BMPN Webinar Transcripts


Chat With Boris Birmaher, M.D.

April 23, 2009

Did you miss our chat with Dr. Boris Birmaher? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Watch your email for more details.

Biography

Dr. Birmaher is the director of the Child and Adolescent Anxiety Program and co-director of the Child and Adolescent Bipolar Services at Western Psychiatric Institute and Clinic of UPMC. He also serves as endowed chair in Early Onset Bipolar Disease and professor of psychiatry at the University of Pittsburgh School of Medicine. Dr. Birmaher is the author of New Hope for Children and Teens with Bipolar Disorder, which can be ordered from our bookstore. In addition to his book, Dr. Birmaher has also published over 200 research articles in peer reviewed journals. 


Nanci - The Balanced Mind Parent Network      

Dr. Birmaher, could you start out by telling our visitors a bit about the programs that you oversee? 

Boris Birmaher MD      
We have a clinic that focuses only on children with bipolar disorder. Also, we have several ongoing studies that range from symptoms of bipolar to treatment and MRI.

Also, we have a consultation service for kids with difficult to diagnose and treat problems or that the parents want to rule out bipolar disorder- this program accepts children from all USA and the world. 

Susan      
I've been told that "kids" can sometimes outgrow bipolar condition. Have you found this in your experience to be the case? Is it more that as the kids mature they become better able to handle their situation but still need to maintain meds., etc.? 

Boris Birmaher MD      
A true diagnosis of bipolar is for lifetime. However, since we still need to learn a lot about bipolar in children, it is possible that some children will improve with time- the same happens with epilepsy and depression. 

Mitzi      
Do you recommend MRIs for diagnosis?  All my doctors say it isn't necessary. 

Boris Birmaher MD      
At this moment it is not necessary- we request an MRI when we suspect that there is another neurological illness that may explain the symptoms of the child. All the new functional MRIs are only for research. Some people are claiming that they can do the diagnosis with fancy MRIs. However, this is not accurate yet (I wish this was true).

Nanci - The Balanced Mind Parent Network      
Have you had any experience with QEEGs as a part of the diagnostic puzzle? 

Boris Birmaher MD      
Unfortunately, EEGs do not help yet.

janzy      
It seems that a lot of kids with mood disorders struggle socially and do not really have any close friends. What have your observations been in this area and do you have any recommendations for how to cope or what has been helpful?

Boris Birmaher MD      
Some children with depression do not have friends (or have problems with their friends because they do not have motivation, are irritable or aggressive). Also, when they are manic or hypomanic they can be too intrusive and disruptive. For these children the first step is to treat the mood problems. 

Also, some children with mood problems have other disorders like ADHD. The ADHD may interfere with their ability to make or maintain friends; in this case the ADHD needs to be addressed. In other cases, the child has problems with social cues or making friends for other reasons- these reasons need to be investigated and addressed individually. 

Nanci - The Balanced Mind Parent Network      
Once the mood disorders are addressed, do you find that in general the social problems improve or do you find that the kids are lacking in social skills because of the amount of time they have been unstable and unable to develop those skills? I realize that's sort of a 'which came first, the chicken or the egg' type of question, but this is a big concern for many of our families. 

Boris Birmaher MD      
Good point- if the child has been depressed for long time, he/she did not have the chance to develop good social skills and we need to help them (similar to a rehabilitation program of a child that has, let say, a broken leg for long time and now he/she is ready to start walking again). However, be sure that the social problems are due to the mood problems and not other causes such as ADHD, anxiety etc. 

cello      
Do you have advice for parents on how to address springtime mania or hypomania?   

Boris Birmaher MD      
Be sure that the medications are in good levels before spring.  If every spring the person gets manic or hypomanic, sometimes you have to temporarily increase the dose of some medications and be sure that the person is not taking medications that can trigger mania or hypomania (e.g., the antidepressants).

sunwillshine      
I just read that your university is researching using Interpersonal and Social Rhythm Therapy to delay or even prevent onset of bipolar in children at risk. I haven't heard of that therapy before; what's it based on? Is this something parents should read up on, or wait till the jury's in? 

Boris Birmaher MD      
I suggest waiting. Basically, some people think that an irregular schedule, going to sleep too late, sleep deprivation etc can trigger mania or make the mood very labile. In these cases, if you regulate your time, schedule etc. you may prevent future episodes of mania or hypomania. There are studies in adults, but not in kids.

janzy      
What is your approach to treating the many symptoms of bipolar disorder? Do you find it generally necessary to medicate for such things as anxiety or sleep problems, or do you recommend sticking to mood stabilizers and other more 'traditional' medications for bipolar disorder. 

Boris Birmaher MD      
For a child with a real bipolar disorder- first, stabilize his/her mood. Then, manage the other symptoms. I prefer to try common sense treatment for the sleep problems (regulate the schedule). For anxiety I like to try first cognitive therapy (if the anxiety is affecting the child's functioning). If therapy does not work, you can try specific medications for these problems. 

marybee      
How often do you find kids to be co-morbidly on the autism spectrum? 

Boris Birmaher MD      
Our clinic specializes in bipolar, then we often see children that have been referred to rule out bipolar, but they end having autistic kind of symptoms and not bipolar- in our BP studies, about 1-2%. 

Mitzi      
Do you see any correlation between BP and sleep disorders? 

Boris Birmaher MD      
Yes, I do. However, remember that one of the symptoms of mania or depression is a sleep problem. 

Susan      
Have you used LENS (Low Energy Neuro Stimulation) for cases with bipolar and ADHD? What are the benefits and risks? 

Boris Birmaher MD      
I do not know the LENS or have seen studies that probe that it works.

Nanci - The Balanced Mind Parent Network      
We have a few therapy related questions, one of which I believe ties into a research article you wrote with Dr. Miklowitz on Family Focused Therapy. 

Susan      
Do you find that the entire family typically needs some type of therapy/treatment? 

Boris Birmaher MD      
Like in many medical illnesses, and in particular mental health problems- family education and therapy helps. In our studies with family focused therapy we found that adolescents who received this type of treatment plus medications were less likely to have depressive episodes. 

Mitzi      
What about psychotherapy in general?  We've been doing that for years and it seems to have very little effect.  What seems to really help is the medication. 

Boris Birmaher MD      
There are many types of psychotherapy (it comes in many different flavors and colors). What we currently know is that psychotherapy alone does not work for bipolar disorder. However, certain type of psychotherapies in combination with medications may help a lot.
 
For example, cognitive behavior therapy can help for depression and anxiety (these problems usually go hand by hand with bipolar disorder). Behavior therapy can help for the oppositional problems and ADHD. Something called dialectical behavior therapy can help for mood lability, impulsive behaviors and suicidal tendencies and as we discussed before family therapy can also help.

Nanci - The Balanced Mind Parent Network      
I’d like to go back to the LENS question briefly. Susan said that it was recommended when a person was particularly stuck in a depressive state. I wonder if this is the same or similar to Deep Brain Stimulation (DBS)?  Are you familiar with that treatment approach? 

Boris Birmaher MD      
Sorry, but I do not know- DBS is an invasive treatment for people with severe resistant depression- it requires surgery and the implantation of electrodes in certain places in the brain- it has not been used in children or teens and not in people with bipolar.

Cindy      
How does bipolar generally present as an adolescent, say 14 or older, as opposed to a younger child? 

Boris Birmaher MD      
Good question that requires a long answer. However, in a nut shell: the older the child the more typical the symptoms of depression and mania. The younger the child the more difficult to ascertain symptoms (e.g., it is difficult to know what pathological elation and grandiosity are in very young children). Young children tend to have more mood swings and less typical symptoms. Also, they have more symptoms of ADHD and behavior problems that may confuse the clinical picture.

scart89      
Dr. Birmaher, I have not read your book, but I've read about it. If you had to summarize your research, what have you discovered which inspires the most "new hope" for pediatric bipolar patients? Can you offer an overview? 

Boris Birmaher MD      
Great question- we are  improving the way we are making the diagnosis, having more research regarding treatments, people are more aware that children may have bipolar and receive more specific treatments earlier. In the past, people waited on average of 10 years to have the correct diagnosis and the best available treatments. Thanks to parents like you and organizations like The Balanced Mind Parent Network the public is more aware and NIMH is allocating more funds for research. 

Pat O      
Do you ever see incredibly restless sleep (leg kicking, teeth grinding, shouting) during sleep with kids with bipolar? We have situation where the child is too anxious to sleep alone but this behavior is often painful for us when we sleep in the same bed. 

Boris Birmaher MD      
Restless sleep is not specific to bipolar- it can be many other things like "restless leg syndrome". Also children with separation anxiety disorder have a hard time sleeping by themselves. There are great psychotherapy treatments for separation anxiety. 

Nanci - The Balanced Mind Parent Network      
We have a few questions about anxiety that I'd like to blend together since we're near the end of our hour. 

Boris Birmaher MD      
ok with me.

Nanci - The Balanced Mind Parent Network      
With your experience as the director of the anxiety clinic I'm sure you can share a lot of good information. From your experience, does anxiety stem from depression, mania or both. And how does one best treat it when a child with BP may not be able to tolerate SSRIs or respond to traditional anti-anxiety medications. 

Boris Birmaher MD      
A large proportion of children (and adults) with bipolar have anxiety problems- we do not know why. But all the studies show the same results- there are two treatments for anxiety 1) cognitive behavior therapy (CBT) and 2) medications, mainly the SSRIs (although medications like Ativan can also help). Recent studies have shown that the combination of CBT and meds works the best.
 
If a child has good treatment for his/her bipolar symptoms- you can try the SSRIs. If the child does not tolerate one SSRI try a different one. Start with lower dosages and increase them very slowly. Another option is to try first CBT alone. 

Nanci - The Balanced Mind Parent Network      
Dr. Birmaher, thank you so much for sharing your time and expertise. We covered a wide range of topics and I know that our families really appreciate the opportunity to be able to ask you questions. 

Nanci - The Balanced Mind Parent Network      
And thank you for all the work you provide to families and to The Balanced Mind Parent Network. 

judy      
Thank you so much Dr. Birmaher 

Cindy      
Yes!  Thank you!! 

Boris Birmaher MD      
You are welcome- I hope all your children will feel well soon. 


