BiPolarDisorderInfo: 2009

Running Head: early onset bipolar disorder

Longitudinal study of adult female client with early onset and lifetime of bipolar disorder

LoLyn Fetzer
Adult Psychopathology
Argosy University

Pediatric Bipolar
An article in Time Magazine entitled: "Bipolar disorder harder on kids than adults" (Elias, May 24, 2005). Elias reported on a landmark study in which researchers at the University of Pittsburgh Medical School tracked a large number of youth, 300 children ages seven to eighteen, who had bipolar disorder. The researchers found that after two and one-half years nearly one-third had not recovered. Those who had recovered had taken about seventeen months. Recovery was defined as eight consecutive weeks with minimum of no symptoms. Four out of five had at least one recurrence.
“During the study, children experienced serious symptoms about two-thirds of the time,” said study leader Boris Birmaher(2006). Children longer duration of illness than adults with BP. They cycled through manic and depressive moods much more rapidly; they averaged sixteen cycles a year, compared to adults’ three and one-half. This article reported there are no solid figures on how many children and teens have Bi Polar Disorder. About one percent of adults have it, or about two million Americans. There is a strong genetic link, in a significant number cases.
Children with BP often are misdiagnosed with ADHD or other behavioral problems. Stimulants or antidepressants can worsen symptoms of BP. A few anti-convulsive drugs are showing promise but not tested yet for kids.
Another article entitled: Course and outcome of bipolar spectrum disorder in children and adolescents: A review of the existing literature (Birmaher and Axelson, 2006), cited a study in which Lewinsohn, Klein, and Seeley (1995) evaluated one thousand seven hundred and nine high school students. Of this group one percent had BP (mainly BP II and cyclothymia).
The students were reinterviewed fourteen months after intake, comparing them with three hundred sixteen subjects with major depressive disorder and eight hundred forty- five healthy students. They found that students with Bi Polar Disorder had worse course with a median duration for their index episode of illness of eighty weeks. They also had “significantly more functional impairment, psychosis, suicidality, comorbid anxiety, disruptive disorder, and mental health utilization than the other two groups” (Birmaher and Axelson, 2006).
At intake, Lewinshon et al (1995) also found that five and seven-tenths had subsyndromal Bi Polar symptoms defined as “a distinct period of abnormally, and persistently elevated, expansive, or irritable mood.” These subjects had levels of impairment, comorbidity, and family history of BP and depression that were comparable to the BP group. However, at follow-up they showed only increased risk of depression, but not Bi Polar Disorder. The article said, “it is not clear whether the negative effects of having Bi Polar Disorder are solely attributable to this disorder, because youth with Bi Polar usually have other comorbid disorders and may be living in families with high psychopathology along with chaotic environments that may also influence the child’s psychosocial functioning.”
Both articles agreed stating the prevalence of BP in children and youth is unknown, however the journal article study gave a better idea of what it probably is. TheTimes article said youth experience serious symptoms two-thirds of the time. They spend more time ill, and cycle through manic and depressive moods more rapidly, as did the journal, and added that youth experience mixed and rapid cycling. The journal article added that youth with Bi Polar Disorder also frequently have added substance abuse problems, suicidal risks, and social, family, vocational, and academic impairment. It also said they have short and frequent periods of syndromal and subsyndromal mania, hypomania, or depression. Bi Polar is more severe in children and youth than adults. Some reasons such as rapid cycling, and more episodes, There are many other disorders and complications which can be associated with Bi Polar Disorder making it more difficult for children and youth.
History of Lithium
In 1949, the very year Lynda was born, (this may have been purely coincidental) a salt mineral was identified which was named lithium. Research showed that the occupants of manic-depressive illness was about 2% of the population uniformly throughout the planet earth's civilizations, except in the areas where lithium was found naturally in the soil, and dissolved in the water was distributed to the inhabitants. In these unique populations, the illness rarely occurred. Within a few years, lithium was being processed and prescribed by psychiatrists experimenting with manic depressive patients.
Manic-depressive illness is brought about by a chemical imbalance in the brain itself. As the name implies, the symptoms range from a highly euphoric manic phase to a deeply depressed phase, sometimes with no pause in the middle for normalcy. The manic phase may be identified by inappropriate singing and dancing and general happiness regardless of circumstances, to sustained energy outbursts, extreme over spending and can even include irrational anger and hostility; the degree of intensity and duration, as well as the inappropriateness of the euphoria are often indicative of the seriousness of the illness. In extreme cases, the patient looses contact with reality in a euphoric fantasy. However in many cases the manic phase inspires great creativity. Some of the greatest artistic creations were created by the artists in the manic phase of this illness.
The depressive phase of the illness is characterized by deep sadness, restricted abilities, and inability to think or feel beyond the feeling of sadness and isolation and hopelessness. And even include anger and rage. The ability to cope with minor daily problems decreases as does desire to be creative or useful. In extreme cases the patient may collapse into loss of movement and be unable to communicate at all; often the depression leads to suicidal ideation, sometimes followed by suicide attempt.
Early experiments with lithium were on manic patients who responded by returning to a normal mood level. Continued experimentation indicated that continuous daily doses actually prevented the extreme highs in manic patients and in manic depressive patients, not only controlled the highs, but decreased the frequency and intensity of the lows. Psychiatrists later renamed the illness "bi-polar," indicating the swing from one end to the other of the emotional extremes. Science had discovered a natural element that replaced the missing chemical in the brain systems of patients with Bi Polar Disorder, and controlled the roller coaster emotional swings in the same way it is controlled naturally in the remaining 98% of the population.
Lynda was not bi-polar all her life. As a very small child, youngest of four, she was a happy, active child. She loved to dance and sing and play house and paint and draw. She loved to admire herself in the mirror. When she was five she encountered her first school experience: summer kindergarten in Phoenix, Arizona. The play ground was so hot the monkey bars and slide burned her hands and legs, and the teacher seemed cross, so a new pain ingram traced, and the message might be interpreted, "teachers are a pain."
Sitting in dance class one day the five year old was told: "you can't be on the TV show, you don't know the dance well enough. If you had spent as much time watching me as you did looking in the mirrors you might have learned the dance." So sister got the pretty costume and danced on the Lou King Rangers, and Lynda traced a message on her brain: loving myself is not good. I should not admire myself in the mirror. I am only worth something when I perform well." This message she perceived in her emotional pain of disappointment, shame, jealousy.
