine. They start to feel normal, and they forget that it’s the Lithium that’s making the difference. Or they’ll start to pine for that great feeling they used to have in the manic phase and decide to go for it again. Many kids deny that they are sick, so they stop taking the medicine to prove their point. Unfortunately, relapse rates are very high, and sometimes kids do not respond as fast or as well the second time medication is tried as they did the first time.
When it comes to the problem of noncompliance with medication, parents don’t always help either. They mean well when they say things like, “There’s nothing wrong with her. Maybe she shouldn’t be taking medication” or “Let’s experiment. Take him off the Lithium,” but their refusal to accept the fact that it’s the medicine that’s making their kids better only makes the problem worse. It’s hard to think of a youngster taking a mood stabilizer for a lifetime after only a single episode, I know, but parents need to understand that a serious disease—which bipolar disorder most assuredly is—calls for serious treatment. Bipolar disorder is a treatable illness, but the only way the medicine can work is if the child takes it. Moms and dads who have doubts should know that more than 90 percent of adolescent manic patients who discontinue treatment for bipolar disorder will have a recurrence of the disease within 18 months.
In addition to medication we recommend psychotherapy for youngsters with bipolar disorder, and we encourage their families to join them. Therapy can help everyone concerned to understand the nature of this complicated illness and deal with the strong emotions that it brings to the surface. One patient with bipolar disorder I have been treating is a 16-year-old girl who blames her father, who also has bipolar disorder, for her disease. “He’s never been any good, and now he’s passed on his lousy genes to me so I have to suffer,” she said. The therapist can help her and her father understand the truth about the disease.
A therapist will help families deal with practical as well as emotional issues. They’ll learn how to cope with the medication, how to detect the early signs of a relapse, and how to identify the stressors that might trigger an episode. For instance, a college student with bipolar disorder should know that pulling all-nighters to study can be dangerous, since a lack of sleep can precipitate a manic episode. Drinking and taking drugs may also act as triggers.
Bipolar disorder calls for prompt, active treatment. Severe mood changes and high-risk behaviors during a child’s formative years may have lasting effects on his development. Left untreated, this dangerous disorder may lead to alcohol and drug abuse and even suicide. The suicide statistics for this disorder are staggering; some 15 percent of all patients with bipolar disorder commit suicide.
PARENTING AND BIPOLAR DISORDER
Parents of children with bipolar disorder have their work cut out for them, and some are better at it than others. One set of parents I know nearly drove themselves to distraction looking for early signs that their son was having a relapse. They were constantly hovering, on the lookout for signs of mania. “One of us is always watching Lee. I’m afraid to go out at night any more. What if he goes haywire while I’m at the movies?” the mother said to me. The parents were obviously passing along their anxiety to their son. Lee called me one afternoon without telling his mother and father. “I can’t take it. I’d rather go back to the hospital,” he told me. “If I laugh two seconds longer than anybody else, they think I’m manic. If I’m upset because I got a bad grade, they’re worried I’m going to fall into a depression.” It is important for parents to be knowledgeable about the disease and watchful for signs of a relapse, but it’s equally important to keep surveillance efforts under control.
With bipolar disorder there are times when hospitalization is necessary. Kids who are very distressed and very dysfunctional may need the around-the-clock medical care and attention that only a hospital can provide. When a kid is not taking care of himself—not bathing or eating or sleeping—and he’s in a severe state of mania, he needs medication and intensive supervision until he gets back on track.
Many parents have difficulty accepting the behavior associated with bipolar disorder as a real illness. Sharon’s parents had always been very proud of their teenage daughter. Smart, outgoing, and funny, she had many friends, and all the parents in the neighborhood used to enjoy her company. Sharon was constantly being invited to her friends’ homes for dinner or a sleepover date. All of a sudden things began to change. Sharon became obstreperous, disruptive, noisy, and very disrespectful to her elders. “She’s turned into a real troublemaker,” one of the neighbors told Sharon’s mother. “I’m sorry, but we just don’t want her over here anymore.”
