Wendy's Changing Behavior
Wendy was a
charismatic, high-school junior with sandy blonde hair and blue eyes.
She was an athletic young woman who loved sports, drama and music. Her
friends described her as a person with high energy, drive and a wide
circle of friends. Her friend Alicia said "Wow, she has the energy of
two people." However, Wendy seemed to be changing, and her friends were
beginning to find her annoying. They thought she seemed depressed, and
they wondered if she had family problems. Alicia remarked, "I don't get
it, one week she's so revved, and a week later she's as slow as a
turtle."
Wendy had been staying up late for two weeks, whizzing
through various projects and spending time on Facebook and YouTube. She
had a variety of hobbies that included fashion design and baking. She
loved designing new apparel and writing articles about her recipes for
the school newspaper. She felt positive and abundantly energetic, and
her projects kept her busy into the wee hours of the morning. She
usually went to bed around 3 a.m. and would wake up at 7 a.m. feeling
energized for her day at school.
Sometimes Wendy felt like
chatting in the middle of the night and would call her best friend,
Phillip, at 2 a.m. This behavior seemed rude and intrusive to him, but
when he tried to talk to her about the problem, she was hard to
interrupt, and didn't seem to be listening. Wendy was experiencing
racing thoughts and some mood swings, and her friends couldn't
understand what was going on.She was not particularly aware of these
changes, but she loved her extra energy. There was another subtle change
that annoyed her friends -- Wendy became boastful, thinking she had
skills beyond her abilities.
She told Phillip that she was going
to bring fame to her hometown by winning at the state tennis match being
held in St. Cloud, Minnesota. Tennis had been part of Wendy's life
since she was in elementary school, and now she was a top player on the
Minneapolis Mavericks. Her net game had improved, but hard work was
necessary to excel in her overall game.Wendy had a good serve and felt
that her backhand stroke was strong, and she was in the best aerobic
condition ever because she lifted weights, ran on her mother's treadmill
and took Zumba classes. She was superconfident that she would win
against the top-seeded player, and she came across as boastful when she
said, "I'll show her tennis she hasn't seen before -- I'm going to blow
her out of the water."Although Wendy had always been good at winning
matches against local teams, she had never played at the state level,
yet she reveled in her self-confidence.
A History of Anxiety and Depression
Wendy
had not always felt self-confident. When she was about 12 years old,
she started struggling with anxiety and depression. She had some sleep
problems, and she occasionally felt down, restless and agitated. For
some people, feeling agitated can be a way to mask an inner emptiness.
Sometimes Wendy had bad dreams in which she was being chased by someone
scary or searching for something she couldn't find.
After Wendy
turned 13, she began to have days when she felt sluggish and didn't have
her normal interest in her many activities. Although she had a lot of
energy, Wendy had down days when she didn't feel like doing much.
Sometimes, while she was working on a project, she would suddenly space
out and vaguely sense that inner emptiness again. Her mother said it
seemed like Wendy was "somewhere else."
Problems sleeping,
agitation, lethargy, down days and a feeling of emptiness are a few of
the behavior patterns that are common among teenagers with both bipolar
II and/or depressive conditions. At this point it was unclear what
condition Wendy had -- her symptoms could be red flags for an emerging
bipolar II condition or a more serious depression, and either can exist
simultaneously with an anxiety disorder. A complete assessment is
necessary to accurately target what disorder may be emerging. The
emptiness and sluggish days can be part of the depressive side of
bipolar; it is common for teenagers with bipolar to start out with
depressive symptoms although some teens start out by experiencing the
elevated energy that is the high side of bipolar.
When she was
about 14, Wendy was getting worse and finally talked to her mother about
her behaviors and feelings. Her mother was worried and took her to see a
relationship therapist who had a good reputation with teens. With some
professional help, Wendy was able to learn positive coping skills and
manage her symptoms well, as many can. She learned to regularly relax
and take necessary quiet time. She continued to exercise daily, which
greatly helped with her depression and helped manage her agitation.