In the same setting, on a different day sister’s first grade report card was read aloud and praised for the positive comment written by the teacher. "I bet Lynda never gets comments like that on her report card when she starts school. ha ha." Another message was traced: "I am not a good person. Sister is good. I am bad." The scripts were written, engraved forever in her brain. So on to school she went, carrying her scripts with her in her subconscious, totally unaware of their content, but following them obediently. She thought of herself as unattractive, untalented, and capable of winning attention only by being disruptive, which she knew was ok as long as it was funny. Although she was not conscious of these scripts, they served as her road map for her actions every day of the first 30 years of her life.
Teachers were to be punished to even the score for kindergarten and dance class, and what a better way than to misbehave in their class while still making honor roll grades. She couldn't make top grades because she knew that was her sister's role. Lynda's dress, her walk her behavior all reflected the deeply engraved scripts she had perceived and recorded as a small child.
Psychologists disagree on the reasons some children record the messages and others seem to ignore them or choose more positive messages to record. It may be that the chemical imbalance is congenital, and because of this there is a predisposition to perceive and record negative messages. There seems to be evidence that experiencing pain while receiving the verbal messages makes it more likely that the pain and the message will be indelibly recorded, so a child in constant pain from congenital malfunction would be riper for receiving pain messages than a healthy child.
Following the script Lynda attended school faithfully, either feeling loved or hated, with nothing in between; worthwhile or not worth a thing. The constant black or white, all or nothing concept of her own worth gained strength with each experience she encountered, even the mildest rebuke for poor penmanship. Every feeling of worth came from outside herself.
At age seven dance lessons were resumed in a different town, a new home and a new life, but the same script ruled her decisions:
"If I do not get chosen for the lead part, I am no good at all."
"I am only worth what I perform."
"Sister is the good one. She is valuable; she is capable; she is loveable. I am the bad one.
I can only get recognition by negative behavior, because I cannot compete with sister."
When Lynda was eight, a man they called Kelly was living with the family and helping out with maintenance and cooking for the motel they now managed. Kelly showed an interest in Lynda and Emily. As he cooked for the family or worked on the buildings, he allowed them to watch and chat with him. All her life those memories were frequent occurring memories, along with the time he had shouted at her for touching the yeast rolls rising on the stove. She remembered clearly that she had patted the rolls whispering, "pat the baby's bottom". Kelly had shouted and that was all she remembered, but she remembered it often along with several other distinct instances from the short year and a half the family spent as managers of that motel. Other memories of that year at the motel were sharp and clear though brief with little detail. Like a flash of a slide on a screen, Lynda would experience a brief upsetting memory of shame and overwhelming guilt. The day she refused to play in the sprinklers without her shirt. She shuddered often at the sudden overwhelming need for secrecy when dressing or bathing. Mostly she experienced the feeling of shame, without a picture, without a slide.
Thirty two years later, out of curiosity, she requested regression therapy in a light hypnotic state to relive that one year of haunting memories. The memory came back clearly of the kitchen, the yeast rolls rising and Kelly shouting. Then the picture in her mind went black. The therapist encouraged her to go on, asking, “What happened next, what did Kelly do next?”
Through tears and heartbreak she became the little eight year old girl being exposed to a threatening, angry man forcing his erected penis into her face. "You want to touch a baby's bottom?" he shouted in her face, "touch this, take this and.... "
Lynda broke the trance herself to get out of the vision of the memory. Later she went back into regression to seek healing and nurturing that had not been available on that one day of her life. Where was Mother? Mother was always there when the two sisters came home from school. She made it a matter of commitment to always be there. But this one day, she had to run an errand at the last minute and asked Kelly to tell the girls she would be right back. Sister had stayed behind to play with a friend. Kelly took advantage of Lynda in the one minute she was left alone, telling her that Mom had put him in charge and he had to do what he said. Then, he threatened her if she said anything that she would be in terrible trouble, because she had been such a bad girl.
This entire story fit with her script, so when mom came home there was Lynda sitting on the cold cement floor of the laundry room sobbing. "Where were you? Why weren't you home when I got here?” But not once did she betray herself by telling what Kelly had done to her. She did not want to be punished as she thought she deserved to be.
Lynda kept this story so deeply buried in her mind that she herself did not recall it until she was regressed in hypnosis. But the frequent flashes of memory of the kitchen, the rolls on the stove, the laundry room, of crying, "Mother,Where are you" haunted her steadily throughout the years. Her mother was able to accept and validate the story when she remembered Kelly leaving early one morning without notice.
Her subconscious perception was that mother was never there when she was needed, although her mother had been the one consistent presence in her life, so Lynda did not try to talk about things that bothered her, her diary entries repeatedly state, "I wish I had someone to talk to."
Lynda got more resourceful at manipulating teachers and friends to give her attention. She found that when she was ill, hurt or depressed, she got attention, and was not being bad. She did not pretend illness or pain, but managed to have enough of it to get the attention she needed. Her script gradually modified to include I can get attention by disturbing, and by having pain.
Fifth grade for Lynda was an island in the hurricane of self hate. Her teacher, Mr. Gordan Wallace, was jovial and fun loving, yet firm with rules of behavior. Lynda spent many hours in the hall for talking or carrying on, but she got attention as well for her poetry and stories. Mr. Wallace had a discipline plan that called for name on the board for first warning, then each mark in a day after the name went up required a 25 word essay for the first mark, then double thereafter. Lynda happily wrote one to five hundred word essays nearly every day. This brought recognition and attention, but what she had not figured out was that she did not have to disturb the class to get the assignment. She could have been writing for the joy of writing. Her reasoning was determined by her script. "I can only be valuable if I misbehave."
Mr. Wallace encouraged her writing and discouraged the misbehavior. She was finally able to understand that writing was a valuable part of her she could write without it being a punishment. By the end of the year she was writing poems and stories for fun, and had settled down in her class work.
Sixth grade was a disaster. Into the class sister was in the year before, and bombarded with, "you cannot be her sister; she was so quiet, so well behaved, such a good student.”
All our work through fifth grade was lost within the first week of sixth. Lynda dug in and if there was a punishment given in that class in a day, Lynda was on the list. She was in control of her life; she could choose to the minute when the teacher would strike, and she could control her attitude toward the punishment.
