Treatment of TDD (or Early Onset Bipolar Disorder)
In my last blog on Temper Dysregulation Disorder with Dysphoria (TDD), I promised that I would write about treatment options for TDD. As I previously wrote, TDD is a diagnosis that will be unveiled in 2013, with the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. Currently, most children who will meet criteria for TDD are diagnosed with Bipolar Disorder. Therefore, to differentiate between the treatment for true Bipolar Disorder and TDD, I will use TDD to describe these children within this blog.
To begin a discussion of treatment, it is important to first talk about what I believe is happening in the brain. Here is a quick lesson in neurophysiology (brain function). Whenever we perceive something, signals are sent to our brain. When I say “perceive,” I mean see, hear, feel, taste, or otherwise experience. Those signals go from our sensory organs (eyes, ears, etc.) to our brain. Most perceptions go through the “grand central station” of our brain, the thalamus. Typically, the thalamus receives those signals from our sensory organs and shuttles them off to the appropriate brain region (e.g., visual cortex for sight). Well, there are some situations in which we do not want this to happen. For example, if you are walking through the woods and see a bear, you would want to respond as fast as possible to get away. You really do not have any decisions to make in that situation. To address this, our body has developed (evolutionarily) a mechanism to override our typical brain function. In these life or death situations, our thalamus receives the information from the sensory organ and, in essence, says “holy cow! That is dangerous!” When the thalamus does this, it does not send the information to the typical brain region (i.e., visual cortex). Instead, it triggers another area in our brain, called the limbic system. We call this “fight or flight.”
When our brain goes into fight or flight, several important things happen. Right away, our body decides that survival is more important than making complex decisions. To survive, our muscles need more food so that we can run fast (flight) or defend our self (fight). How do our muscles get more food? Blood. Blood carries food in the form of glucose and oxygen to our muscles. This is why mothers can lift cars off of their children and we can run faster than that dog chasing us.
While survival is extremely important in these situations, it comes at a cost. Typically speaking, our brain consumes most of the food in our blood. In fact, more blood goes to our brain than any other place in our body (except our heart, of course). As such, when our body goes into fight or flight, most of the blood that would go to our brain, is detoured to our muscles. Our brain gets very little blood at this time. This is typically a good thing. Think about it, when you are running from a bear, you don’t want to be trying to solve an algebra equation or thinking about what you are going to have for dinner.
Once we are safe, our body works to correct the fight or flight system. Several hormones (for those of you wondering, the main one is cortisol) are released in our body to get everything back to normal. for most of us, our body goes through this entire process at the right times and smoothly returns to normalcy.
It is at this point we get to a hypothesis about TDD. Children with TDD seem to trip into fight or flight very easily. It seems that rather small triggers (e.g., the word “no”) are perceived as a “threat” to their thalamus. In response, their body enters fight or flight and they begin to defend themselves in any way they can. They may use words, objects around them, or their own body to get rid of the threat. Unfortunately, the perceived threat is usually mom, dad, sibling, or some other unsuspecting person in their environment. If we use this theory, there are two extremely important things to think about as it relates to treatment.
First, this process happens without the child making a choice. Just as you would involuntarily go into fight or flight when you see a large snake or a bear, they go into fight or flight when their body perceives a threat. This an important point. The brains of these children perceive a threat, whether the threat is real or not doesn’t matter. Parents typically say, “He exploded over nothing” or “His anger comes out of nowhere.” While we may not have seen a trigger, the child’s brain does. As a result, my perspective of this condition is that these children respond with explosions and outbursts involuntarily. Their brain functions in such a way as to make them hypersensitive to things around them and it responds very easily.
Second, as I described earlier, people in fight or flight cannot think or make decisions. The area of their brain that is used for decision making is not getting any food. As a result, parents’ attempt to remind the child of consequences or punishments (i.e., “if you do that again I am taking away your Playstation”) are not registered. In fact, they are often perceived as continued threats, prolonging the “fight or flight” episode.
So we have finally arrived at the treatment discussion of this blog. I guess I take the long road sometimes…
Treatment – Medication
Treatment of TDD will take two forms. As I described above, the brains of these children are hypersensitive. They respond outside of the child’s consciousness. As such, the first treatment form is medication. Medication is used to “calm the storm” in the child’s brain, making them less sensitive to what is happening around them. I am often asked, “Why is medication necessary to keep them from exploding? Why can’t they just stop?” My response is based upon the fact that 99% of children want to be good. They want to make the right decision and make their parents happy. Therefore, if the child could manage these explosions, they would. If they could choose to make the right decision, they would not have any problems. The issue is that they cannot usually make this choice. As such, medication is used to help the child do what they otherwise couldn’t do.
