For Girls Only

 This article was made possible by a generous grant from the Remmer Family Foundation, Inc., which funds research and programs focused on helping at-risk adolescent and pre-adolescent girls make good choices in their lives.   The Balanced Mind Parent Network thanks them for their support.

  by Tracy Anglada

Battles have been fought over them, history has been forever changed by them, and they can completely melt a parent’s heart with just one smile. What special creature holds such power? A girl! Once described as sugar and spice and everything nice, girls are now known for much more than sweetness. They can be strong-willed, with a fierce determination. Women have accomplished some amazing things. They have climbed Mount Everest, swum the English Channel, flown in outer space, served on the Supreme Court, won the Iditarod, won the Nobel Peace Prize, and even run for President of the United States. They have also fought for human rights and advocated for those in need. In fact, it was women who founded The Balanced Mind Parent Network. Yes, girls and the women they become have shown that they can be successful in areas once dominated only by boys.

Quick Fact
The Iditarod Race is an extremely difficult dog sled race in Alaska. Those who enter it race their dog sleds over 1,160 miles in the ice and snow. Just finishing the race is a huge accomplishment. Susan Butcher not only finished the race but won it — four times!

While proving that they can do anything they put their minds to, girls also value their uniqueness. Girls and boys are quite different — different not only in their physical and emotional makeup but also different in their challenges and ways of dealing with these. While both boys and girls can have bipolar disorder, the difference in their emotions, physical makeup and coping strategies can present a unique set of challenges for girls with bipolar disorder. The information presented here has been designed to help girls and young women identify and meet these special challenges.

 

Getting the Right Diagnosis

One of the very first challenges facing girls with bipolar disorder is getting diagnosed correctly. Girls have bipolar disorder as often as boys do, but during childhood boys may be diagnosed more often than girls. What does that mean? One of the things it may mean is that the illness could be overlooked in some girls or mistaken for another condition, such as unipolar depression. If bipolar disorder starts around the beginning of your teen years, your parents may just think that you are having problems because of changes in your hormones related to your monthly cycle. (We are going to talk more about hormones and your monthly cycle later, as this can be a challenge for girls with bipolar disorder.) Another reason that it may be harder for girls to get diagnosed is the way they handle their emotions. Girls are more likely to internalize emotions. That means they sometimes keep things inside or cry alone in their rooms. But a boy might be more likely to show more symptoms on the outside, which would lead to a faster diagnosis.

Real World
Jenny's brother was diagnosed with bipolar disorder very quickly because of his symptoms. But Jenny was first diagnosed with anxiety. Because her symptoms of bipolar disorder looked a bit different than her brother, it took her parents and the doctor longer to identify that she was also suffering with bipolar disorder.

 

To overcome this challenge it will help to understand the symptoms of bipolar disorder. When you understand the symptoms you can keep track of your moods, which may help your doctor give you a correct diagnosis. Also, DO NOT keep symptoms a secret! While it may seem that this is a good idea because you don’t want to burden your family, it will hurt you in the long run. Those who love you want the best for you. That means they want you to tell them even about symptoms that are scary. If your family situation is such that you cannot tell your parents, talk to a trusted adult, such as an aunt, uncle or grandparent, your family doctor, a school nurse, guidance counselor, or someone else you trust. So what are the symptoms of bipolar disorder and how can you recognize them and keep track of them?

Bipolar disorder can affect the way you feel, the way you think, and the way you act. It also affects your energy levels. The symptoms of the illness fall into two main mood states — depression and mania. If you are suffering from symptoms of depression then life may look dark and without joy. Things that used to make you happy may not anymore. You may not want to do things that you used to enjoy doing. You may feel very irritable or agitated. You may cry very easily and feel a strong sense of sadness. You may wish you could just close your eyes and keep sleeping instead of facing the day. Even if you want to sleep, you might have trouble falling asleep or staying asleep. You might have a hard time concentrating and your grades may drop in school. You may feel tired all the time. You may think about death, dying and suicide. You may feel like your life is just not important or that you aren’t worth anything as a person. You might have a change in your appetite and weight.

Quick Fact
Girls have bipolar disorder as often as boys do but during childhood boys may be diagnosed more often than girls.

On the other hand, if you are suffering from symptoms of mania then you may feel on top of the world. You may be silly, giddy or goofy. You might think you are superior to other people or possess special knowledge. You may have too many thoughts at one time and your thoughts may go too fast. You may speak very loudly and rapidly. You may feel a need to continue talking. You may be distracted and have trouble focusing. You may become very irritable. You may need very little sleep. You might do dangerous or risky things. You may have very strong sexual feelings and you may want to act upon these feelings often, even when it’s not appropriate. (This is called hypersexuality, and we’ll discuss this further.) You may do things that are against your own ideas of right and wrong. You may have trouble making yourself stop. You may even see or hear things that aren’t there or feel like someone is watching you.

While all of us go through natural periods of being up or down, the symptoms of bipolar disorder are more severe and last longer. You may have symptoms of both mania and depression at the same time. This is called a mixed state. If you have several of these symptoms that last for more than a week, then be sure to talk with a trusted adult about these symptoms. Keeping track of your moods can help you understand yourself better. It can also help you get a correct diagnosis. Charting moods does not have to be complicated or difficult. You can use many different tools to chart your moods. You can use a journal, a calendar or a printable mood chart that you can find online. (See the link at the end of this article for an example of a good mood chart.) The key is to find an easy method that works for you and to be consistent. Make a note every day about how you felt that day. If your moods change very rapidly, you may want to make a note in the morning, afternoon and night. Writing down how strong your feelings are can help too. So you might rate your feelings on a scale from 1-10. Understanding and keeping track of your moods can help you successfully meet the challenge of getting a correct diagnosis.

Treatment

Quick Fact
Girls can have manic symptoms just as severe as boys but girls tend to spend a longer amount of time in the depressive phase.

Getting the right diagnosis is just the very beginning step for girls who are on the road to successfully managing their illness. The next challenge for you will be finding the right treatment. Treatment for bipolar disorder will be most effective if it includes medication, therapy and support in school. Not all people are the same and not all treatment works the same for each individual, so there can be a lot of trial and error. It may take many tries before you find the right combination of medications or a therapist you feel comfortable with. But don’t give up! Your effort will be worth it.

