It's Nobody's Fault (32 page)

Teenagers with MDD can be particularly annoying to their parents because it seems that they often have enough energy to do certain things, such as go out with their friends, but not others, such as their homework. They’re pleasant enough when they’re in the outside world and save their sullenness and their lethargy for the folks at home. There are occasions too in which a child is unpleasant with one parent but not the other. As difficult as it is to manage sometimes, parents have to realize that the behavior of a child with MDD is not willful. He’s not being impossible on purpose.

Most parents of kids diagnosed with MDD feel more than a little guilty too. After all, it is a parent’s job to make his child happy. Being happy is a basic essential of life. If a kid is depressed, the thinking goes, it must mean that the mother and father are doing something wrong. None of this is true, of course, but even parents who know better sometimes consider themselves dismal failures. The feelings of parental guilt associated with this disorder are very strong, particularly when a child tries to commit suicide. One of the many reasons we recommend parent counseling is that it helps parents understand that
no one
—not the parents, not the child—is to blame for this disease. There’s no reason for a parent to feel guilt or shame.

Another way in which parent counseling can be useful is to help parents redefine and come to terms with their special role as the mother and father of a child with major depressive disorder. Being the parent of a child or adolescent with MDD isn’t easy, to say the least. There are all sorts of unexpected questions that may arise, especially as a child moves through adolescence to adulthood.

“I never know how much slack to cut her,” said the mother of a 15-year-old girl diagnosed with MDD. “I know I have a right to expect
things from her, but it takes so much effort for her to do the easiest things. I don’t want to ask her to do too much and put a lot of unnecessary pressure on her. On the other hand, I don’t want to let her off the hook about everything just because she’s sick.” This mother makes an excellent point. Sooner or later her daughter will have to take her place out in the world, and it’s her parents’ job to prepare her for that day. Parent counseling will bring these issues out into the open.

Even when a teenager is diagnosed with MDD, parents have to learn to let go a little and encourage a child to be independent. Allowing a child to make his own decisions is difficult for any parent; when a child’s decision-making abilities are impaired by major depressive disorder, it can be nearly impossible.

“I’ve always been a little overprotective; I admit it,” said one mother. “My older daughter is 21 years old and perfectly normal, and I still interfere in her life too much. My 19-year-old is the one who’s depressed, and I have to remind myself constantly not to take over her life. I’m tempted to ask her every day if she’s taking her medication and to call the doctor to see if she’s showing up for her appointments, but I don’t. I know that would be wrong.”

Yes, that would be wrong, but the impulse is perfectly understandable. Knowing when to get involved and when to step back and let it happen is a real skill for any parent. Here’s how yet another mother, whose 22-year-old clinically depressed son has just moved into his own apartment for the first time, expresses the conflict: “Part of me wants to let him go completely—say, ‘It’s your life and your problem.’ But then I think, ’Wait. If my son had a broken leg, I wouldn’t just point to the stairs and wish him the best of luck getting to the top. I’d get him a crutch or let him lean on me. Together we’d work out a way for him to get to the second floor.’”

A
ccording to his parents, Leo, nearly 14 years old, had been perfectly normal until about a year before he came to my office for the first time. At the age of 13 the boy had been doing well in school, and he’d had a full social life as well, with plenty of friends and activities. But then things started to change. Leo became rambunctious and difficult to deal with. He was very sad at times, becoming tearful and even crying quite often, and his judgment was poorer than it used to be. He dyed his hair bright red and then streaked it with purple. Then he got himself a small tattoo. Mom and Dad thought it was a rebellious teenager phase at first. Then Leo’s behavior became even more worrisome. He overslept often and virtually had to be forced to go to school. He complained of headaches, neck discomfort, and other assorted pains. He was totally enervated one day and so energetic the next that he claimed he didn’t need sleep. Instead he’d stay up all night practicing the guitar. When I talked to Leo about his music, he told me, in the most matter-of-fact way, that he needed to practice. He was going to be a
huge
rock star.

For the last few months Molly had been talking to herself a great deal, but her mother figured that her daughter was just rehearsing for the school play. At 16, Molly was quite passionate about acting. For the three weeks before I met Molly, the girl had been “blue,” as her mother put it—withdrawn and isolated from her friends and family, unable to concentrate on her studies. Then, two days before Molly came to see me, she came out of her funk with a vengeance. She was yelling and screaming incoherently and talking nonstop even when no one was around. She
would eat only when forced to do so and hardly slept at all. By the time I saw Molly—and checked her into the hospital for a short stay—she was out of control, talking incessantly (mostly about Madonna) and singing songs from
The Sound of Music.
Her first night in the hospital she took off all her clothes and danced in the bathroom. The nurses said that Molly appeared to be having the time of her life.