Unfortunately, medications needed to address these issues are from two classes that are not typically approved for use in children, but are used for their “mood stabilizing” properties. The first family of medications is antipsychotics. I know, it is very scary to think about giving a child an antipsychotic medication. However, generally speaking, these medications help with irritability and agitation. The more common medications include Risperdal, Abilify, Seroquel, Zyprexa, and Geodon, though there are many others that could be used. Generally speaking, there are several side effects that you should be aware of. Most of these medications result in weight gain, some more than others. They tend to cause drowsiness. More significant is the risk for what is called extrapyramidal side-effects (EPS), which may cause some unusual, involuntary movements. If these effects are seen, it is important to talk with the physician.
The other type of medication is a broad class simply referred to as mood stabilizers. In addition to some antipsychotic medications, this class is comprised of medications used for seizures (Depakote, Tegretol, Trileptal, and others) and Lithium (the traditional medication used for Bipolar Disorder). Similar to what I described above, these medications work to “calm the storm.” They reduce extra brain activity, making the brain less reactive to what is happening in the child’s environment. Many of the seizure medications are approved for use in children with seizures, though not for TDD or Bipolar Disorder. Lithium is approved for adults with Bipolar Disorder, but not for children.
Treatment – Non-Medication
While medication is often needed initially to “calm the storm” and make the child available (cognitively) to learn new strategies for managing their behaviors, there are other things that I work on with parents to also reduce outbursts. The main goals are to reduce perceived triggers and consistency.
Reducing triggers can be difficult. Again, sometimes the child’s brain is triggered by something that we do not see. Our best hope at preventing most triggers is to reduce confrontation. As parents, we have to remove confrontation from our interactions. What does that mean? My first recommendation is to get rid of the word “no.” For most children, that one little word can set off an outburst that can ruin an entire day. While I am not saying that the child should have what ever he/she wants, I believe that “no” is an unnecessary definitive, most of the time. In fact, there are very few definitives in the world. Here is an example. Child says, “Mom, can I have some ice cream?” Mom responds, “No, you have not had dinner yet.” Child explodes. I firmly believe that the child’s brain perceives the mother’s response as, “No, you can never have ice cream. You do not deserve ice cream. I cannot believe that you would even ask something that ridiculous.” So, how does a mom not give-in by allowing the child to have ice cream without using the word “no?” The short answer, use a few more words. Here is that same example without “no.” Child says, “Mom, can I have some ice cream?” Mom responds, “That is a great idea. I am almost finished making dinner and you can have ice cream for dessert.” What happens now is the mother validated the child’s interest in ice-cream and made the child feel like their idea was a good one. She also set a limit and identified when ice-cream would be appropriate (“for dessert”). Now, the child knows that ice-cream is in his/her future, a realization that was not made available in the first scenario. This strategy can be used in most situations. I would not say that this will eliminate outbursts everytime, but it will definitely reduce the likelihood.
The last point about reducing confrontation is learning to walk away. When the child has an explosion or outburst, you have to walk away. DO NOT try to reason with or otherwise apply consequences when the child is having an outburst. It will only prolong the episode. As soon as an outburst begins, walk into the other room. Don’t get pulled into the ridiculous perspective that kids should obey simply because you are the parent. Also, recognize that the child’s brain is making the decisions, not the child. this does not mean that the child gets away with the outburst, but it does mean that we change our view from a “bad kid” to a kid whose brain crashes sometimes.
The second strategy is consistency. You have to say what you mean and mean what you say. Parents often “give in” to keep the peace or prevent outbursts. What that means is they will say “no,” the child will explode, then the parent will decide that it was not worth it and give the child what he/she wants. This is a HUGE problem. While most of the child’s explosions are out of their control, kids are not stupid. If they figure out that all they have to do is raise their voice to get what they want, guess what they will do to get what they want. These are learned behaviors that we have to prevent. To do so, you have to consistently hold your ground. You have to do a lot of thinking. Before you respond or say anything to your child, you have to consider how far you want this to go. If you think ahead of time and decide that it is not worth an explosion, respond accordingly, from the beginning. If it is something that you are willing to fight over, respond accordingly. Either way, you must stick with what you say. Even if you make a mistake (e.g., said no to something that really does not matter), you must hold fast to what you said. Overall, choose your battles wisely, but once you make a decision, you must follow through.
I know that this was a very long blog, but I hope that it is helpful. Please feel free to ask questions or post comments.
Dr. B
Long time no see/write
Wow, has it been a long time since I posted anything! I will try to post something this week. I think that I will write about Temper Dysregulation Disorder with Dysphoria (aka, Early Onset Bipolar Disorder).
