--Janice Papolos and Demitri F. Papolos, M.D.
In a previous newsletter, we discussed
the great anxieties that children and adolescents with bipolar disorder suffer.
We wrote in that July issue:
Indeed, there is a surprisingly
robust scientific literature that documents the frequent co-morbidity or association
between bipolar disorder and a number of anxiety disorders, but this association
is frequently overlooked when a differential diagnosis is made. Instead, anxiety
disorders are often seen as diagnoses existing all by themselves - divorced
from the possibility of a co-existing mood disorder. Thus, a child frequently
receives a diagnosis of separation anxiety, generalized anxiety disorder (GAD),
or obsessive-compulsive disorder (OCD). An adolescent frequently gets the
diagnosis of panic disorder, and the anxiety disorders are not viewed as a
possible pre-cursor to a mood disorder...
We wrote about a study reported
by Daniel Geller of 217 children with obsessive-compulsive disorder at the McLean
Hospital/Massachusetts Pediatric OCD clinic. He and his colleagues found that
a full 69 percent of the study sample also carried diagnoses of mood disorders.
The Epidemiological Catchment Area
database supports the conclusion that the lifetime rate of comorbidity for obsessive-compulsive
disorder is particularly high among bipolar subjects.
When people hear the term "obsessive-compulsive
disorder," they think of someone constantly washing his or her hands, or
avoiding cracks in the sidewalk, or even of the detective Adrian Monk whose
fears of contamination are so aptly portrayed by actor Tony Shaloub. However,
contamination fears are not the only kind of obsessive-compulsive fears. The
well-accepted instrument that assesses the severity and type of obsessions -
the Yale-Brown Obsessive-Compulsive Scale (the YBOCS) - lists nine categories
or subscales, one of which is entitled "Aggressive Obsessions." These
include:
- Fear might harm self
- Fear might harm others
- Fear harm will come to others
(may be because of something child did or did not do)
- Violent or horrific images
- Fear of blurting out obscenities
or insults
- Fear of doing something else
embarrassing
- Fear will act on unwanted impulses
(e.g. to stab a family member)
- Fear will steal things
- Fear will be responsible for
something else terrible happening (e.g. fire, burglary, flood)
The fears that children have that
harm will come to them or others is paralyzing and they may not always verbalize
it. One boy did describe his fears for us, but only years after when they were
less acute:
I would be sitting on the bus
that my father is supposed to meet and I kept "seeing" him having
a car wreck and being killed. I got so anxious that sometimes I would shake.
These thoughts were strong and occupied my mind at all times. I still get
them in my down time, but when I was younger I had them all the time.
I also thought I would get a disease, or if I went on a bike ride I would
get really hurt, so I couldn't go.
Kim Nelson, in her soon-to-be published
book, Mommy I'm Still In Here, recalls that her teenage daughter said:
I feel like I'm coming out of
my skin, like my body can't contain my insides. My heart pounds and I shake
all over. It's hard to catch my breath. Thoughts start going through my mind
so quickly, I can hardly recognize them; and then they fly through again,
round and round. Scary thoughts. Bad thoughts. Or maybe they're feelings,
not thoughts. I don't know. I feel like I'm not safe, like I'm in danger. Like an animal when it knows a predator is near (authors' italics).
A sense of threat seems to pervade
the waking and sleeping hours. Many of the children and teens experience nightmares
where predators stalk them, chase them, and kill them or their families in particularly
violent and horrific ways. One has to wonder whether the nightmares are informing
their daytime thoughts, or the daytime thoughts are shaping the nightmares.
Whichever, the children we spoke with described vivid dreams and nightmares
where: "I was being chased by a masked shadowy man and I got to the stoop
of my house, and he kept stabbing me in the back;" or, "I am being
chased by headless men who are going to eat me."
As bipolar children talk about these
dreams, they report the explicit appearance of blood (not just imagined or inferred,
but actually visualized blood) and descriptions of mutilations of bodies, dismemberment,
and the insides of body parts. Their dreams are considerably more affectively
intense than regular nightmares.
It is not surprising that so many
of the children mention their terror of "Chucky, the psycho-killer doll"
from Hollywood's horror movie canon. This psycho killer transfers his "soul"
into a doll in a toy store and tries to kill people with daggers and swords
and axes in order to retrieve a human body. (Please note: the mothers do not
take their kids to see Chucky movies; the kids are running into Chucky stand-alone
placards or posters at Blockbuster stores, or inadvertently, the children see
commercials on television and Chucky gets fixed in their mental landscape.)
The children report being terrified as soon as it gets dark; many find it difficult
to go upstairs alone, even in the daytime.
With such emotionally-charged imagery
penetrating the child's waking hours, and attaching to the dream state throughout
the night, is it any wonder that these children are so often in combative and
irritable modes and that they are terrified of bedtime?
