Beyond Blue

I read with interest Newsweek’s cover story, “Growing Up Bipolar,” for three reasons:
1) Ever since my former therapist handed me my adolescent journals, I’ve been coming to realize that I may have been bipolar as a kid;
2) I just attended the Johns Hopkins Annual Mood Disorders Research and Education Symposium, where Dr. John T. Walkup presented “Bipolar Disorder in Children and Adolescents: Understanding the Assessment and Treatment Dilemma”;
3) I’m starting to wonder if my son David might be bipolar, and I’m very confused how to address this.
Reporter Mary Carmichael begins her article with these two gripping paragraphs:

Max Blake was 7 the first time he tried to kill himself. He wrote a four-page will bequeathing his toys to his friends and jumped out his ground-floor bedroom window, falling six feet into his backyard, bruised but in one piece. Children don’t really know what death is, as the last page of Max’s will made clear: “If I’m still alive when I have grandchildren,” it began. But they know what unhappiness is and what it means to suffer. On a recent Monday afternoon, Max, now 10, was supposed to come home on the schoolbus, but a counselor summoned his mother at 2:15. When Amy Blake arrived at school, her son gave her the note that had prompted the call. “Dear Mommy & Daddy,” it read, “I am really feeling sad and depressed and lousy about myself. I love you but I still feel like I want to kill myself. I am really sad but I just want help to feel happy again. The reason I feel so bad is because I can’t sleep at night. And dad yells at me to just sleep at night. But, I can’t control it. It is not me that does control it. I don’t know what controls it, but it is not me. I really really need some help, love Max!!!!! I Love you Mommy I Love you Daddy.”
This is the story of a family: a mother, a father and a son. It is, in many ways, a horror story. Terrible things happen. People scream and cry and hurt each other; they say and do things that they later wish they hadn’t. The source of their pain is bipolar disorder, a mental illness that results in recurring bouts of mania and depression. It is an elusive disease that no parent fully understands, that some doctors do not believe exists in children, that almost everyone stigmatizes. But this is also a love story. Good things happen. A couple sticks together, a child tries to do better, teachers and doctors and friends help out. Max Blake and his parents may not have much in common with other families. They are a family nonetheless. That is what has mattered most to Amy and Richie Blake since Oct. 31, 1997, the day their son took his first ragged breath.

After reading this, I went looking for the journal I kept when I was around 12. In it, I wrote:

I feel like I’m just looking at the world, not living it. And then I think, no, I’m just tired. I want so much attention sometimes, I’ll do anything, even kill myself. No, I want to live! I am normal! Two people are inside of me and I don’t know which is right. Help me, God. I say, help me!

I had never considered that I might have been bipolar even as a young girl until I attended Dr. Walkup’s presentation as part of the Johns Hopkins Mood Disorders Research and Education Symposium. He said that it was common for bipolar disorder to exhibit itself in childhood as anxiety disorders and ADHD, and in adolescence as eating disorders, substance abuse, and severe depression. Sometime, usually in a person’s early 20s, she will experience her first mania. But typically it takes ten years to receive the proper diagnosis, after I person finally sees a psychiatrist.
For a minute there, I thought he had just read my diary.
As a child, I experienced acute anxiety peppered with just the right touch of OCD. In junior high, I struggled with anorexia. In high school, substance abuse. In college, I fell into a very severe depression. And sometime in my 20s I first experienced what I know now to be manic cycles.
Given all that, it’s very possible I was bipolar as a kid.
Dr. Walkup said that children or adolescents with bipolar disorder are often diagnosed with severe ADHD, agitated depression, severe anxiety disorders, disruptive behavior disorders, substance abuse, history of sexual abuse, fetal alcohol syndrome/effect, and schizophrenia.
It’s all really, really fuzzy. Gray and fuzzy. Explains Newsweek’s Carmichael:

Max’s prognosis has also grown more complex in the seven and a half years since [Dr. Joseph] Jankowski first labeled him as bipolar and hyperactive. “He’s oppositional defiant, he’s dyslexic, he’s ADHD, he’s OCD,” says Amy. “Give me an initial and he has it.” Bipolar children, especially those diagnosed early, often have such a litany of disorders. The bipolar brain tries to compensate for its weak prefrontal cortex by roping in other areas to help; these areas may now become dysfunctional, too. Child psychiatrists thus face an enormous practical challenge: they often can’t treat one disorder without affecting another one. “It’s like a balloon where you push on one side and the other side pops out,” says [Janet] Wozniak, the MGH [Massachusetts General Hospital] psychiatrist who helped define childhood bipolar disorder. With kids like Max, she adds, parents often have to settle for “just having one part of the symptoms reduced.”

