It's Nobody's Fault (33 page)

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 He was withdrawn and somewhat irritable, and his sleep/wake cycle was reversed; he was sleeping in the daytime and staying awake almost all night.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 According to the camp counselors, Benjamin was withdrawn and almost morose when he arrived at the camp, but over the course of that first week he became increasingly euphoric and irritable.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.

“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 school 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.

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.

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.

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.)