Chapter 4 excerpt from my upcoming book “Handbook for Raising an Emotionally Healthy Child”
As I mentioned in previous blogs, I have been writing a parenting book. Well, I am about four chapters into it now and am feeling great about it. In fact, I have sent a query letter to a literary agent with hopes of representation. Because I am always eager to have feedback, I have decided to post an excerpt from the chapter that I just recently finished. So, enjoy and I look forward to you feedback.
Chapter 4: Adolescence
Adolescence (11 to 18 years)
Looking back over the last decade, you have successfully developed routines and you have managed transitions. You even survived temper tantrums and the influence of peers. But you ain’t seen nothing yet. I welcome you to adolescence.
Adolescence is best described by the opening line from the Charles Dickens classic, “A Tale of Two Cities.”
“It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to Heaven, we were all going direct the other way…”
Although Dickens was talking about London and Paris prior to the French Revolution, the words certainly hold true to adolescence. The relationship that you have developed thus far with your child will be put to the test, on a daily basis. There will be times when you look at your child and cry because they are so mature and adult-like. At other times, your adolescent will act so much like a toddler that you will cry, wondering how he or she will ever make it as an adult. There will be other times that your relationship with your child will be so strained, that you will cry because of what he or she said to you or did “just to spite” you. In other words, buy a lot of tissues and get that calming bath ready, because you need to be prepared for frustration and emotion like you have not yet seen.
Now, I am sure that there are those of you reading this who will say that I am exaggerating or being over dramatic. But there will be others who would say that I have said so far is not giving the turbulence justice. As a result, be aware that, like all other areas of development, there is some variability. As such, I will be speaking about adolescents in general, with a few examples, just to help with the points.
Globally speaking, adolescents present a set of challenges that many parents find difficult to tolerate. Parents are often torn between several potential roles. While they want to hold onto their historic roles of parent, authority, and decision-maker, they also find themselves wanting to befriend, bend, and let-go of their child. Many parents will swing between these roles, making them feel as though they are being ripped apart by their own decisions. As such, this may be the first time that you find yourself unsure as to what to say or do. Hopefully, you will find some comfort in knowing that most parents of adolescents are experiencing the same feelings. You should also be comforted in knowing that your adolescent is feeling exactly the same way. In fact, when I work with adolescents and their parents, one of the most common phrases I hear (from adolescents and parents alike) is, “I feel like I am bipolar.” Most of them do not truly mean that they are manic-depressive. Rather, they describe themselves as swinging between happiness to sadness, calmness to hostility, and enjoyment to anger. So, before we talk about some specific strategies for parents, let’s take a few minutes to talk about why this is such a turbulent time for everyone.
Piaget described adolescence as the Formal Operational Stage of development. During this time frame, adolescents continue to develop many of the cognitive skills that began in the Concrete Operational Stage. They begin to have the ability to think abstractly, logically, and in an organized manner, allowing them to think beyond the world of concrete reality and consider symbolism and abstraction. While some adolescents will have completely mastered this new perspective by the age of 15 years, others take longer to become fully able to utilize these skills consistently.
Some of you are probably flipping back to the beginning of this chapter. How can teenagers be capable of such advanced thought and consideration, but behave the way they do? Good question. Here is what I think causes all of the problems, emotion. Let me explain what I mean.
During adolescence, teenagers are attempting to create their own identity. They are developing their independent identities, which means that they must separate from you, their parent, and gravitate towards those who resemble what they see as their own ideal selves (their peers). While this sounds obvious, it is not so clear cut. On one hand, adolescents have their parents. Supports who have always been there for them and love them unconditionally. On the other hand, they have the wax and wane of friendships, relationships that they have to work on. Relationships that are very fragile and inconsistent.
Imagine standing at the base of a rocky cliff at the edge of the ocean. On one side you have the strength of immovable rocks and on the other, you have the ebb and flow of the powerful ocean. When the ocean is calm, you are able to stand with no problem. You can easily manage the rocks and the ocean. As such, you are calm. However, when the oceans are rough. As storms rage. When waves relentlessly crash against you, you find yourself drowning in the water, while your body pounds against the jagged and hard cliffs. You are anything but calm. You begin to panic, because now, everything around you is an enemy. You are unable to problem solve. You are unable to think about consequences. You simply want to survive.
In this analogy, the cliffs did not change, as a parent, you do not change. The ocean, your child’s friends, are ever changing, creating frustration and fear. Creating emotion. It is that emotion, the fear of losing those with whom they identify, that makes it impossible for them to consistently make appropriate decisions. This is the reason why you and your teenager can be getting along wonderfully one minute, but be screaming at one another the next. They are just trying to survive.