Additionally, she was in a support group where she made friends with
others who had mental health challenges. Wendy made it a habit to go to
bed at the same time each night and wake up at the same time each
morning to help regulate her sleep. She also made sure to get eight
hours of sleep. She still had sleep issues but felt generally rested
during the day.
When she was a high-school freshman, Wendy started
seeing a psychiatrist, Dr. Smith, for depression. He had prescribed a
low dose of an antidepressant that had helped her, and she generally saw
him once every three months. During the period before the state tennis
finals, Wendy's behavior became erratic, and she stopped her relaxation
routine, cut back on her exercise and quit the support group. What was
really going on? Fortunately, Wendy's mother made an appointment for
Wendy to see Dr. Smith within a few days.
When she went to see Dr.
Smith, Wendy learned that she was exhibiting the symptoms of bipolar
II. When teenagers have bipolar disorder, it can be difficult for them
to maintain good habits because of the depression and the mood swings
into "hypomania" (the highs of bipolar II). Wendy was surprised because
she had been feeling at the top of her mental game, primarily because of
her exercise, support group and wins on the tennis court. However, the
emerging mood swings were making it difficult for Wendy to maintain her
healthy habits, and she needed an updated treatment plan based on her
new diagnosis. She was especially concerned that her agitated behavior
would push away her friends and that depression would affect her tennis
game.
The Different Types of Bipolar Disorder
Bipolar
disorder is multidimensional in nature, and because of this, experts
are now considering bipolar I, bipolar II, cyclothymia and bipolar NOS
as the "bipolar spectrum." Here are the different types:
- Bipolar I
is identified by episodes alternating between manic periods of abnormal
euphoria, optimism, and energy and depressive periods of sadness,
helplessness, guilt and sometimes suicidal feelings. People with bipolar
I can experience hallucinations and delusions while those with bipolar
II do not.
- Bipolar II is marked by major depressive episodes
alternating with episodes of hypomania, a milder form of mania. People
with bipolar II depression often have extremely low energy, slowed
mental and physical processes, and profound fatigue. People with bipolar
II struggle more with chronic depression while people with bipolar I
struggle much more with mania.
- Cyclothymia is a chronic mood disturbance lasting
for at least two years (one year in adolescents) involving numerous
hypomanic episodes and numerous periods of depressed mood that aren't
severe enough to meet the criteria for a major depressive or a manic
episode.
- Bipolar NOS (Not Otherwise Specified) describes a
disorder with manic or hypomanic features that does not meet the
criteria for any specific bipolar disorder.
Much
research has been done on bipolar I, but less attention has been focused
on bipolar II and bipolar NOS. People with bipolar II don't have the
psychotic features or extreme elevated moods of bipolar I, and hypomania
usually doesn't cause
significant distress or greatly impair one's daily life. However, some research indicates that bipolar II
can
be severe because of the chronic and deep depressions that these people
struggle with. Nevertheless, with advances in education, more people
are getting diagnosed, new medications and treatment strategies are
being developed, and further research continues.
It is especially
important to diagnose and treat teenagers with bipolar disorder because
the condition can interfere with healthy growth and development: mood
shifts can cause a decline in school performance and a loss of friends,
and excessive sleep can waste valuable life opportunities. Bipolar also
causes unnecessary pain and suffering, which can lead to substance abuse
and sometimes suicide in untreated young people.
If your teen
talks about suicide, it is crucial to take it seriously. Call your
doctor, or if the doctor isn't available, contact 911 or your nearest
hotline. Make every effort to get your teen in a support group for teens
with mental health challenges, and, if you are a parent, try your best
to get your teen to a therapist.
Diagnosing Bipolar II
Dr.
Smith had been treating Wendy for several years, but this was the first
time he had assessed her for bipolar II. In order to meet the criteria
for this condition, a history of depression and at least
one episode
of hypomania are necessary. Bipolar II often goes undetected because of
problems with a clear definition and a lack of understanding of
hypomania. Bipolar II is often misdiagnosed because of the overlap with
other conditions such as anxiety, depression, oppositional disorder and
ADHD.
