CO-OCCURRING DISORDERS IN TEENS: Bipolar Disorder--The Great Imitator

Angry outbursts, erratic sleep patterns, sudden mood swings, and changes in personality. If you’re a parent of a teenager, these behaviors can be the status quo—actually, we often take these behaviors for granted. When teens are in trouble, when they are struggling to cope with issues that are too difficult for them to handle, drinking or getting high makes these behaviors worse often to the point of frightening us.

Symptoms of addiction often mimic other behaviors and make it hard to figure out exactly what’s going on in kids who are getting high. We know that kids (and adults) get high to help manage the difficult emotions associated with life’s challenges. And we know that adolescence presents them (and us!) with unique challenges.

Your parental instinct that something is wrong is often correct, but understanding the difference in the root causes of their erratic behavior will help you decide what course to take with your child.

Sometimes the issues are normal external pressures, like arguments with friends, academic expectations, real or perceived rejections by others.

Sometimes the issues are internal, relating to your child’s coping style, temperament, or ability to tolerate frustration. When bipolar disorder is present, however, the internal issues are also related to your child’s brain functioning.

HOW ADDICTION SYMPTOMS CAN MIMIC BIPOLAR DISORDER

It’s important to understand that bipolar disorder is a medical condition of the brain. The person experiences extreme highs (mania) and extreme lows (depression). When I explain below more about what bipolar disorder is, you’ll see how easily it can be misdiagnosed in children and teens as major depression, attention deficit hyperactivity disorder, oppositional defiant disorder, and conduct disorder.

During a manic episode, a person’s mood is noticeably euphoric, irritable, or aggressive. It is common for a person who is manic to think that nothing is wrong with their behavior even though it is extremely distressing to family and friends.

During a depressive episode, a person may feel sad or lose interest in previously enjoyable activities. When severe, thoughts of suicide may be present. Someone with bipolar disorder can experience a variety of mood patterns, such as having mostly episodes of mania or mostly episodes of depression. Another person may cycle rapidly between the two. It is also possible for someone to remain symptom-free for extended periods of time.

BIPOLAR DISORDER AND CHILDREN

Another important thing to know is that bipolar disorder looks different in children and teens than it does in adults. When children or teens have bipolar disorder, they have mood swings with extreme ups and downs. When they are up, they have brief, intense outbursts or feel irritable or extremely happy (mania) several times almost every day. They have a lot of energy and a high activity level. When they are down, they feel depressed and sad.

Children more often experience several severe mood swings in a single day versus the sustained and clearly defined manic episodes that adults have. These intense moods quickly change from one extreme to another without a clear reason. Some children may briefly return to a normal mood between extremes.

Many children change continuously between mania and depression, sometimes several times in the same day. Sometimes children with bipolar disorder have symptoms of both mania and depression at the same time, often showing itself as agitation or extreme irritability.

But because of the “normal” ups and downs of adolescents or for children with sensitive temperaments, times of mania or depression may be less obvious in children and teens than in adults. It’s often difficult to sort out what exactly is going on.

Normal ups and downs of adolescence are exaggerated greatly when kids are drinking or getting high. As with adults, children will resort to getting high in an attempt to feel “normal” or balance out the “feeling crazy” that bipolar contributes to. That’s why when substance abuse is in the picture things get even more confusing.

The good news is that bipolar disorder can be effectively treated usually with a proper combination of medication and counseling. Getting a thorough evaluation by a professional who is experienced with mental illness and addictions is your best bet in determining what course of action to take.

As always, education and support are the best antidotes to the fear and helplessness we feel as parents when our children are suffering from bipolar disorder.

Other excellent resources to learn about bipolar disorder and get support are the Depression and Bipolar Support Alliance and the Child and Adolescent Bipolar Foundation has a great site especially for kids.

WHAT ARE CO-OCCURRING DISORDERS?

Please note: This is the first in a series of blog posts that will address the relationship between addiction and associated mental health problems. I'm starting with a general overview here and will add posts that will be more specific, focusing more on specific mental health issues as they relate to children and the family.