As with the essays in Fifth grade, she got recognition for her amused attitude toward punishment in sixth. Standing in line in the hot Arizona sun for an extra time before lunch. She happily marched, sometimes singing with the other offenders to a late lunch and short recess. Writing, counting, staying after school were all turned into a game to be enjoyed for the recognition she received from her peers and teachers. Not showing signs of settling into strict boundaries, she was unfortunately assigned to a newly hired fourth sixth grade teacher; each of the three old teachers submitted a list of students to be taken out of their class into the new one. Lynda, along with all the other difficult students, was united into one new class, with one totally ineffective teacher.
Preparing this history as her counselor, I moaned to myself, “Let me help you. Let me help you see how brilliant you are, how fun loving and enjoyable you could be if you would use your talents for positive activities.” She firmly followed her deeply engraved script. I am a bad person; I am not valuable; I am not capable; I am not loveable. I can get attention only by misbehaving or depressing. The teacher was too distracted by 25 unruly sixth graders to even notice the pattern that Lynda's behavior had begun to follow. Highly active and talkative, laughing and creating art projects, science projects, school newspaper, anything that took her out of class, she signed up for. Then a period of shut down. Barely completing assignments, lashing out at friends, family and teacher, Lynda appeared to be an angry vicious young woman at the age of 12. By 14 she wrote in her diary using her vocabulary words: ”I obtained a pocket knife to cut into an old golf ball I confiscated. I wondered what was inside; I tried to imagine. It sprang anxiously from my hands. Energized by the propelling bands, the ball sprang to life and expending the captive energy in seconds, unbridled by walls or bounds. When powered by expert skill the energy within the hard white shell flies straight and true, but unbridled, spends its life's breath bouncing and spinning here and there with unproductive energy. That’s the way I feel all the time now, peaceful only if I am contained in a shell.
Junior High school would appear to be the onset of the bipolar mood disorder. The sudden shift in moods, outbursts of anger, blaming, crying, did not go unnoticed. Lynda herself was desperately crying for help, but had not been trained to recognize what she wanted. She was incapable of directly asking for someone to help her.
Finally, in the eighth grade she managed to get a degree of help by following her script and disrupting the social studies class to the point she was spending nearly every day after school for discipline. Deeply depressed, and acting out in anger, she had not only interrupted, but she had been insubordinate and hostile and kicked the teacher in the leg. But alone with the teacher after school crying and arguing she finally ran out of the anger which was shielding her from recognizing the fears she had of what was happening to her.
"I am different from other kids. I don't seem to be in control of what I do. It is so frightening I have to stand back and watch. Am I going crazy?" Lynda was able to communicate her feelings to her teacher through her story writing. Through this medium of therapy she was able to express her need to explore these feelings and fears. The teacher was not trained in psychology; even if he had been childhood depression was not recognized or diagnosed at that time. What Lynda needed most now was someone to listen and he filled that need.
Those who knew her realized she had taken her first step to mental health. She described her feelings in this poem written at age 30.
A Bi Polar Life
I am blue, I am yellow.
In this lies all the extremes of human emotion.
Doctors call me bi-polar and treat illness with drugs.
Drugs channel the moods narrow the channels.
Oral chemical creates in me
Peace which others self produce.
This my cross, my burden to bare.
My weakness has come strength.
My eyes I have seen the world in
sun lit color and toneless shades of grey.
Faces are reflected rainbows,
and smiling friendships
or I feel cruel dull and senseless, lost in a fog.
To some I am manic depressive.
through time and space
Kites, blown windward fly in a sun lit sky,
plunge to earth when freed by the broken string,
in terror to all who watch to control or lend a hand.
I grope to know myself.
Those who surround me fear my change
My children love me in spite of fears.
Medication binds me to the earth
holds my soul within my body.
The spirit tugs to be free to soar,
the depths of hell gape to destroy my light.
When moving in the comfort range
the flood gate opens.
Torrent carries me to a new channel.
within the channel is a learned response.
Choosing feelings, choosing thoughts;
Then I have little choice.
Only choice of thoughts determine the course I will take,
I can no more choose the gate
than choose the shape of the clouds.
Drugs control the gate and
bring me down from my rainbow.
I resent the ties, but have learned gratitude.
I know beyond the rainbow lies unbridled euphoria,
flight into fantasy escape from the bounds of earth,
to crash like the kite, in terrifying free fall
through blinding light to crushing darkness.
Those who live daily a ten point scale of emotion,
spend most of your days at four to seven,
never comprehend a twelve or
a plunge to sub zero of utter despair.
Joy of rainbows and laughter sensuous pleasures
are only heightened the contrasting grays of death.
in sun lit color time exists no grays,
Nor can color and brightness in the grey time.
this is my cross, my laughter, burden, my joy
and faith and study of self
bring me closer to the center line.
Meds will control the swings while I learn the talent it takes
to control my brain chemicals
I will depend on the arm of flesh,
chemicals given by the Lord to man for my protection. (Jacobs, L 1995)
The facts that Lynda’s father, and his mother and sisters had the bipolar disorder was completely unrecognized in the 30’s through 50’s were not even diagnosed much less treated. At least in current times bipolar is recognized and treated as a disorder in children. In the 70’s it was thought early onset was late 20’s, and childhood bipolar was just not credible. If there had been that recognition of the family illness, Lynda might have been treated from childhood. She could have learned the skills she lacked and the social skills she missed out on. She might have learned early to ask for what she needed, and to recognize the phases so she could deal with them in more positive ways. Even popular magazines carry the message today. Ellis, M (2005). Writes “Bipolar disorder harder on kids than adults.” In USA Today. A two day conference from Cross Country University.com was titled: “Is it ADDHD or Pediatric Bipolar? Differential Diagnosis and effective treatment?” Presented by Hanno Kirk, PhD, LICSW he carefully defined the differences for treatment purposes. With current research and understanding of Bi Polar, children like Lynda can be correctly diagnosed and treated, and hopefully save them from the social traumas that came to Lynda, Patty Duke, Barbara Walters, and others like them from misunderstanding, mislabeling.
The University of Utah has blood samples of all our family for three generations to use in a research study on possible genetic connections within families. We have at minimum of four generations that we can identify with Bipolar disorder, and I am sure it goes back many generations more, from some of the stories we have in our early family history. George Jacobs I and his son, George Jacobs II with his wife and daughter were imprisoned and hung for witchcraft in Salem Massachusetts witch craft trials in 1690. In the Video, The Crucible, (http://www.imdb.com/title/tt0115988/) One can see George Jacobs I climbing the ladder to the hangman’s noose .We have the transcript of his trial. (http://www.Growingtogethercounseling,com (2009) Ancestors.) We apparently also have his genes. That would be an interesting longitudinal study.
We are happy to see that Bi Polar Disorder, childhood onset, is out in the open and available for readers to recognize and deal with, hopefully through treatment and medication. But as Hanno(2003) pointed out, using the wrong kind of medication or for the wrong diagnosis gives the reverse outcome desired.