While most of Wendy's friends were bothered by her constant
talking and boastful attitude, they admired her confidence, endless
energy, and various talents. These characteristics can make bipolar II
even more challenging to diagnose because the hypomania may appear to be
a period of successful high productivity and happiness. Because
hypomania can cause a person to feel good, it is
reported less frequently than a painful depression.
Dr.
Smith believed Wendy was experiencing hypomania based on her
grandiosity about winning the state championships, her need for little
sleep and her rapid talking. Upon questioning from the doctor, Wendy
shared that she had been experiencing an increase in her sex drive but
figured it was normal for her age. This cluster of symptoms confirmed a
bipolar II diagnosis and the need for an adjustment in her medication.
Dr. Smith explained bipolar II to Wendy, but she denied that she had it,
explaining that she was just buzzed about the upcoming championships.
People with bipolar II typically don't have the severe mood swings of bipolar I patients, but they may be prone to
longer
depressive episodes. Teenagers with bipolar II disorder may often start
out with the depressive side of bipolar, and helping professionals may
believe that the patient has unipolar depression.
If a person has a
history of substance abuse, eating disorders, schizophrenia and/or major
mood disorders, it's important to realize that these are red flags for
bipolar; however, not all people with this background get this disorder.
Of course, there are a percentage of cases where hypomania
causes significant distress, and it's important to detect hypomania
early on. Some research indicates that teens are more prone to auto
accidents and may suffer a decline in grades because of the
distractibility caused by racing thoughts.There are many faces of
hypomania that can help you differentiate the disorder; however,
remember that any one person has a
cluster of symptoms and not all of them.
Wendy
didn't like the term "hypomania" for the wonderful feelings she was
experiencing, and she didn't want to take any additional medication. Dr.
Smith was concerned when Wendy refused to take the recommended
medication because ignoring hypomania can make bipolar II worse and
possibly lead to the more severe bipolar I. People with bipolar I can
lose touch with reality, so it is crucial to stop the progression of
low-end bipolar conditions.
Fortunately, with education, Dr. Smith
was able to convince Wendy to take a mood stabilizer to regulate her
mood and keep treating her depression. He also referred Wendy to me
because I have a specialty with bipolar II in teenagers. I taught Wendy a
variety of coping skills that will be discussed in the section on
treatment interventions.
Bipolar II and Hypomania
Most people with bipolar II experience a
cluster of hypomania symptoms, but not all of them.The majority of the highs of bipolar II include the following symptoms:
- grandiosity
- a decreased need for sleep
- distractibility
- racing thoughts
- rapid speech, interrupting while others are speaking
- excess energy
- hypersexuality
- a tendency to engage in reckless behavior
- irritability
- silly behavior
*See below for detailed information about these symptoms.
Grandiosity: Grandiosity
is an exaggerated sense of one's importance, knowledge, power, or
identity. A person with grandiosity may seem outrageously boastful,
pompous, or pretentious.
Hypersexuality: Hypersexual
behavior is an excessive interest in, or preoccupation with, sex and a
markedly increased need for sexual gratification. A person experiencing
hypersexuality may appear to be obsessed with sex. In bipolar disorder,
hypersexuality is often seen along with a distinct change in a person's
behavior and personality.
Many people with bipolar II do not
experience hypersexuality, but it was becoming a problem for Wendy. When
she was hypersexual, she would masturbate three times a day and spend
time buying sexy clothes, which she didn't wear when she was in a
stabilized mood. Usually, she was somewhat shy around guys, but during a
period of hypomania, she would become provocative and seductive. When
she recovered from a hypersexual episode, she said she felt guilty
because sleeping with a boy she hardly knew was completely out of
character for her. Fortunately, the right medication (a mood stabilizer)
helped her gain control of her urges before she could be hurt or become
pregnant at an early age. Hypersexuality is an aspect of bipolar that
is reportedly seldom investigated, and education is greatly needed about
this symptom.
Silly behavior: Another symptom of
hypomania is silly and goofy behavior. Sometimes Wendy became silly
around her friends and roared at her own jokes and goofy behavior. For
example, she would make a steady stream of puns throughout the day, and
although her friends thought she was funny, they turned away when she
wouldn't stop.
