Monday, March 25, 2013

Bipolar II Disorder and Teenagers

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.

穢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!


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.

穢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.

  1. 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.

  2. 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.

  3. Make the bed. This gives a beginning sense of accomplishment and makes it harder to get back in bed.

  4. 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:

  1. Put on makeup.

  2. Brush teeth and floss.

  3. Get dressed.

  4. 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.

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