The Balanced Mind Parent Network Chat with Dr. Laura Marshak, Author of "Married with Special Needs Children"

March 29, 2009

Chat With Dr. Laura Marshak
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Laura Marshak? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Watch your email for more details.

 Biography 

Laura Marshak, PhD is a licensed psychologist and the author of   Married with Special-Needs Children: A Couples' Guide to Keeping Connected, a book which addresses a broad range of parenting and marital issues common to parents of children with special needs. She is a professor of counseling at Indiana University of Pennsylvania as well as cofounder of a private practice clinic where she works with many parents of children with disabilities. Dr. Marshak’s professional interests focus on issues related to adjustment across the lifespan for persons with physical and/or psychiatric disabilities. Most of her publications are in that area and include books on the psychological aspects of disability with regard to both the individual and his or her family members.     


Nanci The Balanced Mind Parent Network 
Dr. Marshak, would you care to make any opening remarks before we start taking questions? 

Laura Marshak PhD   
Hello everybody. I have been looking forward to the opportunity to chat with you about this topic. 

Nikki 
Welcome Dr. Marshak 

Jamie 
Hello. It’s wonderful to have you here! 

Nanci The Balanced Mind Parent Network 
Dr. Marshak, could you start out by sharing with us what prompted you to write your book? 

Laura Marshak PhD   
As a parent of children with disabilities myself, I know first hand a good bit about the impact of children with disorders on a marriage. Woodbine House actually approached me to write this book in recognition of the fact that so many marriages are under greater pressure as a result of intensified parenting. They were also aware of the higher divorce rate amongst such couples. 

So I very much wanted to write a book that realistically looks at the challenges as well as practical ways to make marriages work better under such conditions. I also want to add that one of my goals in writing this book was to share ideas from couples whose marriages work well while raising one or more children with disabilities.  

Nikki   
Dr. Marshak, we are a newly formed family--I married Steve (also in the room) last year and he has only lived in the house since August. We had no idea that our daughter had bipolar disorder at that time. Any tips for making sense out of her angry behavior, how to best address it in terms of discipline and understanding, and still keep the peace at home? 

Laura Marshak PhD   
Hi Nikki, Let me address the part of the question pertaining to the new marriage. Am I correct in assuming that your daughter is essentially your step-child?   

Nikki   
No, she is Steve's stepdaughter 

Jamie   
Nikki, how old is your daughter? 

Nikki   
She is almost 15 

Laura Marshak PhD   
I am trying to address this concisely. I did write a chapter specifically about newly formed families, following remarriage in my book. Let me think for just a moment about the few main point that I want to emphasize.   
One of the things that are important is to not rush the children to become a "blended family" too quickly. It takes longer for them to adjust than many people realize-often a few years. And when you add BP into the mix-it is likely to be longer. When too much pressure is placed on children to quickly "blend in" they often act out a little more.   

I also want to add that it is very important to take time to nurture a new marriage (not to mention an older one) even if there is not peace in the home. Marriages can't be put on hold for too long. This means taking some time everyday to connect in ways that are not necessarily child-centered.   

Nanci The Balanced Mind Parent Network 
That's a very good point. I suspect many couples will say that it's very hard to find the time or the energy to connect each day. 

Laura Marshak PhD   
Nanci, I wanted to add a little bit more about what you just mentioned. There are ways to find a little time. If you took 2% of your day to take care of yourself or your marriage-and that is a small percentage-this would amount to 20 minutes. This could be spent in very valuable ways for yourself or your relationship.   

Nanci The Balanced Mind Parent Network 
I like the way you put that into perspective - no doubt we can find 20 minutes somewhere that we can reallocate. 

Nanci The Balanced Mind Parent Network 
Our next question might help to address the issue of how to keep peace in the home and survive. 

Jamie   
I will cut right to the chase and ask you what you recommend to parents of special needs children to help them "survive". My husband and I are constantly in survival mode, which means just trying to get through the day, and having nothing much left to give to each other. 

Laura Marshak PhD   
I really like this question. I am a very firm believer that every life matters in a family and that it is essential to squeeze out some time so that we take care of ourselves. If we don't do this, there is nothing left for a partner. I know this sounds hard but it is a matter of cutting corners in some places and putting yourself on the priority list. Otherwise, it is just too easy to feel resentful of depleted. (That's only one way).   

Jamie   
Dr. Marshak, one of the things that my husband and I fight about most often is how to discipline our BP son. Should it change based on how stable he is at the time? 

Laura Marshak PhD   
Hi Jamie, I do think that there does need to be flexibility based on a child's stability. I am also a big fan of compromise between parents so that they both feel like their perspectives matter. When one parent bosses the other around in these matters, there tends to be less cooperation.   

ChrisaH   
How does a couple handle a child whose disability is such that we can't leave him alone, not even with our older teen son, for more than 20 minutes, so we never get the chance to even go out to the movies or dinner together, let alone a weekend. We have been reduced to spelling each other - he goes away a few days, then I do, sometimes with our other kids, sometimes with friends. And, because of our son's dual dx, we have the real possibility to be like this, well, forever. I worry the stress is driving us to being nothing more than, well, roommates, we'll have nothing to focus on but our special needs son. How can we get our marriage back, while being lifelong caregivers? 

Laura Marshak PhD   
This is a wonderful question. Be patient with me while I share with you a quote a woman sent me that illustrates one way to do this.  

A mother who has been married for more than 25 years and has five children, including one with Down syndrome and one with autism shared this comment about how she keeps romance alive: "My husband and I have a Friday night date night. Cooking is my passion, so I cook us a gourmet meal every Friday. Oftentimes, we each have a child on our lap, but we still sit together with lighted candles and a glass of wine." 
   
Now I recognize that she might be unusual. But, there are many couples that I do know personally that have in-home dates and other creative solutions. I think that devoting some time to intimacy, even under such circumstances is essential. In my psychology practice, I do work with couples whose children cannot be unattended for even a moment. Although tag-team approaches are necessary-there must also be some time to connect.   

Nanci The Balanced Mind Parent Network 
Although to the 'normal' world, the scenario you shared might seem odd or pathetic, I can see many positives. The couple is making a conscious effort to focus on their relationship as husband and wife rather than mom and dad, and they are showing the kids that their relationship is still a priority. 

Laura Marshak PhD 
Absolutely. I also like the fact that she has protected her own interest cooking - rather than give 100% of herself to her family.   

Nanci The Balanced Mind Parent Network 
I'd like to refer back to an earlier question about different styles of discipline and post a follow up question from one of our members. I think the concern is the difference between being flexible and having different styles versus contradicting each other or sending mixed messages to the child(ren). 

Steve
Would it not confuse the child by changing the discipline? I think we as parents must remain consistent. 

Laura Marshak PhD   
I actually agree with what Nanci just wrote. It is hard to do justice to a question about discipline in this format. I do believe in consistency and agreement between parents. I assumed the concern was about using standard discipline during an acute episode. That's what I was referring to.  

sunwillshine   
If anything, what are some things my husband and I can do before a crisis hits, so that we're better able to work as a team and thrive as a couple when we face a challenge? 

Laura Marshak PhD   
I very much believe that couples need to spend time discussing these matters before a crisis hit; and with bipolar disorder (as well as many other disorders) it is likely to at some point. I just worked this week with a couple who needed to "hash out" an agreed upon plan that they both could commit to and have in place. It often takes more than one conversation to do this.   

Let me also add, that if a marriage is attended to in other ways (i.e., nurturing the couple relationship) there is more goodwill to work as a team on difficult child-related issues.  

Nanci The Balanced Mind Parent Network 
I wonder if it might be helpful to back up a little and talk about one of the first things that you discuss in your book - the structure of a healthy marriage. Looking at that might set the groundwork for what all of us need to focus on based on where we are at now in our relationships. 

Laura Marshak PhD
I agree that the marital structure is very important. I actually spend a chapter discussing it. Let me make a few key points.   

There are a few structures that are problematic. One is when the only way a couple connects is when it comes to the children. Then, as one of you mentioned, it becomes parent-partners rather than a marriage. So some time needs to be spent in non-child related ways of connecting.   

Another problem is watch out for is a "divide and conquer" structure. This is where each partner is working very hard-either supporting the family or with the children and home. If there is not bridge to connect with each other as two individuals, marriages are often at greater risk.   

Nanci The Balanced Mind Parent Network 
The divide and conquer situation is one that we hear about frequently from our members. Any suggestions on how to watch out for the pitfalls, or to circumvent this dynamic? 

Laura Marshak PhD   
Yes. One is understanding that although this may be efficient in the short-run, it is risky over time. It works for child rearing but not for sustaining a marriage.  
  
belle77   
Could you give us some ideas of non-child like ways of connecting? 

Laura Marshak PhD   
Absolutely. When possible, and I know that it is not always possible, going out together and making a rule that you will not talk about kids is ideal. For many couples, this is hard to do (separate from the logistics) because they have grown so used to only focusing on the children. But, after an awkward start it quickly becomes easier.   

In addition, I think it is important to connect with your partner in conversation about themselves (about topics that don't concern children). In terms of connecting, I want to add that I think sexual intimacy is also very important. I recognize that this is often one of the first areas of a marriage to be impacted by raising kids with disorders. But, I also think it is possible to protect a sexual relationship.   I know that when couples are depleted, it is easy to lose interest. However, marriages that become devoid of some sexual connection face greater risks.   

Nanci   
At the risk of making a generalization, is it safe to say that there are some basic differences between genders when it comes to communication and dealing with emotions? If so, what things should couples know about the Venus/Mars differences so that they can be more empathetic and cooperative? 

Laura Marshak PhD   
Nanci, It is an important point and often this generalization holds true. This very much becomes a factor in terms of handling emotions about a child's difficulties. I exhort couples not to pass judgment one ach other for having a different emotional style-this is absolutely to be expected.   

I also want to add that in the past many years, while working with many couples--I have become even more aware of how deeply men feel about their children's disorders (while masking its emotional expression). Wives often are not aware of their deep feelings of sadness as well because they are more hidden.   

belle77   
In your first chapter of the book you had a list of ways that couples can connect with each other when faced with time constraints. Email was one of them. Could you review the others from that list with us? 