The Depression of Bipolar
Bipolar
I is considered the more severe disorder because of the accompanying
psychotic behavior, but people with bipolar II generally have more
chronic depression than those with bipolar I. Wendy had been diagnosed
with depression when she was a freshman in high school. She would get
periodic episodes where she just wanted to sleep, felt pessimistic and
dwelled on negative thoughts. Wendy told me that she tried to think of
something positive when she was depressed, but she couldn't even get a
picture in her mind.
Life seemed to have no meaning for Wendy, and
she lost interest in her usual activities. I worked with her to develop
a road map to help her get moving because "action, action, action" is
essential to treating depression. Accomplishing tasks slowly and
successively along with therapy and a support group can help a teen
gradually pull out of a depression.
Based on my extensive
experience with teenagers and young adults with depression, I wrote a
poem that describes the lethargy of depression, and reading it has
helped many teens in my practice to open up. Encourage your child, teen
or patient to find ways to express their pain because expressing pain
can help release it. Here is a verse from that poem:
Toes cold, same socks mold for days in a row.
Energy compressed, can't do my best
Feeling stuck behind a barbed wire fence.
©2006 Patrice Wolters
In therapy, I helped Wendy find words to express her feelings. Here is a verse from her poem:
I don't want to walk and I don't want to talk
I'm feeling so low; leave a message on the phone
No, I don't feel like eating, my energy is depleting
They call it depression, down days in succession
Focus
on helping your teen or patient create some sort of mental health
poetry to help them overcome their unique issues. Remember that people
think in distorted ways when they are depressed, which only makes them
more depressed. Educate teens in the cultivation of empowering thoughts
and help them to make it a daily habit. Teach them to use negative
thoughts as a trigger for repeating their empowering mantras.
Bipolar and Drug Abuse
A
percentage of people with undetected bipolar II conditions may abuse
drugs such as methamphetamine, which helps people escape the chronic
lows of bipolar II. Methamphetamine can energize depressed people and
get them up and out, getting things done. However, they subsequently
crash, become more depressed, and end up in a dangerous cycle. They
gradually need more of the drug, and it kills off important brain cells.
The possibility of drug abuse is another argument for early
identification of bipolar conditions. Alcohol abuse is also common
because it self-medicates the pain and chronic irritability of bipolar
II depression.
Research indicates that college students abuse
prescription drugs, and I expect that the rate is particularly high
among students with depression and an undetected bipolar condition. The
demand for counselors in colleges has greatly increased, but many
colleges don't have the necessary services to meet students' needs.
Bipolar appears most frequently after kids have left home and are in
their early twenties.
If you have a patient or teenager who
you believe is using drugs, make every effort to get him or her to a
drug specialist who has knowledge of mood disorders. Involvement in a
Narcotics Anonymous or Alcoholics Anonymous program has also been
successful and often provides a good support group for people trying to
quit addictive behavior.
Drugs are a dead-end street, and
most people with bipolar conditions need to get on the right medication.
A fairly small percentage of people with bipolar disorder are able to
manage without medication and lead successful lives. A healthy lifestyle
and a variety of cultivated mood management skills can enable these
people to live fulfilling lives. If your patient or teen doesn't want to
take medication, make sure they eat well, sleep well and stay involved
in activities they enjoy. Of course, help them use the positive coping
skills discussed in this article.
The Bright Side of Bipolar
Important
research has been done regarding the special gifts of people with
bipolar conditions. Research by Dr. Kay Jamison indicates that many of
our talented poets, actors, politicians, and painters had bipolar
conditions. Abraham Lincoln, Winston Churchill, Catherine Zeta Jones and
Robin Williams are a few of those with bipolar who have had remarkable
success. There are many people, in a range of professions, who are
making significant contributions when they are effectively treated for
bipolar. In my practice, I have found that many teenagers with bipolar
are highly talented and want to make significant contributions with
their talents.
It's important to realize that the high energy,
creativity and goal-oriented behavior patterns of bipolar II can enable
people to make major contributions to society and/or be highly
successful.
