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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.

HAPPY MOTHER'S DAY! CELEBRATE WITH MOM'S NITE OUT

In celebration of the great jobs moms do, The Partnership at Drugfree.org is promoting 'National Mom's Nite Out' to give moms a well-deserved night off and celebrate who they are besides being a mom--a girlfriend, a friend and a woman.

Locally, there's a fun nite planned here on Philadelphia's Main Line to give moms a chance to strut their stuff at a fashion show and silent auction.

Taking time out for yourself to re-energize and let off steam is crucial to effective coping with addiction in the family. Make sure you don't just wait for Mother's Day!!

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.

"COLLEGE IS A PART OF LIFE; IT'S NOT APART FROM LIFE"

Getting a college degree is an impressive accomplishment that any person can be proud of.

Unfortunately, the faulty expectations that are part of the "mystique" of college life--"These will be the best years of your life!"--undermine the success of many kids' adjustment to college, leaving behind a long line of depressed, anxious, alcohol- and drug-abusing kids.

Many kids hit a wall when they get to college, mostly because they're not prepared for what are the normal challenges of this phase of life that college presents. Yes, it's normal-- no, there's nothing wrong with you!--if you struggle with establishing a life separate from your parents, family, lifelong friends and supports.

Confronting brand new academic, financial, and social pressures that the college experience brings is hard enough for any child, let alone with those with acknowledged learning and/or emotional problems. "Changes of scenery" and "getting away from mom and dad" are not part of a good plan for kids already struggling to manage their anxiety, depression, and/ADHD.

A recent Huffington Post article by Meg Schneider points out that, yes, going away to college offers the possibility of growth and positive change, but it's naive to believe that old challenges can just be erased.

Meg offers many excellent realistic suggestions for embracing the opportunities offered in college that will improve the chances of a successful college experience. Her main message is one of normalizing the college experience, and I love how she describes it: "College is a part of life. It's not apart from life". Perfectly stated.

If your child is unhappy at college, it's crucial to have him/her ask for help. It doesn't mean that there's something wrong with him or her. Getting that diploma may involve a few detours or pit stops along the way, including a few at a counselor's office. It's a normal part of the journey to that impressive graduation milestone.

I'M NOW ON FACEBOOK AND PART OF THE 21st CENTURY

I've finally joined the 21st century and started a Facebook page. It's still early in the century so in that sense at least I'm not that far behind.

I've been hesitant to do it because of what we know about the potential problems associated with social media and my concerns about the ability to maintain the privacy and boundaries needed for a safe and respectful site for any visitors. These concerns are balanced by my wish to be more accessible to the community but feeling somewhat limited by the constraints of my website and this blog.

What I realize now is that the spontaneity and openness of Facebook that I initially feared as a potential problem can be harnessed (I'm hoping!) to my need for more a fluid and dynamic relationship with the community. My comfort level with social media has grown exponentially in the past year, somewhat paralleling the exponential growth of the power of Internet technology.

Throughout history, changes in communications technology (for example, printing press, radio, television, etc.) are initially met with much fear and skepticism. Marshall McLuhan coined the phrase "the medium is the message" in the 1960's to cleverly demonstrate that the content of the message itself is often not as important as how the message is transmitted by a technology. In other words, the Internet technology itself (Facebook, Twitter) that is being used to communicate the message is transforming our lifestyle, attitudes, and behaviors in ways that are more important than the actual messages that are being sent over the Internet.

So, I'm looking forward to learning more about using social media as tools in my work and personal life, but keeping mindful of the problems associated with Internet addiction and the damaging consequences associated with Internet use if we're not careful.

Let me know what you think, and I look forward to seeing you on Facebook!

'NOT MY KID': THE ENABLING TRAP

An article in the Ambler Gazette last weekend about parents in Blue Bell, PA acquitted of charges of hindering a police investigation of their young adult son reflects the potential trap of enabling that many parents face when their children brush up against possible consequences from their substance abuse.

Please note: I’m not intending in any way to make a judgment about these parents, but I’d like to use their situation to identify a common issue among parents who are worried about their children’s drug and alcohol use.