Comments, suggestions, and questions are always welcome and will help me develop and tailor the blog to your interests/needs.

Addiction doesn't happen in a vacuum.

Sometimes we take for granted what our brains are for. We are not robots--our brain controls everything that we do, from monitoring breathing and heart rate to deciding whether to eat a cheesesteak with or without fried onions or reaching for a salad instead.

We know that drug, alcohol, and other addictions are complex problems that involve the interaction among many variables:

• Biological, such as heredity or genetic makeup
• Environmental, such as family, school pressures.
• Social, or interactions and relationships with others
• Emotional, or feelings such as anxiety, depression, anger.

It's the emotional variables that underly and contribute to the symptoms we most often associate with co-occurring disorders and compromise our mental health. I've previously written here before about the interaction between addiction and mental health, but what I want to focus on now is what happens when an addicted person's emotional issues become prominent and seem to take on a life of their own.

'Co-occurring disorder' is a fancy term for mental health problems that occur alongside the addiction, when a person's ability to manage their emotional world becomes a problem in itself. The main types of co-occurring disorders are:

• Anxiety problems: panic attacks, phobias, generalized anxiety, obsessive-compulsive disorder
• Post-Traumatic Stress disorder (PTSD)
• Depression problems: Major depression and Bipolar Disorder
• Attention Deficit Hyperactivity Disorder (ADHD)

The first three listed above sometime start prior to the addiction, when the person turns to drugs (marijuana, cocaine, opiates, etc.), alcohol, or other compulsive behaviors (overeating, gambling, shopping, video gaming, etc.) to help manage their difficult emotions better. Choosing drugs, alcohol or compulsive behaviors helps to escape the painful and/or scary feelings by numbing, avoiding, or disconnecting from feelings altogether. Our emotions are often warning signs that something is wrong. Just like ignoring warning light on your car's dashboard can become a serious mechanical problem, not paying attention to our emotions can lead to coping-with-life problems.

ADHD, on the other hand is related to addiction and emotional well-being in a different way than the emotions described so far. ADHD is a neurobiological, or brain-based disorder, that contributes to increased impulsivity in behavior and emotional expression. Impulsivity often contributes to low frustration tolerance and anger management problems.

Sometimes, when a person becomes sober and lets go of their longstanding coping mechanisms, anxiety, depression, and ADHD problems become revealed and will need specific attention in addition to traditional addiction counseling and relapse prevention approaches.

It's estimated that 60% of people with a drug and alcohol problem also have a co-occurring mental illness. Symptoms of addiction--mood and personality changes, sleep and appetite disturbance, irritability and impatience--often mimic co-occurring disorders. Symptoms of depression are often expressed differently in children and adolescents, so that can complicate things even more.

Research suggests that the best treatment approach is one where both addiction and mental health issues are addressed at the same time. Finding a therapist skilled in treating both addictions and mental illness is crucial if there is any uncertainty of mental health problems.

Don't be afraid to ask a potential therapist if she/he has experience with co-occurring disorders, if you're at all unsure about your child or family member's situation. It will greatly increase the likelihood of getting the comprehensive treatment that's needed.

THE ONGOING AMERICAN TRAGEDY UPDATE

Several weeks have passed since I first wrote about the Tucson atrocity AN ONGOING AMERICAN TRAGEDY expressing dismay at what I described as an ongoing American tragedy: How the American public’s ignorance about mental illness and the shame and stigma associated with mental illness and mental health treatment directly contributes to the lack of appropriate treatment that could reduce the vulnerability of the mentally ill and the likelihood for them to commit these crimes.

I’m encouraged that the predictable blame game has seemed to run its course and some of the national debate has shifted a bit towards turning to a more responsible discussion of the woefully inadequate mental health and addiction treatment system in the United States and what needs to be done with the architecture of this system to reduce the likelihood of another attack.

As information became available about the perpetrator’s drug abuse issues, the silence about the drug abuse use part of the problem has been deafening.

