Bipolar II Disorder and Teenagers: Part Two -- Wendy's Story

In the second article of a four-part series, you'll see the progression of bipolar II through the story of Wendy, a teenager who grappled with the disorder. We'll also discuss the major symptoms of bipolar II -- depression and hypomania.

Wendy was a charismatic, high-school junior with sandy blonde hair and blue eyes. She was an athletic young woman who loved sports, drama and music. Her friends described her as a person with high energy, drive and a wide circle of friends. Her friend Alicia said, "Wow, she has the energy of two people." However, Wendy seemed to be changing, and her friends were beginning to find her annoying. They thought she seemed depressed, and they wondered if she had family problems. Alicia remarked, "I don't get it, one week she's so revved, and a week later she's as slow as a turtle."

Wendy had been staying up late for two weeks, whizzing through various projects and spending time on Facebook and YouTube. She had a variety of hobbies that included fashion design, boxing, yoga and baking. She loved designing new apparel and writing articles about her recipes for the school newspaper. She felt positive and abundantly energetic, and her projects kept her busy into the wee hours of the morning. She usually went to bed around 3 a.m. and would wake up at 7 a.m. feeling energized for her day at school.

Sometimes Wendy felt like chatting in the middle of the night and would call her best friend, Phillip, at 2 a.m. This behavior seemed rude and intrusive to him, but when he tried to talk to her about the problem, she was hard to interrupt and didn't seem to be listening. Wendy was experiencing racing thoughts and some mood swings, and her friends couldn't understand what was going on. She was not particularly aware of these changes, but she loved her extra energy. There was another subtle change that annoyed her friends -- Wendy became boastful, thinking she had skills beyond her abilities.

She told Phillip that she was going to bring fame to her hometown by winning at the state tennis match being held in St. Cloud, Minnesota. Tennis had been part of Wendy's life since she was in elementary school, and now she was a top player on the Minneapolis Mavericks. Her net game had improved, but hard work was necessary to excel in her overall game. Wendy had a good serve and felt that her backhand stroke was strong, and she was in the best aerobic condition ever because she did yoga daily, ran on her mother's treadmill and took Zumba classes. She was superconfident that she would win against the top-seeded player, and she came across as boastful when she said, "I'll show her tennis she hasn't seen before -- I'm going to blow her out of the water." Although Wendy had always been good at winning matches against local teams, she had never played at the state level, yet she reveled in her self-confidence.

A History of Anxiety and Depression

Wendy had not always felt self-confident. When she was about 12 years old, she started struggling with anxiety and depression. She had some sleep problems, and she occasionally felt down, restless and agitated. For some people, feeling agitated can be a way to mask an inner emptiness. Sometimes Wendy had bad dreams in which she was being chased by someone scary or searching for something she couldn't find.

After Wendy turned 13, she began to have days when she felt sluggish and didn't have her normal interest in her many activities. Although she generally had a lot of energy, Wendy had down days when she didn't feel like doing much. Sometimes, while she was working on a project, she would suddenly space out and vaguely sense that inner emptiness again. Her mother said it seemed like Wendy was "somewhere else."

Problems sleeping, agitation, lethargy, down days and a feeling of emptiness are a few of the behavior patterns that are common among teenagers with both bipolar II and/or depressive conditions. At this point it was unclear what condition Wendy had -- her symptoms could be red flags for an emerging bipolar II condition or a more serious depression, and either can exist simultaneously with an anxiety disorder. A complete assessment is necessary to accurately target what disorder may be emerging. The emptiness and sluggish days can be part of the depressive side of bipolar; it is common for teenagers with bipolar to start out with depressive symptoms although some teens start out by experiencing the elevated energy that is the high side of bipolar.

When she was about 14, Wendy was getting worse and finally talked to her mother about her behaviors and feelings. Her mother was worried and brought her to me for counseling. With some help, Wendy was able to learn positive coping skills and manage her symptoms well, as many can. She learned to regularly relax, practice her yoga, and take necessary quiet time. She continued to exercise daily, which greatly helped with her depression and helped manage her agitation. Additionally, she was in a support group where she made friends with others who had mental health challenges. Wendy made it a habit to go to bed at the same time each night and wake up at the same time each morning to help regulate her sleep and stabilize her moods. She also made sure to get eight hours of sleep. She still had sleep issues but felt generally rested during the day.