Adolescents are moody. That’s an indisputable fact, like the sun rising in the east. Parents of teenagers expect erratic behavior from their kids, and so they should. Adolescence is a time for change of all sorts, and hormones tell only part of the story. Kids also go through some important developmental stages at this point in their lives, the most significant of which are separating from Mom and Dad and coming to grips with their sexuality. Normal, healthy teenagers will accomplish these tasks without too many casualties, although there will probably be some serious power struggles along the way. Rebellion and moodiness come with the territory.

The territory occupied by bipolar disorder—also called
manic-depressive illness
—is characterized by a very different, much more serious brand of moodiness. This disorder involves intense, persistent moods that are clearly different from and much more intense than the child’s usual demeanor and are extremely inappropriate to the event and the environment. The mood swings must be severe enough to cause distress and dysfunction.

The word
bipolar
refers to the two poles of this very serious disease: mania and depression. (
Chapter 14
covered major depressive disorder, or
unipolar
disorder.) A child with bipolar disorder will have had at least one episode of mania—or
hypomania
, a milder, less intense version of mania. The symptoms of mania are distractibility, irritability, grandiosity, racing thoughts, a decreased need for sleep, an increased speed of speech, poor judgment, increased risk-taking behavior, and a break in reality testing, usually characterized by delusions and hallucinations. An adolescent having a manic episode, which may last anywhere from several days to a few months, typically will feel hypersexual and expansive, will have unrealistic expectations about his performance, and will make rash
decisions and spend money recklessly. A 16-year-old girl I treated once took her mother’s credit card and bought a plane ticket to Boston to see a rock concert. Another time she was caught shoplifting. “I’m a movie star,” she told the security guard. “My agent will pay for this stuff.”

“Having Rory around is like watching an episode of
Lifestyles of the Rich and Famous”
said a fed-up father of a 17-year-old boy in the middle of a manic episode. “He likes only the finest things—the best watches and the best luggage and the best clothing. One day he charged a $500 ski parka, a $300 pair of alligator shoes, and two Armani sweaters and had it all sent home by Federal Express. Of course, he put everything on
my
credit card.”

To be diagnosed with bipolar disorder adolescents must also have had a depressive episode, which lasts anywhere from two weeks to several months. Its symptoms are loss of concentration, sleep disturbance, change in appetite, fatigue or decreased energy, agitation, lethargy, a feeling of worthlessness, and an inability to experience pleasure.

The incidence of bipolar disorder in children and adolescents is not known. The lifetime risk of bipolar disorder is about 1 percent among the general population—affecting men and women just about equally—but it can be much higher in families in which other members have mood disorders. The condition is very rare in children under the age of 12, although there have been reports of bipolar disorder in children as young as four.

Bipolar disorder often starts in adolescence, but is not recognized and diagnosed until much later, when kids become older and display classic adult symptoms. A survey conducted by the National Depressive and Manic-Depressive Association found that 59 percent of those surveyed reported suffering their first symptoms of bipolar disorder during childhood or adolescence. The age of onset of bipolar disorder is most frequently between 15 and 19.

The distress and dysfunction associated with bipolar disorder can vary greatly, depending on the severity of the illness and which of the two poles—mania or depression—is “in charge.” When adolescents with bipolar disorder are in the depression stage of this condition, they’re
usually pretty miserable. (The elements of the “depressed triad” say it all: feelings of hopelessness, helplessness, and worthlessness.) Mania is something else again. “You don’t know what you’re missing, Doc,” one of my patients told me, describing what it’s like when he’s manic. “There’s really nothing like it. I feel great. I look handsome. I’m brilliant. There’s nothing I can’t do.” Patients in a hypomanic phase are often productive and very pleased with themselves. As long as they are in that state, their heads are filled with ideas, and they have the energy to act on them.

Most of the kids eventually diagnosed with bipolar disorder come to my office complaining about depression. I’ve had only one patient who complained about mania, a shy, soft-spoken, extremely religious 16-year-old girl. She told me that what bothers her most about her illness is her conviction that she’s better than everybody else. “I don’t want to be better than everybody else. I don’t want to feel this way. It’s a sin,” she told me.

Patients in the
mixed state
—described by some experts as being trapped between depression and mania but not quite in either one—are usually in a lot of pain. The combination of feeling sad and worthless and weighed down and, at the same time, having racing thoughts and delusions of grandeur is incredibly exhausting and upsetting to adults; it can be devastating to a child or an adolescent. Many of the patients I’ve treated say they feel out of control, all revved up but depressed and crying at the same time. It’s in this mixed state that distress and dysfunction are often most severe.

One final term to address is
rapid cycling.
Officially defined as four or more distinct mood episodes in one year, rapid cycling may involve even more abrupt and frequent mood swings: up one day and down the next sometimes. Rapid cycling is relatively rare, however. Only about 20 percent of all patients with bipolar disorder have it, and most of them experience it relatively late in the illness. It is much more typical to hear the cycle described the way the mother of one of my young patients put it: “She’s not up and down, up and down, up and down. She’s down and then she’s normal. Then she has an episode where she’s really up, and we worry about her doing something dangerous and foolish. Then there’s a long period of time when things are okay again. Then she’s down again.”