Laura Marshak PhD   
Hi Belle, I thought I knew this book by heart but I didn't see it in the first chapter. However, I will do it off the top of my head.  There are many ways to connect that don't take much time. Yes there is e-mail. But, there is also a kiss and hug hello and good-bye. I bet that takes about 60 seconds. There are phone calls that ask about how each other's day is. There are small symbolic gestures. For example, my husband actually always brings me a cup of coffee while I am in the shower (even if we had been out of sorts with each other.) It is a quick way to show a little love and care.    

What these ways have in common is showing that we see our partner as the person we married-not just as a co-parent. 

Nanci The Balanced Mind Parent Network 
I'd like to finish with a suggestion shared by morah mom on things that she and her husband do to stay connected. 

morah mom   
When we get away we have even made "lists" of favorite places we've been, funny things that we remember, especially for a birthday or anniversary. It's a great way to jump start a conversation and focus on the things that brought you together in the first place. 

Laura Marshak PhD   
That is a lovely idea.   

Nanci The Balanced Mind Parent Network 
I would like to thank Dr. Marshak for sharing her time and expertise with us, and for all of you who offered great questions and comments. This is a topic we could discuss for days but this hour has been a great springboard for all of us. 

Laura Marshak PhD   
Thanks for having me. I enjoyed it!


Chat with Lizzie Simon, Author of Detour: My Bipolar Road Trip in 4-D

February 25, 2009

The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Lizzie Simon? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Watch your email for more details.

Biography

Lizzie Simon is the author of Detour: My Bipolar Road Trip in 4-D. Lizzie has appeared on CNN, Fox, NBC, NPR, the New York PostThe Saturday Evening Post, and Nylon Magazine. She has traveled the country to speak to wide-ranging audiences about mental health. Lizzie also co-produced the MTV documentary “True Life: I'm Bipolar”, and has written mental health pieces forTimeCosmoGirl, and bp Magazine. She is a founding member of the Leadership 21 Committee of the Bazelon Center for Mental Health Law.      


 Nanci - The Balanced Mind Parent Network   
I’d like to welcome our guest, Lizzie Simon.

Lizzie Simon   
Hi Everybody! 

Nanci - The Balanced Mind Parent Network   
We're delighted to have you here today, Lizzie. Would you like to make any opening comments? 

Lizzie Simon
Just that I'm happy to be here! 

Nanci - The Balanced Mind Parent Network   
Could you start out by talking a little about your book and what it meant to you to research and write it? 

Lizzie Simon
Sure. When I was diagnosed with bipolar disorder there weren't a lot of role models and there weren't books from the point of view of a young person with dreams who wants to know she'll be able to achieve her dreams, even after everything she's been through with bp. I knew if I just told the truth, my truth, that other people would relate and feel more comfortable with their truths. 

compassion   
Lizzie, My daughter, 15 was diagnosed with bipolar disorder in July. She entered an RTC (residential treatment center) a few weeks ago. The stabilization process seems to be taking a very long time. Any suggestions? 

Lizzie Simon 
Well it's hard for me to give advice, because I'm not an expert and I don't know your daughter. In general though, it's important to always encourage all of your daughter’s interests and passions and not focus too much on her diagnosis. Let the docs deal with the illness—and develop the young woman she's becoming.  

Nanci - The Balanced Mind Parent Network   
Looking back on your experience, what things did your family (your parents in particular) do well, and what do you wish they would have done differently? 

Lizzie Simon 
My parents did many things right—they encouraged me to get right into the world and have never treated me like I have a disability. Sometimes I wish they had also been more patient when I was depressed. They were very impatient, like, "get over it already", and I wasn't always in control of it.  

I wish my doctor or someone could have supported my parents more during the tough times, that someone could have shared hope with them.  

Nanci - The Balanced Mind Parent Network   
That brings up another question - was your family, or you individually, involved in therapy or was your treatment primarily medications? 

Lizzie Simon
I didn't get therapy until I was 25—because I had trust issues and before that I never really felt any therapists understood what I went through. But looking back, therapy was what really made a significant difference in my recovery, especially where relationships are concerned. My dad started seeking help for his own depression after my book came out—he gets depressed periodically. And my mom went to a massage therapist who she says really, really helped her relax and process her emotions. 

teddyone   
What calming techniques worked for you as a teenager? 

Lizzie Simon
As a teenager massive amounts of marijuana were my only calming techniques. Not recommended. I wish they taught calming techniques in schools! Now I have yoga and meditation and tea and long walks. I have a host of techniques that I didn't have then. 

Nanci - The Balanced Mind Parent Network   
Do you attribute that to your increased willingness to learn or to professionals becoming more educated about bipolar disorder? 

Lizzie Simon
My increased willingness to learn and my wonderful therapist as well.  

teddyone   
Hi Lizzie. Thank you so much for being here. Did you ever feel like you were your illness- bipolar? Or did you always feel like it was only a part of you? 

Lizzie Simon
I have always felt it was only a part of me—I'm a very active person, engaged in the world and service and art projects and writing and none of my friends can really wrap their head around the idea that I have a mental illness—sometimes I wish they got it but I think it's very, very, very healthy to have so many other identities and have so many roles other than that of consumer or patient. 

I worry when I meet kids who rattle off their meds and their diagnoses and can't talk about anything else in their lives. 

sce   
Going back to your last comment, what made you decide not to continue to use marijuana - or to realize there are better/safer/legal techniques? How can a parent convince her teenager this is not a good approach? 

Lizzie Simon 
I stopped smoking pot gradually over the course of college—I really didn't "party" much at all my senior year of college and after. I had serious goals. I didn't like feeling high. Potheads bored me. I think for parents, and I don't have kid yet myself, but when I imagine parenting my future kids, I imagine just trying to encourage their passion and goals. Ultimately when you care about your goals you start taking better care of yourself just so that you can achieve them.  

elliotts6   
What do you tell a newly diagnosed 14-year-old, who is very cognizant of what BP is, and just wants to be "normal"? He feels angry and hopeless, and that his life is "over." He's always been very high-functioning, with a previous MI dx, but now just wants to give everything up. 

Lizzie Simon
Again, I would say, start pursuing his other interests. Is there a travel trip to research and plan together? Is there a class he'd like to take? I think BP can be so many things. There are people homeless because of it and then people living very fulfilling lives with it. I would tell him he has a hand in making it what he decides it will be. I would tell him no one is normal. That the best people are comfortable not being normal. That BP can just be a condition he has to be responsible for, but that's all. Then take him to the slums of India so he can meet people with problems they really can't escape. 

007
If you could give a one minute public relations message to teens and young people about how to successfully live with bipolar disorder, what would you say?

Lizzie Simon
So hard to reduce a lifetime of ideas about a condition that takes a lifetime to understand to one minute of advice. But ultimately, in life, you are responsible for your own liberty. Learn how to best take care of yourself, then get over yourself, and get to work making the world a better place! 

sce   
When our son was in middle school/high school, life was more "normal" in terms of expectations etc. Now that he is 19 and flunked out of college, he seems so lost. Can you suggest any specific ideas/role models/ways to help young adults with BP get and stay motivated? 

Lizzie Simon  
It’s hard when they are out of the structure and community of college. Again, if you can get him on track with something he believes in, helping others, or art, or some kind of expertise, he'll be much better off. He has to get motivated. He has to find some kind of passion or curiosity. You can only encourage it. Maybe try and get him talking about what an ideal version of his life might be? 

Nanci - The Balanced Mind Parent Network   
Education issues are a big part of what many of our parents contend with. Did you find that you needed any accommodations in college because of your disorder? Or, in hindsight are there things that would have been beneficial to assist you, particularly in periods of instability? 

Lizzie Simon
Parents with college or high school age kids should check out a project I worked on with the Leadership 21 Committee at the Bazelon Center for Mental Health Law. It's a book called Know Your Rights and it addresses everything college age kids need to know who have mental illness. It is available on http://www.bazelon.org/.  

Nanci - The Balanced Mind Parent Network   
You've been very active in Bazelon, are there any points you can share with us about the types of issues that you've advocated for or seen students having to tackle in terms of their rights? 

Lizzie Simon
Well yeah, kids should check in with the disability office when they get to school, whether they are doing well or not, just to make the introduction and find out what the deal is if they ever get sick. Knowing this probably prevents a whole lot of stress. 

Nanci - The Balanced Mind Parent Network   
Does that in and of itself insure that their rights will be explained and met? Are some colleges and universities more prepared and willing to be supportive? At the elementary and secondary school level there is a huge amount of disparity. 

Lizzie Simon
Yes, there is a huge amount of disparity, but colleges more and more are providing resources, not so much out of the goodness of their hearts but to cover their butts so they don't get sued. 

sce   
Thank you for your comments. You seem so together and your advice seems pertinent to all teens/young adults. If you are willing to be more specific about a time when you were less in control, how did you know when things were spinning out of control and convince yourself that you needed to get yourself back on track? 

Lizzie Simon
That happens still—what is important is for kids to start to understand how it feels in their head and body at every stage: relaxed, mildly stressed, very stressed, out of control, and to start practicing recognizing when it's out of the realm of mildly stressed, and practicing steps to get back. They have to develop this internal register—it can't be their parents or doctors telling them. And I think teens don't even have the neurological development that makes this possible, so it may take a while before they really get it. 

It helps to remember what works. For me, staying home, cooking, blowing off all appointments, exercise, therapy, meditation—these will bring me back. In high school and college I didn't know when things were out of control. Sometimes I knew. Sometimes I didn't. In my twenties I was more interested and invested in feeling good and balanced. 

Nanci - The Balanced Mind Parent Network   
So, in those volatile teen years, are there ways for parents to gently help our kids recognize that they are a) cycling or losing stability and b) suggest they use their coping techniques for riding through the wave? Or, do we assume that meds need to be adjusted? 

Lizzie Simon 
Raising a teenager must be SOOOOOOOOOOOOOO hard. You all are scaring me a bit. I have no idea how I'll handle these issues! 

Nanci - The Balanced Mind Parent Network   
Sorry, didn't mean to scare you! 

Lizzie Simon
I don't know the answer to Nanci 

Nanci - The Balanced Mind Parent Network   
That's ok, I appreciate your honesty! 

Lizzie Simon 
I struggled with romantic relationships and basically dated a string of drug addicts until I was 29-—ugh—It will break my heart if my own kids do this. And I will want to strangle them. But everything is easier now that I have lousy relationship patterns out of my system. Took a long time for me! 