That’s partly why it takes ten years to get the proper diagnosis. The majority of bipolar children have co-morbid conditions, suffering from a host of different symptoms.
Another reason for this delay, according to Dr. Walkup, is the different schools of thought between child psychiatrists and adult psychiatrists. Often those trained to see children have a simplistic understanding of bipolar disorder, and as he said, rarely is the disorder clear cut. Often, there are contributing symptoms and other diagnoses to consider. Many childhood specialists practice with a predominant psychological focus, and are close-minded to the evolving psychopathology in children. And finally, Dr. Walkup believes that because so many children have been diagnosed as bipolar in the last decade, there is a backlash and a resistance among child psychiatrists to slap yet another bipolar label on a kid.
Carmichael writes in Newsweek:

Many psychiatrists think that in the years since Max’s diagnosis, doctors have erred on the side of seeing it everywhere, mislabeling kids and creating a lucrative market for drug companies. Even one of Max’s docs says he thinks nine out of 10 kids with the bipolar label have been wrongly classified.

Walkup admits that in the past bipolar disorder may have been made too often for these “good” reasons:
1) We don’t have a better single diagnosis for severe treatable psychopathology;
2) As a diagnosis, it is a very “big tent”;
3) Medication treatments are readily available, maybe too readily;
4) Personality disorders and schizophrenia have fewer powerful treatments and may arguable have a worse prognosis
There are those that say definitively that bipolar disorder does not exist in children. Walkup challenges that claim with evidence that adults with bipolar disorder (like me) repeatedly note that they had symptoms when they were children (and lucky for me, I wrote the symptoms down so I had some material for a book, if I ever wrote one). Also, there are kids who exhibit the same types of symptoms as bipolar adults.
Thankfully, we have science and technology working for us.
Researchers like Peter P. Zandi, assistant professor in the Department of Health at The Johns Hopkins University School of Public Health, are involved in a new family linkage study, the largest and most comprehensive study to evaluate the resemblance among relatives across a broad range of bipolar disorder characteristics. In the Spring 2007 issue of Johns Hopkins Depression and Anxiety Bulletin, Dr. Karen Swartz asked Zandi about the significance of his research, and if we are better able to untangle the mix of genetic and environmental factors that control bipolar disorder. Says Zandi:

We currently do not know what causes bipolar disorder. Our hope is that by figuring out what the different genetic pathways to the disease are, we may get a better understanding of how the disease process works and from this develop more rational strategies to treat and/or prevent it.
We are beginning to believe that the causes of bipolar disorder are heterogeneous. That is, there may be different causal pathways, and these pathways may lead to different subtypes of bipolar disorder that have distinct outward characteristics. If we can reliably identify these subtypes, we think it might help us to tease apart and identify the different causes of bipolar disorder.

Neurological studies, with the help of high definition brain scans, have helped researchers understand the brain activity in those children and adolescence with bipolar disorder. Carmichael explains in Newsweek:

Scientists now know that bipolar children have too much activity in a part of the brain called the amygdala, which regulates emotions, and not enough in the prefrontal cortex, the seat of rational thought. “They get so emotional that they can’t think,” says Mani Pavuluri, a child psychiatrist at the University of Illinois at Chicago. More than the rest of us, a bipolar child perceives the world as a dramatic and dangerous place. If he is shown a picture of a neutral face, he may see it as angry. Show him one that really is angry, and his prefrontal cortex will shut down while his amygdala lights up like a firecracker. The typical result: a fury that feeds on itself.

I think Carmichael, for the most part, did an excellent job in covering the daily struggles of a family living with bipolar disorder. Because most stories in the media dealing with bipolar disorder, in my opinion, only contribute to the stigmatization of this disorder. I respect all of the research she did for the article.
But I still shuddered at times, like after reading this paragraph:

There are scientists who have thought about the future of children like Max in great depth. Many still think bipolar disorder is vastly overdiagnosed, but they agree that those who have it face a long, rough road. Two years ago the NIMH released findings from a large study of kids diagnosed between 7 and 17. The ones who fared badly had an early onset of the disorder, as well as psychosis, anxiety, ADHD and a tendency to switch quickly between mania and depression. Max has all these. His chances do not look good.

Because I know better.
Actually, with all the research and technology available today, Max’s chances look good. And so do mine. And so do David’s if we find that he is, in fact, bipolar. If I learned anything from Walkup’s presentation, and from the Johns Hopkins Mood Disorders Research/Educational Symposium, it’s that there is still so much that we don’t know. But that’s a good thing. Because we are gradually filling in the holes of knowledge. With more research and studies, not to mention the use of high definition brain scans and other technology, psychiatrists and neurologists will be better able to diagnose and treat bipolar folks like me.
Our chances look very good.
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