DSM Diagnostic Client: Lynda
I. 296.40 Bipolar disorder
II. 32.8 Sleep disorder mixed type; strong IQ, in spite of emotional damaged by early sexual assaults and dysfunctional family, has learned dysfunctional coping skills.
III. 296, with continual suicidal ideation and death wish while on Wellbutrin and Depecote; Eliminated Summer 2008. Residential care three times for depression. Several surgeries, 2 most recent major surgeries 2006. R.O Somatic or factious. Defer to Neurologist for R/O Alzheimer’s or dementia.
IV. Early onset arthritis, frequent colds and bronchitis, somewhat overweight off and on through life. Early onset of emotional problems with no treatment until 1980’s.
V. Diabetes II by 40, brain damage and muscle atrophy by age 40 from high doses of prednisone during Christmas season 1988-89.
Currently taking Cymbalta and Arecept for fibromyalgia and dementia symptoms.
Arecept was recently omitted because it caused excruciating muscle cramps and pain in all parts of her body, as did Fosomax.
VI. Divorced after 17 year marriage, secondary custody of 7 children. Now all of age.
Parents were married but frequently separated, until father’s death in 1973.
Lynda’s Mother was raised by nuns then Methodist missionaries in boarding schools; orphaned at 5 years, raised children by same standards: no pride in self, strict religious upbringing in LDS church instead of Catholic or Methodist.
Patient has learned to overcome most dysfunctional coping skills with CBT and RET..
Currently attending Argosy University EdDCP program of study, licensed as LPC.
Presents in therapy to better create her business persona as a therapist and teacher.
GAF 75, amazingly high relative to severity of diagnosis and chronic illnesses. According to DSMIVR she would be functioning at 60=71