Nanci - The Balanced Mind Parent Network   
I'd like to ask a question on behalf of a young lady who was in here shortly before this chat started but had to leave to go to work. She is in her early 20's and has the BP diagnosis. She was seeking support from others with BP. Has peer to peer support played a role in your life, Lizzie, or have you relied more on your therapist and your friends? 

Lizzie Simon
I have a couple of friends who have dealt with this first hand, and they are best people I can talk to when I'm really struggling, because of the compassion they know how to give from first hand experience.  

007   
What advice do you have for a young adult just coming to terms with accepting their mood disorder, yet unwilling to call it Bipolar, and handling the stress that comes with trying to reconnect with college, work, family. As her mom I'm also grappling with how to advise her on her good thought about quitting smoking yet knowing that the nicotine has probably been medicating her as well. 

Lizzie Simon
Well...I don't think it matters what you call it as long as you are taking care of yourself. My advice to her is just to keep taking care of herself, get support, and keep focused on her goals. And to quit smoking, but that is hard to do, and she'll have to take it on when she’s ready. 

My last bit of advice is just that I hope you all get the support and encouragement that I know my own parents needed, and that you remember how important it is to take care of yourselves even though it's your kid with the diagnosis. 

Nanci The Balanced Mind Parent Network
Lizzie, thank you so much for sharing your time and experiences with us. Your candor and insight are so helpful in giving us a window into what our kids are facing. And, your advice on wellness and how to be supportive and encouraging is reassuring and much appreciated. 

Lizzie Simon
Thank you!


The Balanced Mind Parent Network Expert Chat with Janet Wozniak, M.D. Co-author of Is Your Child Bipolar

January 13, 2009

Chat With Janet Wozniak, M.D. (2009)
The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Janet Wozniak, M.D? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network expert chats occur throughout the year. Watch your email for more details.

Biography

Dr. Janet Wozniak is the Director of the Pediatric Bipolar Clinical and Research Program in Pediatric Psychopharmacology at Massachusetts General Hospital, and a member of The Balanced Mind Parent Network's Scientific Advisory Council. Dr. Wozniak's research focuses on the characteristics, longitudinal course and treatment of pediatric bipolar disorder.     
                             


Nanci - The Balanced Mind Parent Network   
I'd like to start by welcoming Dr. Wozniak.

Janet Wozniak MD    
I am happy to take any questions.

Nanci - The Balanced Mind Parent Network   
Great, we have several on hand already.

sagabeanie    
How are bipolar disorder and anxiety issues connected? Which comes, first the chick or the egg?

Janet Wozniak MD    
There is a strong bidirectional overlap between anxiety disorders and bipolar disorder. That is, in a sample of bipolar youth, at least half have significant anxiety of various forms, and in anxious children we see higher than expected rates of bipolar disorder; so we know that they 'travel together' but we do not understand the nature of the relationship. It may be likely the genes that are associated with bipolar also produce changes that bring anxiety. 

Sometimes the child has anxiety first, sometimes mood first, and sometimes both come on together. A lot of kids start off with significant separation anxiety along with the moodiness of preschool age and then go on to have full-blown mania depression. We do not know the 'chicken and egg' part, but many parents feel that if their child’s anxiety is treated, the mood reactions would diminish. The problem with this approach is that the best medications for anxiety are the SSRI antidepressants, and these will make mania much, much worse!  

So if both co-occur, our standard treatment approach is to use a mood stabilizer, anti-manic treatment then sequence in an anti-anxiety treatment. We tend to use benzodiazepines, BuSpar, or Neurontin for the anxiety, as these won't make mania worse.

I always find it interesting that person can be shy and inhibited and wild and disinhibited all at the same time, but that is the nature of anxiety plus bipolar.

Sometimes a clinician will cautiously introduce an SSRI. These can be used, but should be sequenced after an anti-manic agent, and used in small amounts with a lot of monitoring for mania.

lezbrez    
I read your book and felt that it really described my 9 year old son. However, getting a local therapist to agree and diagnose him with bipolar seems impossible. Why do clinicians/counselors avoid this diagnosis?

Janet Wozniak MD    
The main one is that many clinicians likely graduated from programs with minimal training in identifying this diagnosis. But I am always amazed at the power of prejudice; that people 'don't believe' that it (bipolar disorder) can exist in children. Rather than get tangled in an argument over the word 'bipolar', instead identify target symptoms such as irritability, depression, anxiety, and impulsivity, then work with a clinician to use medications to get at these problems. 

Mood stabilizers are excellent anti-aggressives and many clinicians use these even if they do not use the 'bipolar' diagnosis. If your clinician thinks it is depression and anxiety and wants to try an antidepressant, you need to worry that such a med could make mania worse or could lead to more disinhibition so you can work with that clinician, using the antidepressant and stopping if worsening of symptoms occur and/or you can suggest a second opinion about the medication.

barbarat    
Can you describe what mania has looked like to you? Can it come on quickly but be of short duration? What have been typical triggers you have seen with mania in elementary and middle school aged children?

Janet Wozniak MD    
Mania is characterized by dramatic moods of irritability and euphoria. The children (and many adults) are often 'labile' in their mood and can change minute to minute. Most parents I see describe what they call 'rapid cycles' of changes throughout every day; flipping from rage, to lower level irritability, to sadness and to euphoria (goofy, giddy, silly, high, energized).

In the book I wrote we described this '5 pointed star' of mood changes:

  • irritability
  • rage
  • depression (sad, crying, hopeless)
  • euphoria (singing, dancing, high, hyper, more than even typical for a youngster of that age)
  • and then a 'typical' kid

Parents see all points of the star for varying degrees, cycling in complicated ways from day to day, week to week, month to month, season to season.

Irritability is most commonly described to us, but most who are highly rageful (most, not all) have euphoric spells, too. But most parents don't mind the euphoria nearly as much as the rage/aggression/violence. 'Tantrum' is a word to describe the typical emotional lability (changeability) of children, but bipolar children are much, much more extreme in their moods than even typical children of young age. There's a lot more to say about this...I can go on but maybe there are some other questions?

Nanci - The Balanced Mind Parent Network   
Can you talk about the rage element a bit. Would that qualify as mania or something else? And at what point is it necessary to remove a child from the home because of the rage?

Janet Wozniak MD    
In psychiatry we have neglected the spectrum of irritability. Odd really, as anger is so disabling to individuals and families. But if we hear that someone has an 'anger problem' most clinicians will look to see what the source is and anger can occur with depression, depression and oppositional/defiant disorder.  This last, ODD, is indeed an 'odd' diagnosis because it rarely occurs all on its own but instead is fueled by the impulsivity/frustration of ADHD, unhappiness of depression or disinhibition of mania. 

One of the contributions from my group in describing and treating children whom we now diagnose as 'bipolar' has been to raise awareness that rage can exist in children; that is, anger is not just typical 'tantrums' or poorly parented children. However, I must say I worry that sometimes I make the point too well the anger/rage we see is EXTREME and it makes people unnecessarily afraid of these children. Most of the most severe rage occurs at home.

You only need one such episode at school to get kicked out! Or, hopefully, placed in a therapeutic setting. But a lot of the children I see with severe rage at home, at school appear ADHD-like or depressed-like or anxious-like. They just keep a low profile.

Think of the brain like the way we think of the heart. To bring out the abnormal functioning, we put the person on a treadmill. We give a heart 'stress test'.  For most individuals, being at home with our loved ones, forming the most intense emotional bonds, this is our brain's emotional stress test. So no wonder that the most dramatic symptoms are at home first. Just like for the cardiac patient, the most dramatic symptoms are walking up the hill on the golf course.

Nanci - The Balanced Mind Parent Network   
That would explain why mom is so often on the receiving end of the rage.

Janet Wozniak MD    
Yes, our brains do something different when we are with our mothers. We use the 'emotional centers'. These 'emotional centers', the limbic system, is likely the 'weak area' for bipolar folks. Even with bipolar adults, it is the spouse or children or closest friends who get the brunt of the abnormal behavior.

Stacey W.    
I am glad you mentioned ODD... how do you differentiate between ODD and bipolar?

Janet Wozniak MD    
Almost all of the bipolar kids I see also have ODD, and in fact a major portion of them have SEVERE ODD.  It is not just, "I won't clean my room, make me!"  It is, " You $$%*&@#$'ing ##$%*&%#, why should I clean my #%$^%^ room???"

It is an important distinction. I think it is a different type of ODD, a severe, grandiose, delusional form that we often see in bipolar. Akin to the adult calling the President to tell him how to run the country (bad example during the Bush administration, ha ha). Or the adult telling his boss off. Bad idea. So in my mind the diagnosis of only ODD is not very helpful. To say someone has problems with authority doesn't help make a treatment plan. The most useful thing to do is to figure out why.  Is it:

  • manic level grandiose defiance, '"whh should I do what YOU say?"
  • or depressed level “I won't do it, can't do it, no energy, no motivation”
  • or anxious, "I won't do it, you can't make me, I am terrified to leave the house, terrified of what might happen”
  • or ADHD level....."homework is hard for me, I won't do, don't make me”

With a lot of the kids I see, it is ALL of these at various times, a lot of different reasons for ODD. We start with the most severe, the manic level and then work on down the list.

Nanci - The Balanced Mind Parent Network   
We have several questions about ADHD so let's switch gears to that comorbidity.

soccermom    
Dr. Wozniak, my 17 year old daughter is diagnosed Mood Disorder NOS and ADHD. She is currently stabilized on Abilify 10mg but while the mood stuff is much better, she still struggles with school related issues. It appears she has little or no executive functioning. I would like to discuss putting her on an ADHD medication with her pdoc but fear increased mania (which still breaks through at times). Do ADHD meds help kids with mood disorders focus better or should we be going for neuropsych testing and educational accommodations?

Janet Wozniak MD    
If ADHD and mood issues co-occur, after mood issues are better (they are seldom 'perfect') then my practice is almost always to try to treat the ADHD. When stimulants make mania worse (and they might as much as 50% of the time) generally things settle quickly when withdrawn, within a day or few days. Not like with antidepressants; with these a bad (manic) reaction can take weeks to settle or longer!