Even though girls can have manic symptoms that are just as severe as boys, research tells us that girls tend to spend a longer amount of time in the depressive phase of bipolar disorder. This can make treatment a challenge as many of the medications are more effective on mania than depression. Girls and young women can also have unique concerns about treatment because of the effects some medications have on their hormones. Plus, if you are a young woman who is sexually active, you should be aware of the effects that medications can have on the effectiveness of birth control pills. Let’s discuss the more common medications used to treat bipolar disorder and how they relate to the specific concerns of girls and young women.

Real World
Leslie has been on eight different medications. Now at age 18 she takes a combination of three different medications that work very well for her.

  • Eskalith, Lithobid (lithium carbonate): Lithium has the longest track record of treating patients with bipolar disorder. It is actually a mineral that is found naturally, but the medication form of lithium is used in treatment to make sure doses are of high quality and in the right amount. Lithium may be of special interest to girls because it has been proven to lower the risk of suicide. Girls with bipolar disorder actually have more suicide attempts than boys.
  • Depakote (valproic acid or sodium valproate): Depakote is a mood stabilizer that targets the manic and depressive symptoms of bipolar disorder. Depakote may increase the risk of polycystic ovarian syndrome in girls. (For more information on polycystic ovary disease see “Side Effects.”) Depakote also has been shown to cause birth defects during the first few months of pregnancy. Young women who are taking Depakote should talk to their doctors about the best way to avoid becoming pregnant before they become sexually active.
  • Lamictal (lamotrigine): Lamictal is frequently prescribed for patients who spend more time in depression and mixed states, which may make it a good option for some girls and young women. However, if you are taking Lamictal and then start to take a birth control pill, your dose of Lamictal may need to be increased. Lamictal will not decrease the effectiveness of the birth control pill, but the pill may lower the levels of Lamictal in your body.
  • Tegretol (carbamazepine): Tegretol is another common mood stabilizer. Young women who are sexually active and who are taking this medication need to be especially cautious as to their choice of birth control. Tegretol can interfere with both the birth control pill and the NuvaRing. However, it does not interfere with the birth control patch, which uses a different hormone to prevent pregnancy. It is especially important for young women to know this because Tegretol can also causes birth defects in the first few months of pregnancy.
  • Trileptal (oxcarbazepine): Trileptal is closely related to Tegretol. It works primarily on the manic symptoms of bipolar disorder. Like Tegretol, it also interacts with both the birth control pill and the NuvaRing but does not interfere with the birth control patch. There have not been enough studies done to know if Trileptal causes birth defects but, because it is similar in makeup to Tegretol, many experts feel that it probably does.
  • Topamax (topiramate): Topamax is sometimes used as a mood stabilizer or as an add-on medication to help reduce the weight gain that can occur on some medication. It also interferes with the birth control pill and the NuvaRing, but not the birth control patch.
  • Seroquel (quetiapine): Seroquel is an FDA approved medication for ages 10-17 years for use in mania, and one of the few medications approved to treat the depressive side of bipolar disorder, which may make it a good option for some girls with bipolar disorder. It may also be used to treat symptoms of mania and anxiety.
  • Risperdal (risperidone): Risperdal is an FDA approved medication for ages 10-17 years for use in mania, and works on manic and mixed states. It sometimes causes an increase in the hormone prolactin. This can affect both boys and girls, but girls are more likely to have difficulties with this. Too much prolactin can result in fewer or no menstrual cycles, lower estrogen levels and, in some cases, it can cause the breasts to produce milk. Prolactin levels can easily be checked through a simple blood test and usually return to normal within 2-3 weeks after stopping the medication.
  • Abilify (aripiprazole): Abilify is an FDA approved medication for ages 10-17 years for use in mania, and another medication used to control the mood swings in bipolar disorder. It is used for both manic and mixed states. This medication may decrease the hormone prolactin. Doctors really don’t know yet if there are any negative effects in girls when this hormone is decreased.
  • Zyprexa (olanzapine): Zyprexa is an FDA approved medication for ages 13-17 years for use in manic and mixed episodes. Zyprexa is used to control manic episodes and mixed states. While many medications can cause side effects such as weight gain, Zyprexa has been shown to cause significant weight gain and blood sugar problems. We will discuss dealing with these common side effects in the next section.
  • Geodon (ziprasidone): Geodon is used for both manic and mixed episodes.
  • Clozaril (clozapine): Clozaril is a medication that is generally only used to treat bipolar disorder when other medications fail. Clozaril requires weekly blood tests to monitor for a serious potential medical complication that lowers the white blood cell count.
  • Invega (paliperidone): This is an extended-release formulation that is a metabolite, and therefore, similar to Risperdal. It may have the same effect as Risperdal on prolactin levels. An extended-release version of a medicine is made to dissolve slowly over time instead of all at once. This keeps a steadier level of the medication in your body.

Dealing with Common Treatment Side Effects

While you may be able to manage your bipolar disorder with only one medication, most people with bipolar disorder require several different medications. This is a tricky balance that may change over time for you. As you try different medications, you may experience different side effects. Some may go away within a few weeks of starting a new medication, but others may cause more difficulty and stick around for a while. Understanding and managing side effects may help you stay on a medication that is working for you. You should always talk to your doctor about bothersome side effects. Sometimes your doctor can change the time of day you take the medication or the dose and this may improve side effects. Other times, the doctor may want to change the medication. Let’s talk about some of the common side effects of medications and see what strategies may help.

Quick Fact
Taking medication with food may help prevent a stomachache. Ginger ale and crackers may help settle an already upset stomach.