Indeed, the rate and frequency of
night terrors and nightmares and their highly disturbing content seems referable
to fight-or-flight mechanisms, and may be coupled with many of the behavioral
problems these children have. Many of the behaviors are congruent with "fight"
(oppositional, defiant, argumentative, and defensive behaviors), while other
behaviors are more consonant with "fright" (anxious, fearful, withdrawn,
and phobic behaviors). The disturbing content and imagery of their sleep may
be contributing to the anxiety experienced during the day, or reinforcing them
on a nightly basis.
The Amygdala
In the brain's architecture, the
almond-shaped amygdala is poised like an emotional sentinel or alarm center
that is involved in fear responses and in initiating the first stages of emotional
memory. The amygdala receives signals that are of potential danger: signals
from the eyes and ears travel first to the sensory thalamus, which transmits
partial information about the stimulus to the amygdala, allowing a more rapid
response well before centers in the visual cortex or the thinking brain have
fully assessed the complete nature of the signal. A primitive emotion such as
rage takes this route to the amygdala, causing a response that it totally raw
and unvarnished. Most of the signal, however, is delivered to the visual cortex,
where it is analyzed and assessed for meaning and appropriate response. If this
more measured response of the signal confirms that a threat indeed exists, the
fight-or-flight response is triggered in the amygdala.
Incomplete or confusing stimuli
from the sense organs signal the amygdala to scan the environment for danger.
Bipolar children and those with learning and attentional deficits have significant
problems with the integration of sensory information. Such disturbances may
cause bipolar children and teens to misinterpret a casual touch or glance as
something threatening or to overreact to normal social cues. These children
can become hypervigilant and show paranoid tendencies as well as to express
severe and prolonged defensive reactions. They can become oppositional, or aggressive,
or withdraw.
Parents are often confused as they
watch a child who, out of fear, appears unable to separate from them, yet, then
flies into a rage with aggression singularly directed at the hands that protect
them. And, then, just as rapidly the child turns to extreme remorse, begging
for forgiveness.
One boy we interviewed told us that
the thing that infuriates him more than anything is when he's raging at his
mother and she turns away or does not look at him kindly (who can blame her?).
He cannot see that his actions are the catalyst of the painful encounter. His
mother should do something to lessen his overwhelming fear and to demonstrate
her concern for his safety and protection. He feels abandoned to his terror.
This Catch-22 situation is impossible for the parent to negotiate.
The Paradox
So we have a paradox here: a child
who is terrified by fearful imagery and who is afraid to be hurt; a child who
needs his or her parents for protection; yet a child who pushes the parent away
for seemingly little reason (a glance, a gesture, or - the big one - the word
"No"); and who is willing to hurt that same parent as retribution
to a perceived slight.
Although aggression has been a hallmark
of juvenile-onset bipolar disorder, nothing in the literature has examined the
relationship between the fearful thoughts and aggressive behaviors of these
children. A new study completed by researchers of the Juvenile Bipolar Research
Foundation found that obsessive fear-of-harm, either fear of doing harm or fear
of harm coming to self, may be closely linked with aggressive behaviors in children
with bipolar disorder.
The Study
Parents of 1,600 children and adolescents
with a clinician-assigned diagnosis of bipolar disorder were asked to complete
both the Y-BOCS and a scale measuring aggression, the Overt Aggression Scale
(OAS), on JBRF's secure online database. The Overt Aggression Scale is designed
to assess observable aggressive or violent behavior. This instrument consists
of four categories: verbal aggression, physical aggression, physical aggression
toward self; and physical aggression toward other people.
When the data was analyzed, the
parents who rated their children's fear of harm as "often" or "very
often or almost constantly" on the Y-BOCS, also significantly endorsed
items on the OAS that reported these same children expressing severe injury
to self and others. This group, called the high fear-of-harm group had more
than twice the rates of self-injury than those children with low fear-of-harm.
Moreover, the high fear-of-harm group was eight times as likely to hurt others.
These very frightened youngsters were reported to make suicide threats much
more frequently than the cohort who was not so afraid of harm to self or others.
To state it another way: excessive
anxiety about aggressive acts done to the child or others very strongly correlate
with the amount of aggression the child expresses toward him or herself and
others. Among the younger children, parents reported that the target of aggressive
behaviors was more likely to be other children rather than themselves. In contrast,
among older children, the target of aggressive behaviors was more likely to
be themselves rather than others.
What To Do With This Information?