But since ADHD is SO disabling, it is worth trying to see if you can help with it. There are one or 2 small studies showing that a stimulant can be safely added to a mood stabilizer with help for ADHD. If the mood is still unstable, the stimulant may not work well. So go back to the mood medications and try to improve the mood. 
When and if to add a stimulant is a clinical judgment call, but is often a good idea given the major upside and minimal downside even of a bad reaction. Beware though that our current ADHD medications are good for focus, attention, concentration, but are not so great for executive functioning things like working memory, planning, global organization. These are parts of what we are calling executive functioning, and if you don't have these pieces it is highly disabling, even if you are very smart. We can see high IQ and poor executive functioning and this can be more devastating to functioning than the reverse. That is, low IQ but intact executive functioning may lead to better academic performance. This is very frustrating for the high IQ/poor executive functioning kid who ends feeling really stupid. So you need to go both routes, consider medication, but work for school support as well.

KKL    
Our now 17 year old son was diagnosed with major depression at 15, bipolar at 16, second opinion said ADHD and not bipolar, 3rd opinion at 17 said to defer any Axis I diagnosis until adult, mixed personality with antisocial and narcissistic. We have experienced the reluctance to diagnose an adolescent as bipolar, and prior to educating ourselves, shared that view to some degree. 

Your book was very helpful and very relevant to our situation. How do we overcome providers’ reluctance and get treatment for our son? Is there other research besides that at Harvard and Mass General that supports your findings? The recent press about Dr. Biederman may be impacting the situation.

Janet Wozniak MD    
In fact, most of the research on pediatric bipolar has been done by other sites. Dr. Boris Birmaher in Pittsburg, Dr. Kiki Chang at Stanford, Dr. Barbara Geller at Washington University in St. Louis, Dr. Robert Kowatch and Dr. Melissa Delbello in Cincinnati and Dr. Robert Findling in Cleveland.

All of them could likely offer an 'expert' opinion either privately or via a colleague or in the context of a research study. If your son is included in a research study on bipolar, it is a good confirmation of that diagnosis because generally researchers want only true 'cases' or else the research won't be valid so it can be a more rigorous way to get a diagnosis regarding the personality disorders. Some clinicians think 'either-or' that is, either bipolar or personality disorder (narcissistic, antisocial, borderline). BUT like with the other 'axis I' diagnoses (Axis I disorders are considered biologically based), people often have more than one thing. 

Personality disorders can benefit from therapy (e.g., Dialectical Behavioral Therapy (DBT) - is great for borderline disorder) and help you understand some patterns of interaction, but do not guide medication treatment or help you understand the 'out of control' part. We do not focus on the personality disorders in our research much, but there is considerable overlap in the criteria for these and other disorders so both bipolar and narcissism can co-exist. Some clinicians are more trained in and comfortable with the personality disorders as ways to describe emotional dysfunction. As long as you agree on the target symptoms, e.g., rage, grandiosity/entitlement, hopelessness, etc, the treatment can proceed.

I am glad you found the book helpful!

Nanci - The Balanced Mind Parent Network
We're almost out of time, do you have time for one or two more questions?

Janet Wozniak MD 
yes

Barbarat
Your mention of the limbic system brings to mind Dr. Amen's work. Have you used or looked into the use of SPECT scans or QEEG's or Occular Light Therapy as possible effective complimentary strategies or diagnostic tools for children with mood spectrum, frustration tolerance, anxiety, ADHD etc. issues? How about the use of bio feedback?  

Janet Wozniak MD 
No matter what you read in brochures, these scans DO NOT make or even confirm clinical diagnoses. I wish they did! We still have to rely on stories of symptoms over time from the individual and his/her significant others (usually parents in my clinic). Some day these scans might help with diagnoses.

Even in studies such as from the NIMH (Ellen Liebenluft, MD et al, another excellent research group confirming the diagnosis of pediatric bipolar) the imaging results are useful only when groups are compared. No clinician can take a scan and tell you what the diagnosis is.

The programs that sell these scans usually ask for a lot of history as well, and I believe they use that to 'guide' the reading of the scan. These scans are not therapeutic either; however, biofeedback is used primarily for anxiety treatment with success, e.g., slowing breathing and heart rate, quelling the panic response. To my knowledge, there is no evidence to date that it is helpful for ADHD.

By the way, regarding the 'validity' of pediatric bipolar disorder: Barbara Geller MD, a major contributor to and pioneer in pediatric bipolar research, published her Magnus Opus (or at least one of them) in the Archives of General Psychiatry a few months back. Nanci, you should excerpt this on the website. She provides compelling evidence that childhood bipolar disorder becomes adult bipolar disorder. In fact, in our adult clinic, 70% of the adults, when asked with detailed questions, described a prepubertal or adolescent onset of their disorder.

Most of adult bipolar disorder (at least in clinical settings) is pediatric onset!

Michelley   
Help! What do you suggest for those of us in really small rural towns where there isn't a medical professional with experience treating a bipolar/adhd diagnosis? Our 10 yr old daughter was diagnosed bipolar and ADHD. She is currently on Abilify and Focalin for treatment. We're new to all of this and don't really know what is SSRI or enough about medication but don't typically see these medications on the forums or other sites as typical treatment. Are these good treatment choices for her?

Janet Wozniak MD   
With this brief information, I will say that Abilify and Focalin sounds like a typical treatment for a 10 year old with bipolar and ADHD. 

The downside to rural settings is the lack of professionals, but rest assured, even families in NYC have difficulty finding a pediatric psychopharmacologist.

Nanci - The Balanced Mind Parent Network  
Our staff and volunteers can help with searches for clinicians in your area. 

Nanci - The Balanced Mind Parent Network  
One last quick one on PDD (Pervasive Developmental Disorder).

Cammi   
My 4 year old has bipolar and PDD. I’m having a hard time telling them apart.

Janet Wozniak MD   
PDD refers to problems in:

  • social interaction (poor reciprocal relationships) and
  • communication (language delays, quirky language, repeating a lot, a general lack of 'pragmatic' skills for communicating language)
  • behavior (but the behavior is a restricted repertoire of interest, rigid thinking, sometimes odd play or physical habits like flapping).

PDD is not a mood disorder, although some percentage (in our clinic about 20%) of PDD children have bipolar disorder. While bipolar kids have social problems, only about 20% or less of them have formal PDD or autism spectrum. This has been muddied because the atypical antipsychotic medications, e.g., Risperdal, have been studied and approved for bipolar disorder, but also for irritability in autism. We might wonder if high levels of irritability in autism is actually bipolar + autism. We had a hard time recruiting autistic spectrum children with irritability for a study of this because when the irritability was at a high level, the child often met the criteria for bipolar disorder.

Nanci - The Balanced Mind Parent Network  
That has been a frequent topic of debate on our groups and forums, the relationship between BP and autism/aspergers.

Janet Wozniak MD   
A complicated problem but well worth our research. We are increasingly turning to this research because in my clinic, well over half are children with this combined problem. They are harder to treat, experience a lot of side effects, don't respond in predictable ways to medication and standard dosing, and have A LOT of co-occurring anxiety.  

Also, we see 'autism spectrum', not just the most severe autism, as part of PDD. Children with PDD are reactive to changes in environment, transitions, sensory overload. But when the reaction is rage, screaming, violence, then we wonder about bipolar disorder and go on to consider that in the diagnosis along with the PDD. Rage is not bipolar. But high levels of persistent irritability along with at least 3-4 other symptoms of mania including euphoria, distractibility, agitation, grandiosity, flight of ideas (in thinking), reckless activities/poor judgment, decreased sleep, and talkativeness is the definition of mania.

Nanci - The Balanced Mind Parent Network  
Dr. Wozniak, thank you so much for sharing your time and expertise. We had a great audience today with many more questions than we could get to, but I hope that we were at least able to touch on a range of topics that related to many of the questions. One member did ask if you were available for phone consultations.

Janet Wozniak MD   
My assistant Meghan is at (617) 503-1451 and can tell folks about how to access me in the clinic or through studies or for one-time consultations.

Nanci - The Balanced Mind Parent Network  
Thanks! Any closing remarks?

Janet Wozniak MD   
Please have me back again! The questions are all very good and interesting to me.

Nanci - The Balanced Mind Parent Network  
We'd be delighted, you are a very popular guest!

Janet Wozniak MD   
Good luck to everyone in working your way through the diagnosis and treatment maze.

KKL   
Thank you!

Jim   
Thank you very much.

Seth   
Thank you!!!

Cammi   
very helpful thank you

4boysmom   
much appreciated!!!


2009 Chat with Ellen Leibenluft, M.D.

January 1, 2009

Did you miss our chat with Ellen Leibenluft, M.D.? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Spring. Stay informed- join our mailing list by entering your email address and zip code in the box in the top right corner of the website.

Biography
Dr. Leibenluft is Chief of the Unit on Affective Disorders in the Pediatrics and Developmental Neuropsychiatry Branch, Mood and Anxiety Disorders Program, National Institute of Mental Health. She received her B.A. from Yale University in 1974 and an M.D. from Stanford University in 1978.  She is now actively involved in research on bipolar disorder in children and adolescents, with a particular emphasis on differences between children and adults in the presentation of the illness; neural mechanisms underlying the symptoms of the illness; and the development of new treatment strategies for early-onset bipolar disorder. 


Nanci   
We are very excited to have Ellen Leibenluft, MD as our guest for this months’ The Balanced Mind Parent Network expert chat. Dr. Leibenluft is a Senior Investigator and Chief of the Section on Bipolar Spectrum Disorders with the National Institute on Mental Health. Her research focuses on the brain mechanisms involved in bipolar disorder in children and adolescents and on diagnosis.

Ellen Leibenluft MD    
It's a pleasure to be with you all.

Nanci    
Dr. Leibenluft, it's been a year and half since we last chatted with you, would you like to update us on what's going on at the NIMH.

Ellen Leibenluft MD
Sure. We've been very busy continuing along with our ongoing studies and starting some new ones. In terms of the ongoing studies, for almost a decade now we have been studying youth with bipolar disorder (BD) and those with severe mood dysregulation (SMD).

SMD is a clinical syndrome we defined to try to address the controversy about whether children with very severe irritability, but without the distinct manic episodes that are characteristic of bipolar disorder (BD), should be considered to have bipolar disorder. We have found differences between BD and SMD in what tends to happen to them when they grow up, family history, and brain function.