Enabling occurs when you begin to lose your way and get confused about how to protect your children’s safety. You desperately want to believe your kids are telling the truth and therefore can be easily convinced that everything is okay, often telling yourself, 'Not my kid'.

Parents who are aware of their teenage children abusing drugs and alcohol are very familiar with enabling. When children are showing problems associated with getting high, a dramatic shift in the family often occurs.

The ‘not my kid’ mindset is a set up. The addict becomes an expert at manipulating and deflecting responsibility onto others and takes advantage of your love and protection to selfishly get what she wants without regard for the consequences or impact on others.

The whole family begins to react in unhealthy ways to accommodate the addict’s behaviors, because confronting them directly creates messy, often embarrassing conflicts.

Out of love, concern, shame, and fear, you become uncertain about how to best intervene. Living with a child with a drug and alcohol problem is like being in the back seat of your car as you are driven around by your inexperienced, untested young driver—the daily out-of-control, often terrifying feelings become unbearable at times.

The world of the enabler is like a yoyo, jerked back and forth across the line between being over involved trying to protect and cover up for your child, to being so angry, scared, and helpless that you want to give up. You swing back and forth between looking the other way and wanting to stalk your child’s every move.

Intervening can feel daunting. Here are some guidelines to make it easier:

• Educate yourselves by arming yourself with facts about drugs and alcohol to be credible when talking to your kids.
• Learn more about the dynamics of enabling.
• Confront your denial: Parent's instincts about a problem are usually correct. Avoiding and ignoring the problem makes you part of the problem.
• Take care of yourself by getting support:

-- Reaching out for help is a way for you to take care of yourself. Start by sharing concerns with spouses, partners, and trusted friends to help feeling less ashamed, overwhelmed, and helpless.

-- Community programs like Al-Anon and Nar-Anon can be lifelines for families struggling to regain balance in their lives.

-- Online communities such Parenting the Addict Child are excellent resources for those who aren’t comfortable with groups or 12-step programs.

SUBSTANCE ABUSE COUNSELING 101 FOR PARENTS

Understanding some basic principles of substance abuse counseling will help you as parents develop an approach to intervening with your child.

Substance abuse is a problem that involves the interaction among physical, emotional, social (friends), and environmental (family, school) variables. In the course of our normal daily interaction with our children, we’re usually aware of any physical, social, and environmental issues. Since children are often not able to articulate their emotional struggles well, we need to look at their behaviors as possible signs of conflict.

Human behavior, no matter what age, reflects choices we make based on how we think and feel. Also, as humans we tend to move towards rewarding activities and away from uncomfortable activities. Problems with drinking and drug abuse are associated with the negative choices we make, often as ways of helping us feel better in the short run. Chemically, alcohol and drugs offer available options ways to self-medicate the uncomfortable feelings of daily life.

For example, a common example of uncomfortable feelings in teenagers is associated with their struggle with self-esteem. Children tend to blame themselves and feel excessive guilt for a loss or trauma in their life and often feel shame about having such feelings. Avoiding these feelings by not talking is like burying them, making children more vulnerable for ill-advised choices for relief.

Using ICE

In my work with clients I explore making healthy choices with them regardless of their age. With parents of teens and preteens, I encourage parents to follow these guidelines for being proactive with their children to lower the risk of drinking or drug abuse: Information, Communication, and self-Examination.

Information

· Accurate information is the best ammunition to counter the risk of problems associated with substance abuse. Arming yourselves with facts about alcohol and drugs as well as about your child’s development will keep you ahead of the curve and help you stay in touch with your child’s potential risk.

· Emphasize facts, not opinions. Certainly your opinion matters, but the idea here is to be a reliable resource for information for your kids. Offer your opinion, don’t force it on them. It’s likely they already know it by observing your behavior.

Communication

· Listening to what children have to say is often a more important communication skill than what you say to them. Talking about general current events and pop culture will give you an opportunity to hear their views and attitudes without them feeling “interrogated”

· Set and always enforce clear rules about drug, alcohol and tobacco use. Discuss substance abuse frequently and emphasize that experimentation is not okay.

· Engage in regular family activities such as eating meals together, “movie/game night”, and family meetings

· Emphasize and provide, safe, sober transportation

· Help children develop resistance skills. Discuss with them specific ways to counter pressure from peers to take part in risky behavior.