  • Headaches: Headaches are an extremely common side effect and can be caused by almost any medication. The good thing is that you may only have headaches for the first 2 or 3 weeks after beginning a new medication. As your body adjusts to the new medicine or the new dose, your headaches will probably go away. Ask your doctor if it is safe for you to take a headache relief medication, like Tylenol, during this transition. In the meantime, you may want to try a few tricks to help with headache pain. Turn the lights off in your room and rest with a warm or cool compress on your head.  Use whichever feels best to you. A warm shower or bath may also help you feel better. Also be sure to drink plenty of water.
  • Stomachaches: A very common side effect that you will probably get at one time or another is an upset stomach. Like headaches, this is a side effect that may happen to you when you first start a new medication or change the dose of a medication. If you get an upset stomach when you take medication, it may help to take it with food (check with your doctor to make sure you can take it with food). Saltine crackers and ginger ale may be especially helpful. If it happens a lot at school, ask your doctor to write a note to your school with instructions for the school nurse. You may be able to keep crackers and ginger ale in the nurse’s office or a different stomach remedy that your doctor approves. Some medications that are known to cause upset stomach are given at night. This may work for some people, especially if they take a medication that makes them sleepy at night. You still get the dose of medication, but you may sleep through the time that makes your stomach upset. Check with your doctor before taking any antacids, like Tums or Mylanta, to make sure they won’t interfere with your medications. If stomachaches continue past a few weeks or get worse, your doctor may adjust your medication.
  • Dizziness: Dizziness is an annoying side effect but, like some of the other side effects, it may go away after first starting a new medication or changing the dose. If you have your driver’s license, don’t drive while you are dizzy! You don’t want to have a car accident. If dizziness continues, your doctor may need to change your dosage or the medication. 
  • Vision Problems: Not everyone knows that medications can affect vision. Some medicines cause your eyes to “jump” or have a short, rapid movement from side to side. The fancy word for that is nystagmus. This isn’t necessarily a serious side effect but can be annoying. For some people it only happens once in a while and they may not even notice it. For others it happens more often and may interfere with reading. Some medications may even cause you to need bifocals. When this happens you and your doctor will want to discuss whether or not the medication is doing its job well enough to put up with the side effect or if the medication should be changed.
  • Hand Tremor: Some people naturally have a small shake or tremor in their hands while others have very steady hands. A small tremor caused by medication may not upset you but your doctor will watch closely to make sure a hand tremor caused by medication doesn’t get worse. Sometimes an increase in dose will cause a hand tremor to get worse for a little bit. If a hand tremor gets worse the doctor may change the dose, change the medication or add on a second medication to make it better.
  • Real World
    When Melanie started her new medication, she felt very sleepy. She even fell asleep in class. When she told her doctor, he changed her doses around so she was taking more at night and less during the day. That helped a lot! Now Melanie can stay awake in class and falls asleep better at night.

  • Sleeping Problems: You probably know from experience that bipolar disorder causes enough sleeping problems on its own. But sometimes medications can cause sleeping problems too. Some medications may make you very tired. This may be a good thing at night but not so much of a good thing when you’re trying to stay awake for school or work. Other medications may make it harder for you to sleep. This could be good during the day but really bad at night. Make sure you talk to your doctor about your sleep patterns. Changing the time of day you take medications can make a big difference! It may also help if you have been keeping track of your moods and sleeping patterns because then both you and the doctor can see when a new medication is having a big effect on sleep. Also remember that some medications make you really tired for the first few weeks but then, as your body adjusts, you don’t feel so tired. So this may be a problem you have to put up with from time to time in order to see if a new medicine is going to work for you.

There are three more side effects that may have a stronger effect on you as a girl or young woman. We are going to talk about each of these separately and talk about ways you can deal with these side effects.

Weight Gain 

Some medications make you lose your appetite but other medications can make you gain weight. This is probably not what you wanted to hear! There is a lot of pressure today to be thin. Most magazines make it look like all beautiful women are very thin. Sometimes they do this by using unhealthy models, camera tricks or by changing the pictures after they’ve been taken to make a person look thinner. But if you think about all the people you know, you will probably notice that this image is unrealistic. Did you know that only 5% of women have the body type that you usually see in magazines? So this does not reflect the real world. Even some of the women who are in magazines may at times struggle with their weight and wish they really did look like the picture of themselves that you see in the magazine. You only have to look around to know that real-life women come in all shapes and sizes but they are still quite beautiful.

Quick Fact
It is normal for girls to gain between 40 and 50 pounds as they go through puberty.

When you are going through your teen years there are some natural things that happen with your body and weight. Did you know that it is normal for girls to gain between 40 and 50 pounds as they go through puberty? Why? You are growing all over. In fact, you may grow up to 10 inches!  Your body needs to build bones and muscles, which means your body needs more weight. Plus, in order for your body to go through all the changes to become a woman, it also needs healthy body fat. During this transition, it’s quite common for girls to get stretch marks. That just means your body is growing very fast. All girls can be self-conscious during this stage. When you already struggle with these natural changes and then have to take a medication that makes you gain weight, it can be even harder.

First, you should know that a medication that makes one person gain weight may not make you gain weight. Some medications only have a small effect on weight gain. There are, however, other medications that can make you gain a lot of weight, and some can even cause you to have other complications from weight gain, such as diabetes. If you begin to notice that a medication is causing weight gain, what can you do? Never stop a medication without talking to your doctor first! He may adjust your dose, add on a medication to slow down the weight gain, or try a different medication that causes less weight gain. Sometimes just switching to a different version of the same medication may help. For instance, changing from the tablet form of Zyprexa that you swallow to the kind that melts in your mouth helped some patients lose weight. Others have noticed an improvement in their weight when they switched to an extended-release version of the same medication. Your doctor may also ask you to give the medication trial a little more time. Just like some of the other side effects, like headaches and stomachaches, weight gain may be worse for the first couple of weeks and then level off, or you may be gaining weight in a natural way as part of a growth spurt. Giving the medication a little more time may make this clearer.

Quick Fact
Over-the-counter weight-loss pills can be dangerous, even if they claim to be “natural” or “safe.”

Some girls are tempted to buy over-the-counter weight-loss pills to try to counteract the weight gain caused by some medication. This is very dangerous. Even though it may be tempting, never take any weight-loss pill, even if it says that it is “natural” or “safe.” These are advertisements meant to sell the product. Just because something is natural doesn’t make it safe, and even if it’s safe for one person it may interact with your medications or your moods.