We are continuing these studies, comparing children with SMD and BD on brain function in particular, using neuroimaging. We have also started new treatment trials, both for youth with SMD and those with BD. And, finally, we have started a study of children with a family history of bipolar disorder (that is, children with a parent or sibling with the illness). So as you see we have been very busy.  

Nanci    
Before we start taking questions, (and please feel free to submit them at any time) could you go into more detail about the differences you are finding with SMD and BP?

Ellen Leibenluft MD    
As children with SMD grow up, they appear to be at risk to develop depressive disorders and anxiety disorders, but not mania (in other words, not bipolar disorder). That's probably the most important difference, and it raises the question as to whether the treatment should be different between the two groups.

Nanci    
That was going to be my next question! What is your assessment of irritability as a symptom, as well as rage?

Ellen Leibenluft MD    
Irritability is very common in children with SMD and in those with BD. The difference is that, with SMD, the irritability is there pretty much all the time. With BD, there may be irritability, but there are also definite periods of time, lasting for at least a few days, when the child is much more active than usual, much happier than usual, different sleep and activity patterns, etc.

So with an SMD child "what you see is what you get," the child looks pretty similar year after year (very irritable, kind of sped up). In BD, there are clear periods that you can point to where the child was different, in terms of their activity level and mood, either up (manic) or down (depressed), and those periods lasted for at least a few days.

Nanci    
Does depression come into play with SMD?

Ellen Leibenluft MD
Excellent question. Yes, a certain percentage (maybe 15%) of the youth we see with SMD have already had an episode of depression. But what we find is that, as they get older, they are at increased risk (relative to children without SMD) to develop depression. So both SMD and BD develop depression, but only BD develops mania.

Nanci    
As a parent, I have to say a huge thank you to you for doing this research. So many of our families are caught in this quandary over diagnosis.

Ellen Leibenluft MD    
You are so kind!! It’s comments like that that keep me (and my team) going. It takes a team of course.

Nanci    
Well, our questions are pouring in so let’s get started . . .

lindad    
So, in a child with bipolar disorder the mania is actually an elevated mood vs. irritability? I have been led to believe that irritability is a child's way of manifesting mania.

Ellen Leibenluft MD    
Great question again. About a decade ago, researchers started suggesting that mania manifests in children as irritability, not euphoria, and that children with BD don't have episodes...instead, what children with BD have (the argument went) was very severe irritability, without episodes of mania like what you would see in adults.

It was to address that question that we defined the SMD group, and started recruiting them and comparing them to children with clear, episodic mania. Most children with clear, episodic mania have euphoria during at least one of their manic episodes. By "most" I mean 85%.   But what we have found is that SMD differs from BD, in terms of what happens to them when they grow up, and in terms of family history and brain function. So our data indicate that irritability, without clear manic episodes, is not the way that children manifest BD.  

Cindy    
Can you talk what is happening when a very anxious or depressed child is treated with an SSRI medication to address those symptoms and then develops many of the more expected signs of mania such as grandiosity, hypersexuality, severe rages, excessive motor activity, and decreased need for sleep?

Ellen Leibenluft MD    
There are several sorts of problems that children can develop when they are treated with SSRI. A relatively rare one is to develop a true manic episode that has all the symptoms of mania and lasts for at least a few days, usually even longer, even after the medication is withdrawn.  Most people think that sort of reaction is an indication that the person has BD, and may develop more manic episodes even without a medication tipping it off.

What's much more common, however, is an "activation" response, which is different from a true mania. It’s much more short-lived, hours or maybe a day or so, resolves quickly, and often doesn't recur if the medication is restarted, at a lower dose, or a different SSRI is used.

So it's very important to distinguish between mania from an SSRI, vs. activation from an SSRI, because in the first instance you would avoid SSRIs, and in the second the child might ultimately do well on them.  

Jessica    
How can we encourage more cooperation between psychiatry and neurology? In the category of SMD kids there are some (like mine) who turned out to have not bipolar disorder but undiagnosed neurological dysfunction--temporal lobe epilepsy. Neurologists have become very aware of the effect on mood that seizures have…yet as far as I can tell, psychiatrists are not looking for a neurological etiology when they see a patient with atypical bipolar symptoms.

Ellen Leibenluft MD    
That's also an excellent question. Often an important link in that chain is the pediatrician. Psychiatrists should talk with the child's pediatrician, and the pediatrician can be thinking about whether a neurologist should also be brought in. If things aren't going well, it's very appropriate to ask your pediatrician to call the psychiatrist, or vice versa.

Robin    
How is ADHD with irritable depression different from bipolar disorder in children and can stimulants and/or SSRIs exacerbate or bring on bipolar disorder in at risk children.

Ellen Leibenluft MD    
ADHD with irritable depression differs from bipolar disorder in that in ADHD with irritable depression there are no manic episodes. A manic episode should be a distinct "up" time, with decreased need for sleep, grandiose thoughts, increased activity, and other symptoms. In ADHD with irritable depression, there may be a distinct "down" time, but there isn't a distinct "up" time.  

I realize I didn't answer the second question. It is very controversial as to whether stimulants or SSRIs can exacerbate or bring on mania in at risk children. I assume we're defining "at risk" as with a parent or sibling with BD. It's important to remember that most people with a sibling or parent with BD don't themselves develop BD. In fact, the most common mood disorder in the families of people with BD is not BD, but unipolar (major) depression.

So we don't withhold treatment with stimulants or SSRIs from at risk children (if it's indicated), but we are very careful about dosing and we follow them closely.

Mimi    
Do anti-psychotic medications work for both bipolar disorder and severe mood dysregulation?

Ellen Leibenluft MD    
Unfortunately we have very little data on what works for SMD because it was so recently defined (we know that antipsychotic medications work for BD). Because children with SMD have ADHD, and often have anxiety, we actually usually start their treatment with stimulants and an SSRI (which you wouldn't use in BD!). We do it slowly and carefully, and we find that many children respond well. We prefer not to start with antipsychotics because they tend to have worse side-effects than stimulants and SSRIs. However, there are 2 other important things to say.

1) Sometimes children don't respond to SSRIs and stimulants, and then we do treat them with a low-dose antipsychotic, and 2) what I am telling you is based on clinical experience, not a clinical trial. We are currently conducting a clinical trial of SSRIs and stimulants in youth with SMD, and if you are interested in participating you can call our referral line to learn more.  

Nanci    
I'll post the link and the phone number again at the end of our chat. We have several questions on teen issues and a general one that I'd like to put through so that we can cover a range of topics.

Belle
What are your thoughts on the 9/29/09 study published in Journal of Abnormal Psychology; "Are There Developmentally Limited Forms of Bipolar Disorder?" MU researchers found an age gradient to indicate young adults may outgrow bipolar disorder.

Ellen Leibenluft MD    
Yes, there is a possibility, and this points out how little we know about the course of these illnesses. But there are two things to be aware of in terms of that article.

First, the design of the study wasn't longitudinal. In other words, they didn't follow a group of people with BD over time and see if it went away. Instead, it was a cross-sectional design...they compared rates of the illness in people aged 20-25 (something like that, I don't remember the exact ages but you get the idea), to people aged 25-30, etc etc. Often, studies that use cross-sectional designs to try to address longitudinal questions don't pan out when someone actually does the longitudinal study.

The other important thing is that this was an epidemiological study...it looked at people in the community, not people in clinics. While that is a very important design to answer many questions, it means that the assessments are done by trained lay people, not clinicians.

As we all know, it is difficult to diagnose BD, especially in young people. The authors do address that issue in the paper, but it still does concern me. And, as I said, the cross-sectional issue is a big one. So the answer is we don't know, and we need to do the longitudinal study.

We follow our youth with BD, and our youth with SMD, longitudinally, and we are very grateful to the parents and children who work with us on that, because longitudinal studies are very difficult to do.  

Robin    
How does a doctor test for bipolar disorder in teenagers? Teens are known for mood swings.

Ellen Leibenluft MD    
Again great question. First, remember that depression and mania aren't just about mood. When someone is manic or depressed, their sleep pattern changes, their activity levels change, thought patterns change, eating, etc etc.

Second, the changes should be much more extreme than what one usually sees in a teenager. And, third, the teen is having trouble.

People around the teen, people like teachers and coaches (and child psychiatrists) who spend lots of time with teens say, gee, this isn't the usual thing. But remember, it's not all about mood...it's about these other things changing too, and staying "abnormal" for a while, not fleetingly.

Cindy    
Is it possible to achieve long term stability with medications? If so, is there a prescribed time that a child or adolescent should take medications once stability is achieved?

Ellen Leibenluft MD    
Yes, it is possible to achieve long term stability with medications. Certainly it is not uncommon for adults with BD to do so...we know less about children, but some do.

The question as to how long to stay on the medication is one which has to be very individualized. It depends in part on how sick the child got when he or she was ill, how many episodes he or she had, how much stress he or she is under, and other factors. And, if the child is withdrawn from medications, it should be done slowly, under close supervision, so that medication can be restarted if symptoms start coming back.

Nanci    
Along those lines of stability in kids vs. adults, do you see any difference in the amount of cycling or stability once kids are through puberty?

Ellen Leibenluft MD    
Another great question. We don't yet have enough long-term data to address that question systematically, so I don't think I can answer that yet. Maybe by the next chat!

Nanci    
Ah, can I take that as a commitment to doing another chat with us?!

Ellen Leibenluft MD    
Of course!! Love talking with you all.  

Charlie

Is anyone anywhere close to using neuroimaging to help with diagnosis in a clinical setting and not just for research.  It is such a guessing game, especially when multiple issues may be going on....

Ellen Leibenluft MD    
Certainly neuroimaging can not yet be used to help with diagnosis...yet. I don't know how long it will be, but it will be a number more years. But eventually we do hope that neuroimaging might aid in the process.

It will never replace careful clinical assessment, but it probably at some point will supplement it. But the other important thing to remember about neuroimaging is that, the more we learn about the brain mechanisms underlying the illness, the more new potential targets we have for treatment. So that's another very important reason why we do neuroimaging studies.