· Reward healthy choices and activities.

Self-Examination

• We often forget that we were once teens. Take a look at your own childhood for clues about what parenting approaches worked and what didn’t work for you and adapt those guidelines for today’s lifestyle.

• How do you cope with stress? What coping strategies do you use? How manageable is your family’s schedule? The answers here are usually transparent to your child; honesty is required if you expect respect and trust back from her. Reward healthy choices and activities.
• Examine your own substance use/abuse and model healthy, responsible behaviors. For example, never drink and drive; don’t use illegal drugs.
• Seek help for yourself if you become aware of your own substance abuse problem.

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.

AN ONGOING AMERICAN TRAGEDY

This post is not like any other post I’ve written.

I feel the need to respond to the Tucson AZ chapter of an ongoing American tragedy. I’ve been waiting for my feelings and thoughts to settle down a bit before I responded because I needed some time to think through what happened and put it into a context that makes sense to me. It’s very hard to do since much of what is being discussed in the media about it doesn’t make too much sense to me.

Not to belittle the traumatic and senseless loss of life from yet another mass murder by an untreated severely mentally ill person, but the predictable 24/7 media carousel that horrific events such as these generate is disgusting and intolerable.

The issues surrounding the killing spree that are thrown out to us from our many screens, if we choose to watch or listen, focus mostly on all the sources of blame for the tragedy: the hateful political climate, right wingers, left wingers, schools, parents, guns, public apathy, inadequate involuntary commitment and treatment laws, among others.

Hidden in there somewhere is an American tragedy affecting millions of us, but seemingly few want to acknowledge. The public’s ignorance about mental illness in general, how violence is associated with mental illness specifically, and the shame and stigma associated with mental illness and mental health treatment—directly contributes to the lack of appropriate treatment that would lower the likelihood for many vulnerable mentally ill people to commit these crimes.

This tragedy goes ignored, so unfortunately attacks like the one in Tucson occur on a fairly regular basis in the United States in a variety of public, private, and corporate settings and across varying political climates throughout our country’s history.

A commentary I read by Paul Heroux in the Philadelphia Inquirer this week helped put the tragedy in perspective for me. He verbalizes what I see as a blazing red neon warning sign, but what few people fail to recognize as a constant in these tragedies when he says “How much we know about mental illness can tell us how prepared we are to deal with [such attacks]”. We’re never prepared because the issues of mental illness and its treatment are virtually ignored by those in control to make changes.

He also discusses the recent issue of the Harvard Mental Health Letter (HMHL) that reviews the various factors that contribute to violent behavior in the mentally ill. According to the HMHL, those with schizophrenia or bipolar disorder are three to four times more likely to be violent if they also have a substance abuse problem. In addition to substance abuse, Heroux explains, “genetic and environmental factors, such as poverty and early exposure to violence, have also been found to be partly responsible for violent behavior”.

Since substance abuse is a trigger for violence in the mentally ill, research cited by the HMHL suggests, “adequate treatment of mental illness and substance abuse may reduce violence”. It also recommends long-term interventions including a variety of treatment approaches including cognitive-behavioral therapy, conflict management and drug and alcohol treatment.

Events like Tucson are especially painful for those like myself who provide treatment and counseling for the tens of millions of Americans with mental illness and drug and alcohol problems. The woefully inadequate resources and thoroughly broken system within which we try to work to take care of these people is often overwhelming and disheartening.

I’m actually a fan of the principle of managed care, which can be an effective tool for managing healthcare costs. In the United States today however, managed care is a euphemism for a system designed to ignore, neglect and abandon people with the chronic illnesses of schizophrenia, depression, and addiction.

Sadly, the trend is towards eliminating and restricting care. For the past several years, I’ve seen more and more people in my practice whose employers no longer choose to pay for health insurance that includes mental heath care. The people with more serious mental health issues will fall through the cracks, creating more Tucsons.

I’ve written elsewhere on my PARC blog about the need to continually educate and inform people about what mental health problems are and what treatment is, in order to help lower the ignorance quotient that keeps the stigma barriers so high. I’m hopeful that maybe this time (or the next time?) the powers that be will start to address the power of stigma that fuels the tragedy to continue.