What if you have to stay on a medication that makes you gain weight? Sometimes, due to severe symptoms, you might have to stay on a medication — at least for a time — that causes you to gain weight and perhaps feel worse about your appearance. Remember that you aren’t alone. This tough situation happens to other people with bipolar disorder and even other medical problems too. People with seizures, migraines, asthma, tumors, diabetes and other conditions often gain weight.  Many of them feel very self-conscious about it. Don’t suffer in silence. Connect with people who understand. It can really help to reach out to a friend who knows what it’s like. Also, don’t be afraid to speak up if people are saying mean things about your weight in school. It’s not okay for people to make fun of you because of your weight. Talk to your parents and your teachers if you are being made fun of. Work with your therapist on ways to combat negative feelings about weight. Never feel ashamed to talk about your struggle. Try to stay active and make healthy food choices no matter what your weight is. Exercise improves how you feel about yourself even if your weight doesn’t change. Above all, don’t give up! Researchers and doctors are always looking for better treatments with fewer side effects. It may be that very soon you will be able to stay healthy on a medication that doesn’t cause weight gain.

Real World
When Sarah had an episode with hallucinations, she had to start a new medication. Within one month, none of her clothes fit. She had to buy jeans that were two sizes larger than her normal size. The medicine did work and stopped Sarah’s hallucinations. Sarah was very happy that the hallucinations were gone but she wasn’t happy with her new size. Sarah and her parents talked to her doctor about their options. She had to stay on that medication for a while but was able to eventually change to a mediation that didn’t cause weight gain.

 

Acne

For some people, acne feels like the teenagers’ curse. At this important time in your life, as you change from girl to woman and experience a lot of different feelings about your appearance, along come red bumps, whiteheads and blackheads in the most obvious place — your face. The advice you get from family and friends may not help either. “Don’t worry, you’ll grow out of it” or “All teenagers have acne” may be of little comfort when you have to face the mirror each morning. What may help more is to understand what causes acne and what you can do about it.

Though most teenagers do have acne, they aren’t the only ones. Acne can start many years before you are a teen and many adults struggle with acne too. Most people will have acne at some point in their lives. As a teen or young adult, you face an especially difficult time because the hormones that trigger your body to grow and change also trigger the oil glands in the skin. While oil is good for your skin, too much can clog up your pores and then mix with dead skin cells and bacteria to form a pimple. You may have worse breakouts the week before your period. This relates back to the hormone levels in your body. It may all sound scientific but if it’s the night before a school dance or a date you probably care less about why it happens and more about getting rid of it!

If you go into any pharmacy, you will see shelves full of medications promising to improve your acne. Some of these may work for you, or at least help, because they contain medication. But if these fail to do the job, or if your acne is severe, you may want to see a dermatologist for other treatment options.

Real World
Monica was scheduled to give a presentation in front of a whole group of people. She woke up that morning with a new breakout right in the middle of her chin. She tried to cover it with makeup but there was no hiding it. Why did it have to happen today?

What does your medication for bipolar disorder have to do with acne? It used to be felt that all anticonvulsant medications (like Depakote, Tegretol, Topamax, etc.) caused a worsening of acne. You can even find some websites that say they do. But studies have shown that this is not the case. Anticonvulsants do not cause more oil secretion or more acne. Even so, acne is listed as a possible side effect of some medications used for bipolar disorder, including Lithium, Lamictal, Risperdal, Zyprexa, Abilify and Topamax. But the chances of this side effect are lower than headaches, for example. Usually the chance is listed at about one or two people out of a hundred. But what if you happen to be that one person? If you are the one who gets a rare side effect, then it affects you 100%.

If a medication is causing acne for you, then it may be because of the way that the medication is changing certain hormones in your body. For some teenagers this will just be a mild problem and they can use over-the-counter products to help fight it. But for others it is a serious matter that could leave scarring, both on the outside and in the way they feel about themselves. If you are having a tough time with acne that clearly started when you began a new medication, then you and your doctor will have to weigh out the risks and benefits of changing treatment. If the medicine is working great and keeping you stable then it may be better to add on treatment to fight the acne. In other cases, a change in your medicine may result in a decrease in your acne.

Polycystic Ovary Syndrome

Quick Fact
1 in 10 women have Polycystic Ovary Syndrome.

Girls who take Depakote and are obese are at increased risk for polycystic ovary syndrome. Your ovaries are small organs in your body. They are about the size and shape of a walnut. Every month hormones in your body trigger an egg to develop and be released. But sometimes this process goes wrong. When a woman has polycystic ovaries, the ovary has a lot of little pockets of fluid or cysts where an egg was supposed to develop and be released, but didn’t. Other symptoms of polycystic ovary syndrome include too much hair on your body, acne, obesity and high levels of ‘male’ hormones (all people have both male and female hormones but in different amounts). Doctors don’t know all the reasons as to why this happens. Treatment for polycystic ovary syndrome may include both medication and lifestyle changes, like losing weight.

Depakote may cause polycystic ovary syndrome in some girls. If you are already taking Depakote and you start missing your period or having periods that are unusual for you, be sure to report this to your doctor.

You and Your Hormones

What exactly are hormones and why do girls with bipolar disorder need to know about them? You can think of hormones as your body’s messengers. One part of your body releases a hormone that travels to another part of your body. Once it gets there, the hormone gives a message to a cell or an organ. In response, this cell or organ does something. You may know that hormones control a girl’s monthly cycle, but did you know that hormones also help control digestion, growth, hunger, sleep and production of red blood cells? There really isn’t much your body does without using a hormone! So hormones are very important whether you are a boy or a girl.

Premenstrual Syndrome (PMS)

Premenstrual Syndrome, or PMS, is sometimes the punch line of a joke or sarcastic remark about a woman. But PMS and its symptoms are no laughing matter. PMS is a real condition related to a woman’s monthly cycle that can really mess up her emotions and can even trigger a worsening of her symptoms of bipolar disorder. Symptoms of PMS generally begin about two weeks before your period and get better once you have your period. Symptoms may include headache, tiredness, bloating, mood swings, irritability, anxiety and acne. There is good and bad news about PMS and girls with bipolar disorder. The bad news is that well over half of all women with bipolar disorder report having worsened symptoms before their period. That’s twice as many than women without bipolar disorder. The good news is that women whose bipolar disorder is well controlled actually have fewer premenstrual symptoms than women without bipolar disorder. Women who continue to have PMS symptoms usually improve with further treatment for bipolar disorder.