So as the winds of adolescence blow, we as parents have a choice. We can continue to be immovable and allow our children to crash against us, or we can be a solid foundation, while finding some flexibility in our expectations. Either way, parents must learn tolerance. You must be able to look beyond the immediate and remember that this is a marathon, not a sprint.
Update
I have not posted a blog in the last few weeks for several reasons. First, the holidays made it difficult to keep up with posts. I tried to cut back on “work” and just spend time with my family. It was great and we had loads of fun, but I am glad to be back at work.
The other big reason for my absence is that I have been working on a book. I am actively writing a parenting book that I hope to finish and have published within the year. It has taken a considerable amount of time, but it has been a great process. I have considered posting excerpts of it on this site, but I am cautious because I do not want anyone to take my ideas before I can get them published. As I continue to fight with myself about this, I will keep you posted.
Anyway, I will post more when I can. I am considering a few specific topics for my next real post, but I have not decided on one yet. If you have any requests, please feel free to ask.
Hope your New Year has been great,
Dr. B
How to Maintain Your Mental Stability Throughout the Holidays
The holidays are a challenging time for everyone. On the one hand, it is a time full of cheer, love, and celebration. Regardless of your beliefs, the holiday season is one of the few times of the year when families get together and spend time with one another.
Unfortunately, the holiday season is a very trying time for a lot of people, especially in the economically challenged times we are living in right now. As a result, I thought that I would write a quick post to discuss five things that you should do to help maintain your mental stability over the holidays.
1. One of the main reasons people struggle with the holidays is because of money. We feel obligated to buy gifts for others and usually spend much more than we intended. Most of the time, this is a stress that we impose on ourselves. No one says, “When you buy me a gift, make sure you spend a lot of money.” As a result, it is important to be economical and realistic about gift giving. For those outside of your family, a nice card is usually sufficient to express your love and appreciation for them. For those in your family, a family picture or other homemade gift could be given instead of a costly store-bought present. When buying for your children, I understand that gifts are “necessary.” However, remember that their expectations on gifts are only as high as you set them. That is, there is no reason to imply to them that they will get a $900 ATV when you can only afford a $50 remote control car. To give you a ball park, there are those who suggest spending no more than 1% of your annual income on Christmas gifts. Therefore, if you make $50,000 per year, you should only spend a total of $500 on gifts.
2. Another way people get stressed in the holiday season is because they become over committed. That is, they keep saying, “Yes.” Unfortunately, the more one says yes, the more one has to do. There are those families in which one person agrees to make dinner for the entire extended family. There are those families in which one person agrees to host three holiday parties and get-togethers. This stretches not only monetary resources, but also one’s mental and emotional resources. While I know that it is nice to be the one the rest of the family can rely on to make things happen, remember, that there are times in which the best thing that you can do for yourself, is to say, “No.”
3. Time is another huge issue for families this time of year. In fact, it is such an important issue, that it makes up 2 of the 5 issues that I am talking about. The first issue with time is related to how you delegate your time. Many people plan with the idea that there are 24 hours in a day. While this is true, there are in fact 24 hours in a day, it is important to remember that all 24 hours are not usable. You have to sleep and you have to eat. In all, you only have about 16 usable hours in a day, and that reduces to 8 if you work full time. Therefore, it is important that you delegate your time accordingly. Do not expect to do 8 hours worth of work in 2 hours. Be wise and don’t be afraid to ask for help!
4. The second time-related issue has to do with quality. A great deal of time can be saved if you use your time wisely. For example, when shopping for gifts, it is important to create a list of gifts before going shopping. If you are an internet person (if you are reading this post, I assume that you are), you know that most stores have websites. Explore websites to find which stores have the items on your list and make note of which stores you need to visit. This will save you considerable time, as you will not have to go store to store looking for a particular item. This quality use of your time will help with your frustration, save you time, and will probably even save you money!
5. Finally, to combat those holiday blues, it is important to remember the true reason for the holiday. Despite your heritage and particular celebratory activities, the holidays are here as a time of joy and cheer. They are not intended to see who can spend the most money, who can do the most for the family, or got the biggest present. The holidays are here to close out the year on a positive note. To reflect on the past year and make plans for the next. Sit with your family and talk about the good things that happened over the past year and come up with ideas for how to make next year even better!
I want to wish everyone a happy holiday and remember, if you aren’t happy, you can’t make anyone else happy!
Dr. B
Update on joining
I guess I should have included some of this information in my initial post. To join, you will click the Log In button at the top right area of the page. You will then want to click on Register. The site will ask for your username and will e-mail to you a password (please be sure to check your junk mail box). Once you log in, you will be able to change your username, password, and other profile information.