Aggressive obsessions may serve
to distinguish the boundary between a case of obsessive-compulsive disorder
and bipolar disorder. In other words, if a child has the hallmark features of
early-onset bipolar disorder (such as rapid shifts in mood, elation and grandiosity
and poor modulation of aggressive impulses), as well as a family history of
mood disorders, and scores "high" on the aggressive obsessions section
of the Y-BOCS scale, then perhaps the primary diagnosis to be considered would
be bipolar disorder rather than obsessive compulsive disorder. In such cases,
antidepressants (commonly given to patients with OCD) would be avoided as they
may trigger mania, rapid cycling, behaviors that are even more aggressive, and
greater incidents of self-harm . Since it only takes parents a few minutes to
complete the Y-BOCS scale as well as the OAS, these instruments could be extremely
helpful in the diagnostic evaluation.
How Can the Clinician Help the
Child or Adolescent?
The treating physician or therapist
should be aware that an entire behavioral and intra-psychic repertoire can develop
as a result of a poorly-regulated arousal system. This might include:
- Difficulty regulating aggressive
impulses
- Disorders of sleep arousal (parasomnias)
night terrors and nightmares with themes of pursuit and abandonment, and content
of dismemberment and gore
- Fear of abandonment (caretakers
will be killed).
- Emergence of daytime fears and
separation anxiety, sensitivity to rejection, obsessional routines or rituals
that develop around bedtime with a resistance to going to bed
- Shame and helplessness about
his or her actions and inability
to control the fears and anger, and to act like all the other children
The treating physician or therapist
would do well to ask the youngster specifically about the nature and extent
of his or her fears, and help the child understand and talk openly about the
aggressive outbursts. The children may be relieved that someone is aware of
their struggles and that they are not bad or hurtful people. The children's
misperception that people are hurting them can be explored so that they may
not need to feel that they are defending themselves out of dire necessity.
Questions a therapist can ask: Do
you usually feel fear when you are alone? What are the fears that you have at
these times? What frustrates you most? What triggers the lash out? What is it
like inside when you feel the anger? Do you believe you could control these
impulses?
Providing a model that helps children
understand their behavior based on biology, one that takes into account the
difficulty that they have in regulating fear and aggression, can go a long way
toward establishing a therapeutic alliance.
What Can Parents Do?
If parents become more aware of
the child's internal experience - that he or she may be reacting to a perceived
threat - the confusion and the pressure on the parents will ease a bit. Parents
can gain some sympathy for the child's bewildering and hurtful behaviors, and
respond less defensively as well, thus helping matters to de-escalate.
Only then can they help the child
navigate this territory of fearfulness and defensive aggression. Perhaps the
issue of sleeping alone and being alone in a room is one that can be dealt with
at a later time, when the fears are not all so front-and-center (they do tend
to become less acute as time goes by).
After proper medical management
of her son's mood disorder, one mother was able to say to her son: "Josh,
you are stable now, and you have a window of opportunity when these powerful
aggressive impulses can be downgraded, and you can pause and reflect and find
a way to control the feelings."
In Conclusion
If both clinicians and parents are
aware of the correlation between obsessional anxieties (severe fear of harm)
and aggressive behaviors, it can be discussed and worked through and the youngster
may not struggle so deeply with these overwhelming feelings alone. Techniques
can be developed that help the child reign in the fear and misperception that
add to the likelihood of aggressive behaviors toward self or others.
Medications are key to stability,
but the defensive and knee-jerk reactions that have developed as a result of
a dysregulated arousal system - so early in life - must be addressed if the
child is to move forward in life, less afraid and less ashamed.
We always look forward to hearing
from you. Meantime, as the holiday season approaches, may you find harmony in
your homes.
Janice Papolos and Demitri F. Papolos,
M.D.
Acknowledgments
The authors would like to thank Connor
Langer, Katie Williams, Kevin Williams, and Karen Williams for their valuable
assistance in preparing this newsletter.
Bibliography
Goodman, W. K., at al. "The
Yale-Brown Obsessive Compulsive Scale II. Validity." Archives of General
Psychiatry 46 (1989): 1012-1016.
Papolos, D., J. Hennen, and M. Cockerham.
"Obsessive fears about harm to self or others and overt aggressive behaviors
in youth diagnosed with juvenile-onset bipolar disorder." Journal of
Affective Disorders September 26, 2005. (In press.)
Papolos, J., and D. Papolos. "Anxiety
Symptoms in Children and Adolescents With Bipolar Disorder." The Bipolar
Child Newsletter (http://www.bipolarchild.com),
July, 2003.
Papolos, J., and D. Papolos. "Night
Terrors." The Bipolar Child Newsletter, (http://www.bipolarchild.com),
July, 2000.Silver, J. M., and S. C. Yudofsky. "The Overt Aggression Scale:
Overview and guiding principles." Journal of Neuropsychiatry (1991):
S22-S29.
Yudofsky, S. C., J. M. Jackson,
J. Endicott, and D. Williams. "The Overt Aggression Scale for the Objective
Rating of Verbal and Physical Aggression." American Journal of Psychiatry 143 (1986): 35-39.
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