If you are suffering from increased symptoms before your period, an adjustment in one of your medications may help quite a bit. Other treatment approaches may include a medication that is only taken the week or two before your period or the use of a birth control pill to regulate hormones. There are other things you can do to help reduce mild symptoms of PMS. These include healthy lifestyle choices that are good for all of us, such as regular exercise, eating right, getting enough sleep and avoiding things that can have a negative effect, such as caffeine and smoking.

Menstrual Irregularities

Quick Fact
Over half of girls and women with bipolar disorder have abnormal or irregular periods.

So, you’ve gotten past the rough few weeks before your period but now it’s that time of the month again, complete with cramps, water weight, bleeding — none of which is even remotely fun! It’s the process women go through each month when the egg released by the ovaries is not fertilized and does not develop into a baby. For some women this happens like clockwork every month. But did you know that over half of girls and women with bipolar disorder have abnormal or irregular periods? That means that you may skip a month or two between periods, have longer or shorter periods, or you may have your period too soon after your last one. For some women this is just an annoyance. But for others it may signal a specific problem, like polycystic ovary disease. If your periods are irregular, talk to your doctor. If it is a continued problem, treatment may be necessary to regulate your hormones and keep your periods regular. This may also help your moods to stay more stable. Remember that even if you haven’t had your period in a month or two, you can still become pregnant.

Living with Bipolar Disorder

We’ve talked about many of the medical issues that face girls and young women with bipolar disorder, and these are important to know about in order to manage your illness successfully. But you are probably just as concerned about how your illness affects your day-to-day life. Each girl with bipolar disorder is unique. While you may have unique concerns, you also have unique talents and abilities. Take a moment to think about your special gifts. What is it that makes you the person that you are? What do others value in you? What do you value in yourself? Appreciating and nurturing your abilities and gifts can help you deal with life even when it gets challenging. If you are having trouble identifying your unique talents, ask your parents or a friend to help you with this. You don’t have to be a straight ‘A’ student or an amazing artist to be special. Perhaps you have a big heart or maybe you are a great negotiator. Take a minute to think about these two questions:

  • What do other people say they like about me?
  • What am I most proud of about myself?

During depression it may be hard to keep these things in mind because bipolar disorder likes to fool people into thinking that they are worthless. But that’s the illness talking. If you are having trouble maintaining self-esteem then write down your positive traits on a sticky note and put it on your bathroom mirror or another place where you will see it and read it every day. You are a valuable person, and remembering that each day will help you cope.

Friendships

It feels good to have a friend you can trust and to be liked by others. But making friends is not always easy for girls and young women with bipolar disorder. Making a good friend is even harder. How can you make and keep friends? One dictionary defines a friend as “a person whom one knows, likes and trusts.” While it may sound simple, the first step to making a friend is ‘knowing’ that person. Getting to know someone starts with an introduction, but for some people this is the hardest part. Having good self-esteem can help you with this. If you don’t feel confident in yourself or you have anxiety along with your bipolar disorder, then you may find it difficult to get past this first step. If this step is hard for you, don’t beat yourself up over it. That will cause your confidence to drop and make it even more difficult to make friends. To work on your self-confidence in this area be very aware of your inner voice and what you tell yourself in your mind. We all have ‘self talk’ — that little voice inside that encourages us or discourages us. If your voice inside says negative things it will make it harder for you to truly have confidence in yourself and to make friends. So start paying attention to what you say to yourself and, if you see it is mostly negative, then make an effort to change it. Ask yourself, “Would I say something that negative about someone else?” If you wouldn’t say it to someone else, why say it to yourself? When you catch yourself saying a negative thing in your mind, immediately say a positive one. This may not come naturally and you may need to write down a few positive remarks about yourself to substitute for the negative ones in your mind. But if you keep practicing this, you can help improve your self-esteem. Of course, the more stable you are the easier it is to change this inner voice.

Real World
Julie wanted to meet a new girl in her class. She finally got enough courage and walked over to the new girl’s desk after the bell rang. Halfway there the voice in her head said, ‘She’s not going to like you. Why would she? You’re so stupid.’ Julie lost her nerve and headed toward the door instead. She wondered if the voice in her head was right. What if the new girl didn’t like her? Then Julie realized that she was talking bad about herself! Julie repeated her positive phrases to herself: ‘I am beautiful. I am strong. I am valuable. I can do this!’ She took a deep breath and, as the new girl walked by, she said, “Hi, I’m Julie. What’s your name?” The new girl sighed with relief. “I was beginning to think nobody would ask! I’m Mariah. I hope we have the same lunch hour because I hate sitting alone.” That was the beginning of a good friendship.

 

Here are some ideas for positive statements. Think about what makes you special and add two more of your own:

  • I am a strong person.
  • I am smart.
  • I am valuable.
  • I am beautiful.
  • I can do it!
  • ____________________________
  • ____________________________

Another thing to think about when making friends is, What kind of friend do you want? Not all friends are ‘real’ friends and not all will want the best for you. If someone claims to be your friend but encourages you to get involved in drinking, drugs or other things that will hurt you, are they really a friend? Being choosey about your friends is a good thing because friends can have a lot of influence over you. A true friend will look out for you and want the best for you.

Once you make a friend, the next challenge is keeping that friendship. This is a challenge for everyone. Friendships are never perfect; they are a work in progress. You and your friend may both make a few big mistakes that wear on your friendship. Keeping a good friend means you have to be willing to forgive mistakes. It means that you should respect her feelings. You may have to give a good friend some space for a while. It also means you will have to apologize when you mess up. If that all sounds hard, it’s because keeping a good friend is hard work, but it’s worth the effort.

Your illness can have an effect on friendships too. If you are going through a depression, your friend may think that you don’t like her anymore. If you are going through a mania, your friend may feel very overwhelmed. If you are changing moods rapidly, your friend may just be really confused and not know the real you. If you have a very good friend who you trust, at some point you may want to explain to her about bipolar disorder and how it affects you. This may help her understand your ups and downs and not take it personally. But don’t feel that you have to tell every casual friend about your illness. Sometimes you just want to enjoy the company of someone. They don’t have to know everything about you.

Quick Fact
Eighty percent (80%) of adolescents reported bullying incidents during their school years.