Bibliography
Bibli Birmaher, B., and Axelson, D., (2006). Course and outcome of bipolar spectrum disorder
in children and adolescents: A review of the existing literature. Development and psychopathology. Cambridge: December 2006. Vol. 18, Iss. 4; p 1023.
Elias, Marilyn (2005). “Bipolar disorder harder on kids than adults.” USA Today
24 May, 2005, p 6D
Fetzer, S. J., Fetzer, L.L. (2009). Pop-Culture Article Review. Pediatric Bipolar.
Argosy University Psychopathology and Assessment.
Hanno, Kirk. Cross Country university.com was titled “Is it ADDHD or Pediatric Bipolar? Differential Diagnosis and effective treatment?”
Jacobs, L.L. (2000) A Guardian Angel. Awaiting publication. clinical records,
Lynda’s autobiography and self report.
Lewinsohn, P. G., Klein, D. N, and Seeley, F. R. (1995). Bipolar disorders in a community
sample of older adolescents, prevalence phenomenology, co-morbidity, and course. Journal of the American Academy of Child and Adolescent Psychiatry, 454-463.

Monday, May 4, 2009

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Saturday, May 2, 2009

James Phelps. M.D. psycheducation.org

Bi Polar disorder summary of dis ease

BiPolarDisorderInfo

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