Che'    
This is a two part question: How long does it generally take for doctors to actually find the correct combination of medication to help? My son currently takes 3 types or classes of meds but now that he has gained so much weight from one of them, they don't seem to work now. How do we combat the weight issue when it's caused by medications?

Ellen Leibenluft MD    
In terms of how long it takes, that's very individual and really depends. Some are lucky and find ones more easily, and others it’s a longer and more frustrating road. In terms of combating the weight issue, the usual interventions involve dietary management (meeting with a nutritionist to see some ways to make that work) and exercise.

It's very tough, unfortunately. There are some medications that people think might help with the weight gain but a) it's not clear they do and b) they have their own side-effects.  

Nanci    
This hour went by incredibly fast and we had so many more questions than we could cover so I look forward to you coming back again.

Ellen Leibenluft MD    
For me too. You folks are wonderful.

Nanci    
First, a huge thank you to Dr. Leibenluft for sharing your time and expertise and for working so hard to help our children. Second, here is the link and phone number:

Thank you so much, Dr. Leibenluft for your time.

Ellen Leibenluft MD    
And I want to thank everyone for your questions tonight, and for working with us in the research. Obviously, we all have to work together to learn as much as we can to the children as much as we can. It's an honor to partner with you are...we are grateful to you for letting us into your lives in the way that you do. 


The Balanced Mind Parent Network Expert Chat with Ross Szabo, Author of "Behind Happy Faces"

August 28, 2008

The Balanced Mind Parent Network Live Event Transcript

Did you miss our chat with Ross Szabo? Read the transcript of this exciting and informative chat. The Balanced Mind Parent Network will be hosting several more expert chats this Summer. Watch your email for more details. 

Biography

Ross is currently the Director of Youth Outreach for the National Mental Health Awareness Campaign and began speaking about mental health at age 17. In the last 6 years he is the only person in the country who has spoken to well over 500,000 young people in high schools and colleges about mental health issues. He has been featured in Parade and Seventeen magazines, appeared on CNN, MTV and CBS, and had his presentation turned into a television program for PBS. He was named 2007 Best Male Performer of the Year by Campus Activities Magazine, which recognized him as one of the top speakers in the country on the college speaking circuit. Ross is a founding member of the Leadership 21 Committee of the Bazelon Center for Mental Health Law.


Nanci - The Balanced Mind Parent Network
Ross, welcome to The Balanced Mind Parent Network! Would you like to make any opening remarks? 

Ross Szabo   
Sure. Thanks everyone for logging on. I know the DNC (Democratic National Convention) is on and there are a lot of things people are wrapping up at the end of summer so I do appreciate you taking the time to chat with me and we will be done in time for Obama if people are interested. 

Nanci - The Balanced Mind Parent Network   
LOL, you didn't know you were going to have such competition! 

Ross Szabo   
No, we forgot about that one. 

Nanci - The Balanced Mind Parent Network   
Could you tell us a little about your book, ‘Behind Happy Faces’ and why it would be helpful for parents and young people? 

Ross Szabo   
I wrote “Behind Happy Faces” because everywhere I went people had the same questions and concerns. I learned early on that while some people are concerned about treatment, a lot of people were more concerned with what they could do outside of treatment and how they could handle situations with family, friends, relationships and more realistic settings.

So I decided to use my personal story to start each chapter but we use over 25 other people's stories to frame each chapter. The chapters discuss what it's like to be young dealing with mental health issues, the main reasons people don't seek help, differences in race, class gender and sexual orientation, what an individual can do, family, friends and relationships.  But the main goal is to have a positive example on these issues, and focus more on mental health not specifically on bipolar disorder or mental illness 

Sunwillshine   
What has been the most effective thing that's helped you bounce back from bipolar disorder, out of everything? 

Ross Szabo   
I really think it came down to caring enough about me to want to deal with bipolar disorder is a responsible and healthy way. Unfortunately the largest byproduct of bipolar disorder for me was self-hatred and because I hated myself I didn't care about treatment or talking or anything. I always tell people the mania and depression and hallucinations and anger paled compared to my self hatred and I needed to deal with it before I could deal with bp. 

Isobel   
Ross, how can we help our 15 year old daughter to want to learn more about her mental health? I like your perspective- concentrating on the health part rather than what is wrong.

Ross Szabo   
I think getting young people to care can be a challenge but one thing I have found is that there are clear reasons people don't want to care and it doesn't matter what age they are. So sometimes it can help to switch the dialogue from here's what you need to do to get better and start asking why she may not care about learning more about mental health. Some common reasons can be she may feel embarrassed or ashamed, she may not feel comfortable, she may have a host of other reasons and if those reasons aren't addressed then she may feel even more uncomfortable.  So I think it's always good to start some dialogue about how someone feels about that education and what you can to do help them be more comfortable with it. I hope that helps. 

FizzyPapa   
How did you find a support network in college when all the other kids were out drinking and doing things that would cause serious issues for you given your diagnosis? 

Ross Szabo   
Well my first experiment with that didn't go so well.  In my first attempt at freshman year I looked at college as a place to start over and move on where no one knew me or my issues and the labels that came with it. So instead of researching what I could do, where counseling services were, who I could meet in a healthy way I tried to do what I was doing in high school and hope someone would know what to do for me. 
The issue I found was no one knew what to do for me mainly because I didn't know what I needed for myself. And my freshman year ended after 2 months and I had my stomach pumped from alcohol poisoning as well as had a major relapse with bp. I took the next 4 years to learn about myself and see what I did need. 
When I returned to school I think the biggest thing that kept me away from negative influences was having the confidence to know I couldn't be near them. I needed to find a routine that worked for me and stick to it, I needed to go to bed at the same time every night, wake up at the same time everyday, not drink, not smoke and take care of myself. It also helped that I had a job and was paying for school because I took it a little more seriously. 

So I would say it's important to have the confidence and knowledge to know what you need, and then either translate that to people who are around you and if they don't get it find people who can, or engage in healthy activities on campus that do exist. Not everyone is drinking or doing these things and you can join a lot of groups that may help that. 

A from Ca   
How important were your parents in getting you through this or was it mostly about you and when you were ready to deal with it you did? 

Ross Szabo   
That's a really good question too! My parents came from homes where these issues weren't discussed, my grandfather on my dad's side was an abusive alcoholic and my dad never even had friends over his whole childhood. My mom was raised by parents who told her women weren't allowed to talk about emotion so she didn't deal with emotion well either, and when me and my oldest brother started having problems they didn't know what to do, but it wasn't truly their fault.

 I felt really embarrassed about telling my parents what I was going through because I wanted to be ok for them. They did everything they knew how to do for us and I felt like I was letting them down so I hid everything from them. My mom and dad both say unfortunately they have learned more about my life listening to me speak to thousands of people now than they did living with me 

I will say my parents were there for me every step of the way. They took me to get help, they took me to the hospitals, they picked me up from college when I left and helped me move back in when I went back. They dealt with a lot of crap from their "friends" abandoning them when we had trouble, but outside of that basic support they didn't know how to give the emotional support.

It's only been in the past couple of years that we've opened up communication and they've been closer to me, I relied more on friends and relationships when I was going through the worst times and rely on friends, my brothers and my girlfriend the most now.

minigymnast:-)   
I’m nervous about starting middle school and what my friends will think about me being in special education because some of them don't know about my diagnosis and I'm not sure how to deal with that. 

Ross Szabo   
Starting middle school can be hard without a diagnosis so I hear you on being scared. I think there are a couple of good things you can do though:

1. I think a lot of people don't get that the brain is a part of the body. When someone breaks their arm or leg or hand most people help them out, but when it comes to bipolar disorder or other mental health issues they don't know what to do. So you could try to explain to your friends that this diagnosis is a health thing; some people deal with diabetes, some people deal with other issues and you have this thing going on in your brain. That doesn't make you less of a person or anything like that.

2. In some schools unfortunately people can be afraid to enter special ed classes because of what people may say about them, but I think if you try to again explain the brain piece of this it can help lessen that fear.

3. BE HONEST! I know with my friends they didn't know what to do for me or say to me unless I let them know. We had a lot of hard times because I never spoke up for myself and they never knew how I felt. Yes I had friends who were mean to me even after I let them know how I felt and then I knew they weren't my friends, but I also had friends who got me and helped me out. I've only had like 2-3 friends like that in my life, so don't aim for everyone to understand. If you're not honest you can't give people a chance. 

4. Last one is to have people like your parents, therapist or someone who you can talk to about this and have them help you when times are rough. I wish I could say everyone will love you and everyone will get it, but that's not the truth for anyone. I know I got through a lot of rough times with the 1 or 2 people who I trusted and could let them know when I wasn't doing well or was angry that people made fun of me or wouldn't be my friends or other terrible things. I know it may not seem easy and you are afraid but you can do this. 

jourdan   
I just found out I have bipolar. What next? I am an 18 yr old freshman in college and I am out on a medical leave!

Ross Szabo   
it's interesting to me when people find out they have bipolar disorder because some people are relieved, some are horrified and some just want to ignore it. I'll try to cover all of those situations with my answers. 

I think the biggest mistake I made was when I got the diagnosis I thought it was over. I thought they could give me something and that would be it. But the key thing to remember is that the diagnosis is just the starting point. When someone tears ligaments in their knee and gets a diagnosis they have to go through rehab and surgery and a lot of pain before they can walk again and with bp we have that process too. 

So after the diagnosis it's important to learn as much as you can. Ask your doctor questions. Ask questions about any medications and what they could do to you. But most importantly be honest. I lied about what I was going through and told my therapist everything I thought he wanted to hear instead of the truth. My lying only led to more problems for me and it wasn't helpful for anyone. 

If you're having any trouble with treatment let people know. And also remember that like you said you have bipolar disorder. Some people walk around and say I am bipolar. When people do that it's almost like the diagnosis defines them and tells people what they are. I always say I have bipolar disorder, because it doesn't define me. It's not easy or fun to deal with, but dealing with it has made me stronger and a better person. Also remember that treatment isn't just medication. You have to take care of yourself outside of it to learn what is you and what is your disorder. I know that's a lot and I hope it helps! 

Regarding being on medical leave, I was 18 and out on medical leave and while I am not you I can tell you what I did wrong. I beat myself up. I told myself I was a failure. I told myself I wouldn't be like my friends, I would watch them graduate and I deepened the self hatred I had for myself even more. I did that for a while. But eventually I realized I was going to have to take a different path in life no matter what and that's fine. 