When she was a high-school freshman, Wendy started seeing a psychiatrist, Dr. Smith, for depression. He had prescribed a low dose of an antidepressant that had helped her, and she generally saw him once every three months. During the period before the state tennis finals, Wendy's behavior became erratic, and she stopped her relaxation routine, cut back on her exercise and quit the support group. What was really going on? Fortunately, Wendy's mother made an appointment for Wendy to see Dr. Smith within a few days.

When she went to see Dr. Smith, Wendy learned that she was exhibiting the symptoms of bipolar II. Because I specialize in the treatment of mood disorders, Dr. Smith referred Wendy back to me. When teenagers have bipolar disorder, it can be difficult for them to maintain good habits because of the depression and the mood swings into "hypomania" (the highs of bipolar II). Wendy was surprised at the doctor's analysis because she had been feeling at the top of her mental game, primarily because of her exercise, support group and wins on the tennis court.

Given the new diagnosis, I decided on an updated treatment plan for Wendy because her mood swings were making it hard for her to maintain her healthy patterns. She was especially concerned that her agitated behavior would push away her friends and that her depression would affect her tennis game.

Bipolar II and Hypomania

Most people with bipolar II experience a cluster of hypomania symptoms, but not all of them. The majority of the highs of bipolar II include the following symptoms:
• grandiosity*
• a decreased need for sleep
• distractibility
• racing thoughts
• talking too much, interrupting while others are speaking
• excess energy
• hypersexuality*
• a tendency to engage in reckless behavior
• irritability
• silly behavior*

*See below for detailed information about these symptoms.

Grandiosity: Grandiosity is an exaggerated sense of one's importance, knowledge, power, or identity. A person with grandiosity may seem outrageously boastful, pompous, or pretentious.

Hypersexuality: Hypersexual behavior is an excessive interest in, or preoccupation with, sex and a markedly increased need for sexual gratification. A person experiencing hypersexuality may appear to be obsessed with sex. In bipolar disorder, hypersexuality is often seen along with a distinct change in a person's behavior and personality.

Many people with bipolar II do not experience hypersexuality, but it was becoming a problem for Wendy. When she was hypersexual, she would masturbate three times a day and spend time buying sexy clothes, which she didn't wear when she was in a stabilized mood. Usually, she was somewhat shy around guys, but during a period of hypomania, she would become provocative and seductive. When she recovered from a hypersexual episode, she said she felt guilty because sleeping with a boy she hardly knew was completely out of character for her. Fortunately, the right medication (a mood stabilizer) helped her gain control of her urges before she could be hurt or become pregnant at an early age. Hypersexuality is an aspect of bipolar that is reportedly seldom investigated, and education is greatly needed about this symptom.

Silly behavior: Another symptom of hypomania is silly and goofy behavior. Sometimes Wendy became silly around her friends and roared at her own jokes and goofy behavior. For example, she would make a steady stream of puns throughout the day, and although her friends thought she was funny, they turned away when she wouldn't stop.

The Depression of Bipolar

Bipolar I is considered the more severe disorder because of the extreme manic moods and the fact that some people lose touch with reality. However, people with bipolar II generally have chronic depressions which can make coping very challenging.

Wendy had been diagnosed with depression when she was a freshman in high school. She would get periodic episodes where she just wanted to sleep, felt pessimistic and dwelled on negative thoughts. Wendy told me that she tried to think of something positive when she was depressed, but she could hardly get a picture in her mind.

Life seemed to have little meaning for Wendy, and she lost interest in her usual activities. I worked with her to develop a road map to help her get moving because "action, action, action" is essential to treating depression. Accomplishing tasks slowly and successively along with therapy and a support group can help a teen gradually pull out of a depression. Research indicates that learning realistic and positive patterns of thinking can greatly help in motivating a person to get busy and get things done. We'll discuss these skills in the fourth part of this series -- "Bipolar II Disorder and Teenagers Part Four: Positive Coping Skills."

I want to reiterate that teenagers with bipolar think in distorted ways when they are depressed, which leads to more depressed feelings and constricted behavior. Listen carefully to the content of teens' thoughts so you can help them become aware of how they are thinking. Then help them substitute realistic and empowering thoughts to get them to move forward behaviorally.

Through Wendy's continuing story, we'll discuss the difficulty of diagnosing bipolar II in the next article in the series: "Bipolar II Disorder and Teenagers: Part Three -- Diagnosis."