Another challenge is knowing when to let go and move on. Let’s face it, girls can be really mean sometimes. Even someone who used to be your best friend can change and say and do hurtful things. First, understand that this isn’t just happening to you. If you talk to girls who are older than you, I guarantee they can tell you all sorts of stories about people who used to be friends with them but who aren’t friends anymore. If a friend starts excluding you from a group, spreading hurtful rumors about you and trying to influence others not to be friends with you, this is not a friend, this is a bully. Recognizing a bully is important. It will help you deal with the situation for what it is. If you are being bullied by someone who used to be your friend, don’t keep it to yourself. Tell a trusted adult, your therapist or someone who is a true friend. A bully tries to take away your self-confidence, but you don’t have to allow that to happen. There are true friends out there who won’t tear you down but instead will be there to help you.

Risky Business

As you transition from teenager to young adult there will be times in your life where you will need to take a risk — to step into an unknown area without knowing if you will succeed. It’s risky to start a new job, enter into a new relationship, or make a long-term career choice. When making these decisions, people weigh out the risks versus the benefits and consider the possibility of success as well as the consequences of failure. This is the healthy process of growing up, which means taking some risks. Girls and boys are different in how they handle risks. They even use different parts of their brains to make these decisions. The good news is that you have a little advantage over the boys in this area. Girls, in general, are better at making good decisions when it comes to risks. Take a minute to enjoy that advantage before we talk about the bad news.

Quick Fact
Each year 27,000 young people die from making bad decisions.

The bad news is that at times your illness will make it harder to make good decisions. How so? During mania, a person has more impulsive behaviors (doing things without thinking about the consequences) and her judgment is worse. In a mixed state or a state of depression, a person may just not care about her own safety or well-being. Even during a stable mood, people with bipolar disorder tend to be more impulsive and take more risks than people without the illness. Sometimes a risky behavior is used as a substitute for medical treatment or as a substitute for more positive ways to cope with the illness. It may be bad news but it’s important for you to know this and to understand the traps of risky behavior and how this could mess with your life. Risk taking in bipolar disorder could include all sorts of things, but we are going to name a few of the more common ones:

Drugs and Alcohol:
The connection between drug and alcohol abuse and bipolar disorder is strong. One study showed that about a third of teens with bipolar disorder abuse drugs and alcohol. This connection is rather complicated so we can’t jump to conclusions about all the reasons why this happens. But some people use drugs and alcohol to try to calm down their symptoms. This is called ‘self medicating.’ While it may seem to work at first, it actually can cause a worsening of symptoms. Alcohol is a depressant. While a person may feel better when having a drink, in the long run it can contribute to more depression. Drugs are very unsafe and may even cause a person to have an episode of hallucinations or trigger very manic behaviors. This risky behavior can make the long-term outcome for your illness worse. In some cases it even causes death. A person with bipolar disorder may also be more likely to become addicted, which means that it may be much harder for a person with bipolar disorder to quit using drugs and alcohol.

Unsafe Sex: Unsafe sex is especially dangerous, considering the risks to both mother and baby during pregnancy. In addition to the risk of getting pregnant, it also carries the risk of sexually transmitted disease. Risky sexual practices also leave emotional scars and create a dangerous cycle in which a girl feels worthless afterward and then seeks out more sexual encounters to try to feel loved or worthwhile. This risky behavior can be spurred on by hypersexual feelings, which will be discussed further (see “Hypersexuality”).

Daredevil Acts: There are many daredevil acts that may create a temporary thrill because of the real-life threatening danger that is involved. Drugs and alcohol further impair a teenager’s judgment when attempting daredevil acts. Car surfing, drag racing, speeding, racing trains, and walking or climbing in dangerously high areas are all life-threatening daredevil acts.

Shoplifting: Shoplifting is much more common in people with disorders that impair impulse control, including bipolar disorder. It is a very risky behavior because it can lead to serious consequences, including arrest and a criminal record. It can ruin future job opportunities and leave you feeling guilty and bad about yourself.

Self-injury and Cutting:
Some teens turn to self-injury or cutting as a way to numb emotional pain. Cutting has been likened to a drug because it causes your brain to release a chemical that temporarily causes you to feel better. Like drugs, over time it takes more and more self-injury to get the same effect and can be addicting. Girls tend to do this more than boys and it may also come along with an eating disorder. Self-injury leaves permanent scars and doesn’t give you a real way to cope with your pain. It is also a risky behavior because over time cutting becomes more frequent and more severe. It can be associated with risk of infection and blood loss.

You may know that you are involved in risky behavior but if you are already caught up in it, what can you do? First recognize that risky behavior is a sign that your illness may not be under control. While many teens hide this behavior, it is important for your psychiatrist to know about it because he may need to change your treatment. Your doctor will not be shocked or upset with you; he or she knows that these behaviors are common among people with bipolar disorder — you should be open and honest! Your doctor may adjust your medications and he may also want you to work with a specific therapist to deal with these issues. Friends can also influence you, either for good or bad, in this area. A true friend will not want you to hurt yourself and won’t encourage you to do these things. But there are plenty of so-called friends who will encourage self-destructive and risky behavior. You may have to re-evaluate your friends and change who you spend time with. There may also be times that staying home is the safest alternative. If you are not stable, your parents may take away the car keys and restrict your activities, not as a punishment, but to keep you safe. At the time this may seem very unfair and you may be angry. But as you stabilize you may realize that this was for your own protection. What if you live on your own? There may not be anyone to advise you that you should stay home so you have to learn to recognize your own mood states and try to avoid these dangers. This is where charting your moods, like we talked about before, will be helpful. If you are already addicted to a certain risk-taking behavior, such as drug abuse or self injury, you may need extra help to break this cycle. There are special treatment centers that can help you stop these behaviors and replace them with good coping strategies. This will not be easy but you and your future are worth the time and effort it takes to learn how to manage your illness in a positive way.

Quick Fact
60% of teens with bipolar disorder experience hypersexuality.