One area that needs research is the creative
management of hypomanic symptoms for success in life. For example,
racing thoughts can be used for brainstorming, journaling and creative
writing. For a person who commits to the practice, meditation or a
martial art can calm thoughts down and help to open new vistas. Writing
about symptoms can enable a teen to work through issues, solve problems
and move toward positive goals. The chronic irritability and
hypersexuality of bipolar II can motivate people to begin a daily
fitness program and stay fit for life. People with bipolar II can also
learn to channel their irritability into assertiveness and get a lot
accomplished.
Working through a depression requires teens to
develop resiliency (the ability to master the biological and
psychological challenges of life) and take responsibility for their
moods and behaviors. Additionally, cultivating discipline and a support
network helps bipolar teens cope with their symptoms and develop success
skills. Teens can become compassionate and sensitive to the pain of
others when they deal with the depressive side of bipolar, and this can
motivate them to become involved in important social causes.
Overcoming a depression is
a struggle
that allows young people to develop a variety of strengths and
capacities such as willpower, ego strength, flexibility, patience,
persistence and, most importantly, responsibility. Bipolar conditions
provide an ongoing challenge for teens to find their outer limits in
life and become multidimensional people. I like to call this "the
bipolar challenge."
Positive Coping Skills
We
have come a long way in terms of treatment for bipolar conditions, and
many people benefit from a combination of therapy and medication.
Nevertheless, more research is needed in determining how people can
manage this challenging illness. There are several important skills that
can help teenagers, and adults, with bipolar disorder.
Determination: One of the most important things to develop is a
determination
to make positive coping skills lifelong friends and to turn symptoms
into assets. Here is a verse to give your teens if they struggle with
lethargy and lack of persistence. Positive thinking in a rhyme format
will help teens remember important mental maps that can help them get up
and get going. Adults can also help teens write their own rhymes based
on inspiring words that motivate them. Do whatever works!
Persistence
I can pull myself up against my own resistance
To get a job done that I don't want to do
And I can do it over and over for as long as it takes
To alter my existence, based on my insistence
That I can create the world that I want.
©2006 by Patrice Wolters
Focus on health and strength: Teenagers
with bipolar disorder generally need a variety of outlets for their
energy and good strategies to pull out of a depression. They often
require some form of medication, the benefit of a healthy diet, and good
sleep hygiene. Since bipolar teens may feel bad about themselves, it's
essential to help guide them to think realistically and optimistically
about their condition and to help cultivate their strengths.
Teach
your teens and patients to write their strengths on an index card and
have them post it where they can see it regularly to remind them of
their strengths. People with bipolar disorder, and depression, need to
find positive thoughts to replace the chronic negative ones. Remind your
teens that they are brilliant, talented and resourceful (or whatever
words might inspire them).
Postponement: Hypersexual behavior had a compulsive quality for Wendy, but the medication decreased the
intensity
of her urges and helped her settle down. Still, she needed some
strategies to control her urges, so I taught Wendy to use postponement
to manage her sexual urges. When she felt hypersexual, Wendy learned to
take charge of her thinking by saying to herself "I can postpone this
urge and get something physical done instead." She would often lift
weights, run or work on an unfinished project. With practice, Wendy
learned to develop the habit of postponing her desires to masturbate, go
to parties, and buy sexy clothes. Wendy gradually learned to be more in
charge of her hypomania and developed some self-esteem as a result. She
sometimes reflected, "I can do anything I set my mind to."
Wendy
also made use of a thinking tool I developed called "Take charge,
channel and change." When she felt a sexual urge, she would talk to
herself in a proactive and
realistic manner by saying something
like "Okay, I'm starting to feel hypersexual, and this is a signal that
I need to get moving with my projects. I am 'in charge' of my moods.
Right now, I'm going to
postpone acting on these urges and
'channel' my energy to get a project done. It's dangerous to act on
these urges, and I will not. I am in charge of me, and I can 'change'
some each day." These realistic thinking patterns helped Wendy take
charge of her sexual urges. Learning to postpone any behavior that feels
excessive or intense can be challenging at first, but it can do wonders
for self-esteem and a sense of empowerment.