Unfortunately, Sharon’s parents were not able to recognize how severely ill their daughter was. As a matter of fact, the father thought he could solve the problem himself. Convinced that Sharon was just being willful, he decided to punish her for her behavior. Needless to say, the punishment did not improve Sharon’s demeanor or her behavior; if anything, her disease grew steadily worse. Her parents, finally realizing that they couldn’t fix things for their child, brought her in to see me.
Most children being treated for bipolar disorder will need help regaining their confidence and self-esteem, especially after a manic episode. There’s a good chance that children who go through a manic episode are severely embarrassed by their behavior afterward, and even though they had no control over what they said or did, they may need to be forgiven by their families, their friends, their teachers, and even their doctors.
I’ll never forget a girl I treated for bipolar disorder in the hospital several years ago. In the throes of a manic episode she was completely out of control, screaming curses and ethnic slurs at me and being sexually provocative. We soon got her Lithium to the right level, and she was fine. In fact, she was a lovely girl, charming and good-humored. As she was leaving the hospital, I could see that she was in tremendous pain when she said good-bye to me. With tears in her eyes she said, “I can’t stop thinking about the terrible things I said to you. I called you such awful names.”
I told her not to give it another thought. “That was your illness talking, not you,” I explained. What I told the girl was true, of course, but that didn’t make the burden that she was carrying any less heavy. Understanding, sympathetic parents can do a lot to lessen a child’s load of guilt and shame.
CHAPTER 16
Schizophrenia
The first time I met Thomas, he was 15 years old, and his parents had just about given up on him. According to Mom and Dad, Thomas had been a problem child for a long time; he was always acting “kind of weird,” they said. A few days before I saw him, Thomas’s school bus driver said the boy had “flipped out” and refused to get off the bus when they reached the school. A couple of teachers finally had to pull him off the bus and into the building. Thomas’s parents had been trying to cope with their son’s behavior by themselves for several long months, but the night before our meeting, he had crossed over the line. When Thomas’s father came home after work, Thomas walked up to him and, without saying a word, punched him in the face, hard. The event could have been interpreted as typical adolescent conflict gone haywire, but after spending only a few moments with Thomas I realized that there was something a lot more serious going on. Thomas was hearing voices, and those voices told him that his father was out to get him. That’s why he struck his dad. He couldn’t get off the school bus because he was too frightened. The lights in his homeroom emitted rays that were controlling his mind.
Sixteen-year-old Miranda was transferred to my care from the emergency room of a near
by hospital. Miranda had gone to the ER by herself after school that afternoon because she wanted to have X rays taken. Miranda was convinced that there were rats living in her stomach, and she wanted proof. When Miranda’s mother and father were called, they were horrified but not really surprised. They hadn’t heard about the rats before, but they knew very well that Miranda sometimes saw and heard things that weren’t there. She thought that the television was talking to her, and she had been communicating regularly with Marilyn Monroe and Elvis Presley; in fact, Marilyn had recently been telling Miranda not to bathe, change her clothes, or go to school. Recently Miranda had started to use drugs and hang out with a bad crowd.
THE REALITY TEST
All children enjoy make-believe. One of the best pans of childhood is being able to pretend, to create fantasies and make up stories. Even imaginary playmates are acceptable under the right circumstances; they’re part of the package of being a normal, well-adjusted kid. However, being controlled by rays from lights in the classroom and taking orders from Marilyn Monroe—these are a far cry from the enchanting world of make-believe. They are the symptoms of a extremely serious brain disorder called schizophrenia.
Schizophrenia affects about 1 percent of the country’s population. According to the National Institutes of Mental Health, about a million people in this country are being treated for schizophrenia on an outpatient basis. In childhood the gender distributions of schizophrenia is marginally weighted toward boys, but by adolescence the female-male ratio is just about even. Among adults there are as many women diagnosed with schizophrenia as there are men.
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