Hypersexuality is a symptom of bipolar disorder that happens during the manic state. It doesn’t always get talked about because it can be an embarrassing topic but it’s very important for you to know about this symptom. During your teen years, you will experience normal sexual desires because you are growing from a child to an adult. This happens to everyone. But in addition to this, 60% of teens with bipolar disorder also experience hypersexuality. The “hyper” part of hypersexuality means “over” or “too much.” So while it’s normal to have sexual feelings, a girl or young woman who is hypersexual may have very intense sexual feelings that are not a normal part of growing up. A girl could be a virgin and still experience hypersexuality because it is an intense feeling. A girl or young woman who is hypersexual may also act out on these feelings. She may masturbate frequently, undress in front of other people, wear sexually revealing clothes, and talk a lot about sex. She may end up having sex with people she doesn’t know, people much older than her, or several different partners. Hypersexuality can lead a girl into very dangerous situations. The way she dresses and acts may bring a lot of sexual attention to herself, and there are plenty of people out there who will take advantage of that.

There are some really big risks to the activities that may come along with hypersexuality. It puts you at higher risk of getting a sexually transmitted disease, such as HIV/AIDS, hepatitis, gonorrhea, herpes, genital warts and so on. It also puts you at greater risk of becoming pregnant. While condoms may reduce these risks they are not foolproof. In addition to these risks, it can hurt your reputation socially, which can also have an effect on your self-esteem. This activity may also be against your own moral feelings, which can lead you to feel very angry and upset with yourself.

If you are a young girl who is struggling with hypersexuality you may feel powerless to stop these intense feelings, but there is help for you. If you are suffering from hypersexuality, the first thing to do is to break the silence. This is a symptom of your illness. Speaking up may lead your doctor to re-evaluate your treatment. One of your medications may be making manic symptoms worse and contributing to your hypersexuality. Or perhaps you need a change in dosage or an additional medication to help control your mania. Many young people find that once their mania is well controlled the symptom of hypersexuality eases off quite a bit and may even go away completely. The second thing to do is manage this part of your illness. Knowing it is a symptom is the first step but you also must protect yourself. If you are feeling hypersexual, don’t put yourself in a situation where you will do something you regret. While it may seem that having sex is the cure for being hypersexual, it is not! The feeling only goes away temporarily and then returns, which starts the cycle all over again. What will bring relief is getting the manic symptoms under control.

Pregnancy

If you are a girl or young woman with bipolar disorder who is having sex, then it is important for you to understand that you could get pregnant. There are risks that come along with pregnancy that you should know about. When a woman becomes pregnant the first concern is the health of the mother and the health of the baby. How does bipolar disorder affect this? There are several ways. During pregnancy there are changes in a woman’s hormones that can affect her mood. It is very common for women with bipolar disorder to have a relapse of symptoms during or right after pregnancy. You may not realize it but a relapse in symptoms is not only bad for your health but also for the health of an unborn child. Women with bipolar disorder are more likely to have a baby that is born too soon, which can also lead to medical problems for the baby. Medications are another concern because some of them may cause birth defects if taken during the first few months of pregnancy. But not taking medications causes concerns as well. As you can see, this is a complicated time in the life of a young woman with bipolar disorder. If a woman with bipolar disorder decides to start a family then it is very important for her health and the health of her baby to plan this in advance. Planning in advance will allow a woman to talk to her doctor about all her choices and give time to make adjustments in her treatment that will give her and her baby the best shot at being healthy during the pregnancy and afterward.

Quick Fact
Half of all women who get pregnant didn’t plan to, and some girls get pregnant the first time they ever have sex.

Some women worry that their child will also have bipolar disorder. This is a natural concern because bipolar disorder does run in families. While it is important to know that this is a possibility, you should also know that if at least one of the parents is healthy then there is more chance that a baby will be born without bipolar disorder than with it. All estimates of genetic risk are really best guesses by researchers, but the risk is never 100%. Risks when one parent has the condition range in estimation from 10% to 35% but risk rises if there are other family members with the illness. The more family members who have it, the higher the risk. When both parents have the illness the range is from 50% to 70%.  Even though you may be concerned about the possibility of passing on bipolar disorder to a child, don’t overlook the fact that people related to those with bipolar disorder also have a higher genetic chance of being very intelligent, artistically gifted and creative. So you may be passing on some very positive genetic traits.

Perhaps you are young and not even thinking about starting a family right now. You may not be worried about getting pregnant because you may think it won’t happen to you. Did you know that half of all women who get pregnant didn’t plan to, and that some girls get pregnant the first time they ever have sex? Symptoms of hypersexuality may increase your chances of getting pregnant, and so can some medications if you don’t realize that they interfere with birth control (see the section on “Treatment”). Not having sex is the only sure way to avoid pregnancy. Some girls don’t want to tell their psychiatrist or doctor that they are having sex because they are embarrassed or they don’t want their parents to know. But the risk to your own health and to a baby if you get pregnant is more important than any embarrassment you may feel. If you are having sex, or thinking about it, then you need to talk to your parents and doctor about the risk of getting pregnant, birth control and your medications.

What if you are sexually active and you miss your period? It may not be uncommon for you to miss a period or even several periods. A home pregnancy test, which can be purchased in any drug store, can tell you whether or not you are pregnant. What if the test is positive? Perhaps you didn’t plan to get pregnant, but you are. What now? Some girls hide a pregnancy for as long as possible because they don’t want it to be real or to face their family. But consider this: you can’t hide a pregnancy forever. You will have to face your family at some point. It’s better to do that earlier, when you can get better care for you and your baby. Don’t stop your medications on your own. Talk to your doctor right away. There are many things that your doctor will take into consideration when looking at your medications, including how long you have been pregnant. You, your psychiatrist and your obstetrician will want to work closely together in these decisions.

Real World
Amanda didn’t plan to get pregnant at the age of 14, but she did. Like many girls who are pregnant this young, she had her baby too early. Her little boy lived for only a few days.

If you are pregnant, or planning to become pregnant, you can find more information at
www.womensmentalhealth.org

Eating Disorders

Quick Fact
One percent of teenage girls in the U.S. develop anorexia nervosa and up to 10% of those may die as a result.

Bipolar disorder can mess with a girl’s eating patterns. Both depression and mania can cause changes in your appetite and so can medications. But sometimes these simple changes in eating become much more. Girls with bipolar disorder are at greater risk for having an eating disorder. Eating disorders include Anorexia Nervosa and Bulimia Nervosa. People who suffer from eating disorders usually are very worried that they will become overweight. They often have a distorted image of themselves. An extremely thin or underweight girl may look in the mirror and think she is fat. Girls who suffer from eating disorders may also feel a strong need to be in control of their eating when other things in their life (such as mood swings) make them feel out of control. Let’s learn more about eating disorders and what you can do about them.