Let me fill you in on the field of addiction psychology’s version of the blame game. It occurs thousands of times every day when decisions about who will provide the care for a mentally ill person who also abuses alcohol and/or drugs. Or, alternately, when a substance abusing person with serious mental health issues needs treatment.

Substance abuse and addiction never exist in a vacuum. Although I’m simplifying here for illustration purposes, addictions are a result of the interaction among our biological and emotional makeup and social/environmental influences. Problems that addictions cause are associated with the negative choices we make, often as ways of helping us feel better in the short run.

As humans we tend to move towards rewarding activities and away from uncomfortable ones. People with mood problems (depression, bipolar disorder), anxiety (panic attacks, excessive worry, obsessive-compulsive rituals) and schizophrenia (unwanted systematic delusions and beliefs) sometimes turn to alcohol and drugs as available options to self-medicate their brain disorders that create constant and intense emotional pain for them.

Professionals refer to this common and intertwining nature of mental health and addiction problems as a co-occurring disorder. Unfortunately, our treatment system forces us to split the person’s problems up in order to find the appropriate treatment program. Treatment programs are usually more prepared to address either the mental health problem or the addiction. This makes finding adequate, comprehensive care extremely difficult.

Our field has come a long way since the mid 1980’s, when, as an on-call clinician looking for an emergency hospital admission for a person who likely would be out on the street without immediate treatment, I’d have to stand by on the phone while administrators [a.k.a. those paying for the care] would literally argue over who had responsibility for the care. And I’d often be on the other end having to deliver bad news to the client: the comprehensive care he/she really needed wasn’t available. I then had to make a makeshift plan for the person to ensure the person’s safety for that moment until we manufactured a Plan “B”. These administrative “turf” battles are rare now and the dichotomy between mental health care and addiction is better today, but not much.

It’s evidenced daily by the responses in hospital emergency rooms when a mentally ill intoxicated person shows up, or when police are called to homes when a mentally ill family member is acting scary and threatening. “He’s drunk, he needs to sober up”; “He’s high on drugs. What do expect us to do?” are the usual responses of first responders. Parents and family members of those with co-occurring disorders live with the fear, dread, shame, guilt, and helplessness associated with these scenarios that are regular occurrences for them.

When someone has diabetes, cancer, or heart disease, their condition usually can be treated comprehensively with the necessary multidisciplinary approaches available. Good luck to the person with an emotional problem and corresponding substance abuse problem looking for quality, comprehensive care. It rarely happens. Part of this is due to the above dichotomy in care, but the major problem is due to the unwillingness of insurance companies and shortsighted employers who purchase insurance plans for their employees to provide funds necessary for the adequate care of mental health and addiction problems.

The Mental Health Parity and Addiction Equity Act of 2008 provides insurance for employed people. People with severe co-occurring disorders can’t keep jobs, so not much help there. President Obama’s Patient Protection and Affordable Care Act of 2010 is a step in the right direction, but the reality is that insurance rarely provides enough coverage for the seriously mentally ill and/or the chronic disease of addiction.

DJ Jaffe, a national advocate for the seriously mentally ill, displays insight and irony in his Huffington Post depiction of “Mom [as] the new mental institution, given the responsibility to see their loved one stays well but not the ability to enforce medication compliance or get the mental health system to take action….Mrs. Loughner never wanted Jared to become a headline for hate. This is the mental health system we have in America. It caters to the well not the ill”

It takes an enormous amount of courage to ask for help for an addiction or mental health problem. It’s usually even more difficult for parents and family members (and yes,especially the Mom’s!) to reach out for help for their loved one. I’m hoping the national debate will allow more people in the mainstream of America to learn more about the true nature of mental health/addiction problems and treatment, reduce the shame and stigma associated with asking for and receiving help, and give our moms and all the members of our families a better chance to be productive members of our families and society.

What happened in Tucson is a horrendous tragedy. What’s happening on a daily basis to the millions of Americans with co-occurring disorders who are not able to receive proper care is a tragedy we can actually do something about.