I started slowly. I took a year off from college. Then I took classes at a community college near my house to get back into going to school. Then I went to a local college near my house where I had my mental health professionals and support networks. Then I took another year off from college. I returned to American U. where I originally started 4 years after my original freshman year. When I was back at school I made a plan to prepare myself for any breakdowns etc. I wanted to be able to handle situations and deal with what came my way. I was able to graduate because I learned what I needed for myself. 

And I also learned to have fun doing it. While all of my friends were looking for jobs I was on spring break and finding more about myself. It turned out to be ok and I hope it does for you. 

A from Ca   
Going back to your earlier comments about your own experiences, I have heard the type of story you shared many times over, and as a parent it scares the daylights out of me. Do we as parents just need to sit back and watch this in order for our young adult son to figure it out? 

Ross Szabo   
It's kind of funny, my dad just told me he told someone that the hardest thing for him to do was watch as he felt helpless and hopes I figured it out.  However I told my dad that wasn't necessarily true. There are parts I needed to figure out. No matter how much someone told me I was a good person, or someone who could deal with this or someone who deserved to get through it, I did need to see that for myself to want to try and deal with it 

However, if my dad didn't give me a roof over my head, stand by me in the hospitals, take me to doctors and do so many little things for me then I may have never seen it. We all know these issues don't always work out, and so I think as parents you need to have a balance. You need to care and love and be there, but you also need to take care of your mental health, talk to people about how you feel, what it's like for you, your fears, and everything else. You can't take care of your son's mental health if you're not taking care of your own. And talk to your son, his doctor, whoever you can to learn as much as you can. If he won't talk to you always let him know the door is open and that you care. 

rob   
I’m 16 years old right now. When I found out I had bipolar I was 14 and nothing really changed. I mean I take meds and go to therapy but that’s really it. I feel better when I take the meds and it helps a lot with the anger but I don't know. Right when I think everything is getting better everything goes wrong. I go on drug binges for a while, I'll say I quit and then everything calms down again but then it will repeat every couple of months. I don't know what to do 

Ross Szabo   
That's a tough spot. I will say that it can take years to really find what works best for people. I definitely struggled to find what worked best for me from about 16-22. Part of the difficulty for me was that I would turn to alcohol to shut my brain down and stop it from running. And, I wasn't being honest in therapy and again was hoping people would just figure this out for me. I'm not saying you do that, but if you are doing any of it then you will need to change that. But besides that, it sucks when you feel like you're doing everything you can and things aren't turning around. 

So all of the things I told the person who said they were just diagnosed (jourdan) I would say to you. But also I would say it's important to not give up. I'm not saying you have but sometimes when it gets hard people think it's not worth trying. I know a lot of people who when they try to get better and have a slip up will define the rest of their life on that slip up and not on the positive work they did before it. 

So as hard as it may be keep trying to be honest, to ask questions, to learn about yourself, to laugh at some things along the way and hopefully through time you can find something that holds on. And, remember brains don't mature until age 22-24 so your brain is still going through a lot outside of bp. 

Nanci - The Balanced Mind Parent Network   
Ross, we have a great turnout of teens and young people this evening. And I think that the comments and questions coming through are the ones we need to address. So I'd like to put through several for you to consider and perhaps you can make some comments to address what seems to be a common theme.

Ross Szabo   
OK, I like common themes.

jourdan   
At this point I hate life and want everything to go away!... I don’t want to label myself as that! I just want everything to be normal again! And not have to deal with bipolar!

jourdan   
I go to college and because I did not take meds they told me to take a medical leave and now I have to stay home till I get better.... which sucks! I hate being home its so boring I like to be on the go 

darcy   
I’m also an 18 year old and I just feel frustrated and confused on how to live life normally. I’m starting college next year and that really scares me. 

Nanci - The Balanced Mind Parent Network   
That's a lot to answer, but I sense that we have people here in chat that are hurting and really need to feel a connection to someone who has walked in their shoes. 

Ross Szabo   
OK, so let's start with the going back to normal questions. I said it earlier but I think it's only natural when things are out of control to really want to get back to whatever it was like before this hit. I craved getting back to what I had before I started having mood swings and breaking my knuckles and being awakened by hallucinations. But I will say I didn't do everything I could to get back there and again it really started with me hating myself and not caring about myself because I have bp. 

So if you're in that situation where you are being held back by self-hatred or fear or don't have the words to begin to describe how you feel or whatever it may be, maybe try by starting to work on that and see if working on the how you feel about having bp helps. When I was diagnosed no one ever asked me “how do you feel about having bp”. “How do you feel about going to seek help?” They only said take meds and do this, and I found by focusing on how I felt I was able to deal with it a little more. But it didn't get better right away; it did take time and a lot of learning. So that's the returning to normal thing.

As for the not taking meds and having to leave college thing, the only legal way a college can ask you to leave is because you are deemed a threat to yourself or others. If that didn't happen and you still had to leave, do what you need to do to get back, don't beat yourself up and take it as a learning process and something that in the end can be good instead of bad. 

jourdan   
My parents said that since I have bipolar I can not drink... is that true?  Did alcohol help you ... is it really that bad for you??? 

Ross Szabo   
If you're on psychiatric medication of any kind then no, you shouldn't drink alcohol. The labels on the meds may say you can have like one drink per hour, which a lot of people take as “I can drink ‘til I pass out every night” and it's not good. Alcohol can really mess up your treatment, especially meds and then you can be back at square one all over again. However you can find balance and eventually later in life you may be able to drink again. So saying you have bp and can never drink again isn't necessarily true either. 

Jenna
Do you ever feel behind your friends? 

Ross Szabo   
No, definitely not. I had to grow up so much more than they did when I was trying to figure this out that I am light years ahead of just about everyone I know that is my age or my friends age and I credit it to learning how to deal with these issues. 

Nanci - The Balanced Mind Parent Network   
I have to agree with you completely on your comments about feeling behind. My oldest daughter is 15 and in so many ways she is SO far ahead of her peers as far as her insight, compassion, empathy and ability to face life's hurdles. I guess that is one of the silver linings of the illness. 

Ross Szabo   
It can be if the person sees it. It took me a while to see it 

Nanci - The Balanced Mind Parent Network   
You did a great job, Ross, answering that long group of questions and please, if I missed something from our teens, put through your question again. We're getting a tremendous input of questions. 

A from Ca   
Were you ever suicidal and if so what was the most helpful thing that got you through this? 

Ross Szabo   
I was hospitalized for attempting to take my own life when I was 17. I was a senior in high school and from the outside everything looked fine. I was class president, varsity b-ball player etc. etc. etc. but I had depression and there wasn't a real reason for me to take my life other than depression. When I finally got out of the hospital I didn't magically want to live again. I had to find a way to release the thoughts of wanting to take my own life healthily so they didn't build up to the point where I wanted to try again. That's when I started being honest in therapy and started being honest with my friends and started trying to be honest with myself. Being honest with myself helped, but I said back in the beginning of the chat what turned it around for me was caring about myself too. 

A from Ca   
Do you have any advice for parenting an 18 year old dx with bp who wants to handle it all on his own but is clearly not ready to yet? We want to get the message that we are a support system that is not trying to control him but unfortunately the relationship is very combative. Any thoughts? 

Ross Szabo   
That is tough and again I would try to focus on the reasons your 18 year old wants to be independent. Then hopefully find a way to come to a happy medium. I am assuming there's more confrontation than conversation happening in this process and hopefully by finding a way to help your 18 year old be comfortable you can have conversations about this. I would also say talking to a therapist about how you can do this is a good idea. To be honest these situations are so different in each individual that it would be hard for me to say well just do this or that, but moving from confrontation to conversation would be a good start. 

Nanci - The Balanced Mind Parent Network   

We are almost at the end of our hour, so I'd like to put through one last question. 

rob   
how hard was it for you to quit drinking when all your friends were out doing it? 

Ross Szabo 
  
It was hard and unfortunately drinking got to a point for me where I was going to die if I kept doing it.  I used to enter 20-30 hour alcohol induced comas where no one could wake me up, no one could move me. I would drink so much that everything in my body shut down except my heart and lungs. I was lucky to make it through those times. 

One night I passed out for 22 hours and when I woke up started crying. I said to my self  “Ok, you're either going to keep doing this and die, or change.” I chose to change, but the hardest thing to change wasn't stopping the drinking, it was why I was drinking. I drank to ignore bp, I drank to shut my mind down, I drank because I didn't know how to talk about this, I drank because I hated myself. So it wasn't like my friend who drank for fun, I drank because of serious issues and when I went sober I knew I would sometimes be around alcohol but I told myself that there was a reason I needed to go sober to find a different coping mechanism. And in my years of sobriety I did find healthy coping mechanisms. I realized then that one day I could go back to drinking because I wasn't doing it for the wrong reasons and I wasn't an alcoholic. The healthy coping mechanisms were the same yes but much healthier. 

rob   
Ya, but I do drugs instead of drinking. 

Nanci - The Balanced Mind Parent Network   
But, Rob, isn’t the end result or what you're looking for the same? An escape, a way to kill the pain? 

Ross Szabo   

Drugs and drinking are similar, very similar, if people are using for the same reasons. The big difference is drugs aren't legal over 21 and shouldn't be used so that's a difference. But the coping mechanism was the biggest part and that's what I had to learn. 

Nanci - The Balanced Mind Parent Network   
Ross, thank you so much for sharing your tremendous insight and experience, and I am so glad that we had so many young people join us tonight. Can you suggest any resources that might be helpful? 

Ross Szabo   
I just want to thank everyone again for their questions, I'm sorry that I don't have all of the answers, I found in my life very few people have the answers but hopefully we opened some doors for you to find the answers! Hang in there everyone. 

Ross Szabo   
you can check out our website at http://www.nostigma.org/  Another sites is http://www.halfofus.com/.   

Isobel   
You have given me a lot to think about, Ross and a lot of hope! I plan to get read your book. 

rob   
Thank you, Ross.

Nanci - The Balanced Mind Parent Network   
Thanks so much! 

Ross Szabo   
Thank you everyone, I wish you the best and EMBRACE YOUR FREAKISHNESS!!!!


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