Anorexia Nervosa: People suffering from anorexia nervosa have extreme weight loss, many times through starvation methods. They may also use diet pills, laxatives, extreme exercising and even vomiting to try to lose weight. Anorexia may cause a girl to completely stop having her period. It can cause malnourishment, brittle bones, weakness, shortness of breath, irregular heartbeat and, in some cases, death.
 
Bulimia Nervosa: People suffering from bulimia may be in the normal weight range but, like those with anorexia, they are intensely concerned about their weight. People with bulimia feel compelled to eat large amounts of food and then compensate for that by vomiting, excessive exercising, using laxatives or fasting. This is a cycle that is repeated several times in a week and usually includes much shame, guilt and self-hatred. Bulimia can cause problems with your teeth and throat from throwing up so much, and problems with your stomach and intestines. It may also lead to kidney problems and severe dehydration.

There is help for those who suffer from eating disorders. Treatment may include medication, therapy, nutritional counseling and sometimes hospitalization to treat malnutrition. Some of the treatments for bipolar disorder may also help eating disorders. Like some of the risky behaviors we talked about earlier, eating disorders may start as a way to cope or feel in control. But this is not a healthy way to cope. Working with a therapist on dealing with your bipolar disorder, as well as other stresses of life, can help you find healthy ways to cope. Cognitive behavioral therapy may be especially helpful.

Conclusion

As a girl or young woman with bipolar disorder, you face many challenges, but with the right information and treatment, you can successfully meet these challenges. There are actresses, authors, psychologists, business women and just regular women and girls like you who have all learned about their illness and manage it every day. That doesn’t mean the road is easy or that you will never have problems. But when problems do come up, you have a place to come for answers and for support. You will never be alone as you fight the battle to stay well. It is our hope that one day there will be a cure for bipolar disorder. But until then, remember that the The Balanced Mind Parent Network is here to help you through.


Links

Mood tracking chart for girls http://www.bpchildren.org/files/Download/MyMoodChartforGirls2.pdf

The Balanced Mind Parent Network Girls' News Corner http://www.thebalancedmind.org/flipswitch/for-girls-only/news

Women and Bipolar Disorder article http://psychcentral.com/lib/2007/women-and-bipolar-disorder/

Information for pregnant women with bipolar disorder
www.womensmentalhealth.org

Dove Campaign for Real Beauty
http://www.dove.us/Social-Mission/Self-Esteem-Toolkit-And-Resources/

Information on polycystic ovary syndrome for teens
http://kidshealth.org/teen/sexual_health/girls/pcos.html#a_What_Is_Polyc...

Teens against Bullying
http://www.pacerteensagainstbullying.org/

Teen Bipolar Advocate Blog
http://support4bipolarteens.blogspot.com/

Flipswitch: the Depression and Bipolar Connection - a weekly audio show and blog on living well with mood disorders.
http://www.thebalancedmind.org/flipswitch/podcast

References

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Blanco, C., et al. “Prevalence and Correlates of Shoplifting in the United States: Results from the National Epidemiologic Survey on Alcohol and Related Conditions (NESARC).” American Journal of Psychiatry 165(7) (July 2008): 905-13. Epub April 1, 2008.

Chawla, B., and H. Luxton-Andrew. “Long-term Weight Loss Observed with Olanzapine Orally Disintegrating Tablets in Overweight Patients with Chronic Schizophrenia. A 1 Year Open-label, Prospective Trial.” Human Psychopharmacology 23(3) (April 2008): 211-6.

Dove Campaign for Real Beauty. “My Body ... Facts and Fiction.” http://www.dove.us/#/cfrb/girlsonly/body_facts.aspx/ (October 12, 2009).

Duax, J.M., et al. “Sex Differences in Pediatric Bipolar Disorder.” Journal of Clinical Psychiatry 68 (2007): 1565-1573.

Geller, B., et al. “Psychosocial Functioning in a Prepubertal and Early Adolescent Bipolar Disorder Phenotype.” Journal of the American Academy of Child and Adolescent Psychiatry 39(12) (December 2000): 1543-8.

Greenwood, R., P.B. Fenwick, and W.J. Cunliffe. “Acne and Anticonvulsants.” British Medical Journal (Clinical Res Edition) 287(6406) (December 3, 1983): 1669-70.

Jiang, B., H.A. Kenna, and N.L. Rasgon. “Genetic Overlap Between Polycystic Ovary Syndrome and Bipolar Disorder: The Endophenotype Hypothesis.” Medical Hypotheses (June 23, 2009).

Karadag, F., et al. “Menstrually Related Symptom Changes in Women with Treatment-responsive Bipolar Disorder.” Bipolar Disorder 6(3) (June 2004): 253-9.

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Levinger, I., et al. “Psychological Responses to Acute Resistance Exercise in Men and Women who are Obese.” Journal of Strength and Conditioning Research 23(5) (August 2009): 1548-52.

Lunde, A.V., et al. “The Relationship of Bulimia and Anorexia Nervosa with Bipolar Disorder and its Temperamental Foundations.” Journal of Affective Disorders 115(3) (June 2009): 309-14. Epub November 12, 2008.

Payne, J.L., et al. “Reproductive Cycle-associated Mood Symptoms in Women with Major Depression and Bipolar Disorder.” Journal of Affective Disorders 99(1-3) (April 2007): 221-9. Epub October 2, 2006.

Rosenblitt, J.C., et al. “Sensation Seeking and Hormones in Men and Women: Exploring the Link.” Hormones and Behavior 40(3) (November 2001): 396-402.

Strakowski, S.M., et al. “Characterizing Impulsivity in Mania.” Bipolar Disorder 11(1) (February 2009): 41-51.

Wieck, A., and P.M. Haddad. “Antipsychotic-induced Hyperprolactinemia in Women: Pathophysiology, Severity and Consequences.” British Journal of Psychiatry 182 (2003): 199–204.

Wilens, T.E., et al. “Risk of Substance Use Disorders in Adolescents with Bipolar Disorder.” Journal of the American Academy of Child and Adolescent Psychiatry 43(11) (November 2004): 1380-6.

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