Sorry for the additional steps, but again, I hope that the site will be a comfortable place to find answers.
Thanks,
Dr. B
What is The Mental Breakdown?
Well, what does one write for their first blog? I guess I should pass along some information about the site that you have found. So, what is The Mental Breakdown?
I will start out by telling you a little about me. My name is Dr. Berney Wilkinson (you can call me Dr. B) and I am a clinical psychologist. I began working in the mental health field in 1997, when I came to be employed at a hospital in-patient facility. At the time, I was completing my undergraduate degree and helping with research in the Department of Psychiatry and Behavioral Medicine at the University of South Florida. Between my hospital work and my research experience, I developed a deep interest in working with children and adolescents with mental health issues.
In 1999, I began my graduate training in the School Psychology program at the University of South Florida. School psychology was my field of choice because my initial goal was to work primarily with children and adolescents, and where do they all go… school. While in graduate school, I had the unique opportunity to combine my medical experience (from my research in psychiatry) with the training I received in school. Together, these paths converge in a wide array of interests, including pediatric psychology, neuropsychology, and parent training. Upon completion of my graduate studies, I returned to my roots as an Assistant Professor in the Department of Psychiatry and Behavioral Medicine at the University of South Florida.
While working as an Assistant Professor, I helped with medical student education and the training of psychiatry and pediatric residents. In addition, I began working in forensics and completed a postgraduate program in school neuropsychology. My primary role, however, was as a clinician in the Silver Child Development Center. I completed post-graduate training with a clinical psychologist and was subsequently licensed in the State of Florida as a clinical psychologist.
In June 2008, I resigned from my position at USF and entered a private psychology practice in central Florida. In my private practice I work with patients and clients of all ages. I conduct psychological, psychosocial, psychoeducational, psychosexual, forensic, and neuropsychological evaluations. I work with individuals struggling with a wide array of mental health conditions. In fact, my broad expertise has afforded me the opportunity to present lectures at state and national conferences. In addition, I now teach graduate level counseling courses at Webster University’s regional campuses across Florida.
Despite my history of work in hospitals, at universities, and in private practice, I have felt as though there is so much more that needs to be done. While I enjoy working individually with my patients, I have always wanted to reach people on a broad scale. It is from this frustration that I developed my vision of The Mental Breakdown.
So, here we are, back to the initial question, “What is The Mental Breakdown?” Though the name is a clever title suggested to me by a colleague, my vision and concept of The Mental Breakdown is so much more. This site will begin as a simple blog to talk about mental health issues. I will “Breakdown” mental health information so that it is meaningful to the people who need it the most. I have always been frustrated with the medical and psychological field and their relative inability to communicate in a language that most people can understand. Sure psychologists and physicians can talk with one another in a jargon that they understand, but when it comes to communicating with those of you who have not had the same training, they so often fall short. Further, The Mental Breakdown will bring mental health concepts and issues to you when you need them. I will be posting blogs regularly to discuss a wide array of topics, from specific mental health conditions to treatment modalities. We can even discuss public policy issues, medications, and school related issues. As the site grows, so will the information provided. I will keep an archive of my posts and your questions so that others can benefit from your inquiry. Over time, the site will shift from strictly blog format, to a fully functional website that has all the information that you will need to answer your mental health questions.
To ensure that this site is a safe place for interested individuals to post questions, seek answers, and consult with me and others who have experience with mental health concerns, the site requires that you join and I will have to approve your post. While this safeguard is not meant to serve as a censor, it is designed to ensure that everyone feels comfortable posting their questions without the risk of confrontation, arguments, and conflict. Therefore, I encourage you to join my blog and ask questions. I will respond to questions regularly and will give you the most up to date information that I have available, without the smoke and mirrors, and in a language that you can use. I also encourage each of you to respond to questions and posts on the site. Although I will provide my impressions and ideas, each of you have experiences and suggestions that may be just as valid and useful for others. So please, share your own experiences, you never know how they may help others.
There is one last issue to present, which you will likely read throughout my blog. While I am a licensed psychologist, I have to inform you that the information that I provide is not to be considered a form of treatment. The information on The Mental Breakdown or any other web site should not be used as a substitute for professional healthcare. You should always consult your health professional before acting on any information seen on this site.
So there it is. This is The Mental Breakdown and I hope that I can make it live up to my expectations. To do so, I hope that what I have to say gives you the information that you are looking for. I hope that you will take part in this venture and together, we can help bring awareness of mental health issues to those who are most in need.
Thanks for reading and I will be writing again soon.
Dr. B
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