Wendy made up a list
of the following projects to get involved in when she felt either
hypomanic or depressed. The projects required a push with the
persistence rhyme, but they were easy physical tasks that gave her a
sense of accomplishment and got her moving through the challenging
symptoms.
- Clean room
- Organize closet
- Wash clothes
- Iron clothes
- Clean bathroom
- Run, practice tennis or weight train
- Vacuum room
These were all things that she could
do at home, and they provided a focus for her excessive energy. When
broken down into mini-steps, the projects also provided a focus for when
she was depressed, and they facilitated "change." Wendy was artistic,
so she created a picture with the tasks drawn in cartoons that helped
her get going when she felt down.
Of course, Wendy would still get
some urges while involved in her projects, but she practiced bringing
her mind back to the task at hand. The statement"I am in charge, I can
channel and I can change" became her mantra to get started, follow
through and complete daily living tasks. The completion of tasks
reinforces positive thinking, which eventually became a mind-set for
Wendy.
Get up and going -- 1-2-3-4: When Wendy
was depressed, her biggest challenge was to get out of bed. Together,
Wendy and I laid out an initial 1-2-3-4 routine that would get her up
and going on the weekends. This routine has helped many teenagers with
bipolar depression beat the bipolar blues. It has also helped those with
unipolar depression.
- Lie in bed and set a priority
for the day. When Wendy was depressed, her priority was often to get
out and practice some tennis because she knew it helped her mood. Most
any athletic activity is an effective treatment for depression.
- Shout, "Two, I can bust my mood!" and jump out of bed. Just getting
up is a big achievement when a person is depressed, and shouting gets
the energy going.
- Make the bed. This gives a beginning sense of accomplishment and makes it harder to get back in bed.
- Get a cup of coffee or tea, and eat some breakfast to provide nutrients for the day and get some energy flowing.
At
this point, it was time to perform the next four steps and to continue
this process throughout the day. Built into this behavioral pattern was
breaking Wendy's day into small tasks that helped her build some
momentum. While people vary on their steps, the next four for Wendy
consisted of the following:
- Put on makeup.
- Brush teeth and floss.
- Get dressed.
- Get out the door.
Once she was out in the fresh
air and on her way to the tennis court, the probability of her going
back to bed was low. Encourage your teen or patient to create a routine
and make it a habit. Using numbers or some type of sequence can
facilitate breaking steps down to help teens get moving and begin to
beat the blues. Talking or singing to themselves can be helpful because
action is the name of the game. Teens who are not in treatment for
bipolar disorder can get help from healthy friends, community groups, or
trusted ministers.
Learn to master procrastination: Many
depressed people procrastinate because their motivation and energy are
low, but they can move toward creating positive energy by getting things
done that they don't want to do. The trick is to set aside
some time for the completion of unpleasant tasks. Wendy didn't like her
history teacher, and she often arrived late to class. It was her first
class of the day, so it was easy to sleep in longer. She would
imagine
how boring the class would be and think, "Well, I'll be on time
tomorrow," but her tomorrows became a string of yesterdays, and she had a
D average by the middle of the semester.
So, Wendy was to start
her day by imagining how good she would feel with a B in the class. She
was to schedule "History at 9 a.m." on her iPod and get to class
regardless of her mood. If she was depressed, tired, anxious or
unmotivated, she was to get up and go anyway. Taking charge of this
problem and other aversive tasks gave Wendy positive energy and a sense
of empowerment because she was taking care of business. Learning to push
through lethargy is a habit that can gradually transform your world.
Bipolar
II is a challenging condition, but it is treatable. Knowing the early
symptoms of this condition can increase the probability of an accurate
diagnosis in your teen, your patient or yourself.
You can do something about bipolar, and you can get well. Remember, you are
not your illness, you
have
an illness, and I encourage you to form mood management habits for a
fulfilling life. Although social stigma may still cause considerable
shame about coming forward with bipolar symptoms, you can be one of the
people who seek help, and help can make all the difference in the world.
Remember there is hope, there is help and it can be just a phone call
away.