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Section 5
Self Destructive Behaviors and Bipolar Child Clients

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In the last section, we discussed three differences in symptoms of ADHD and bipolar disorder: rage, mood fluctuations, and other standard criteria.  Also, we examined the possibility of comorbidity and the danger of misdiagnosis.

In this section, we will examine three self-destructive behaviors commonly practiced by bipolar child clients. These three self-destructive behaviors are eating disorders; self-mutilation; and substance abuse.

3 Self-Destructive Behaviors

♦ 1. Eating Disorder
The first method of self-destructive behavior comes in the form of an eating disorder, most commonly bulimia. As you are already aware, bulimia is a series of binging and purging which can seriously harm a young client’s esophagus. Usually, I have found that female clients have a stronger propensity towards eating disorders because of the unique societal pressures about body types that they face. At first, many psychiatrists treat bulimia by itself, but in some cases, the underlying cause may be bipolar disorder or a co-occurring borderline personality disorder. 

Cynthia, age 11, reported her bout with the eating disorder. She stated, "Of course my parents didn’t know I had an eating disorder. How could they?  I kept all the laxatives under my mattress so they wouldn’t find it and I’d make myself vomit when they weren’t home. I ate regular. In fact, I felt like I couldn’t stop myself. Afterwards, I would feel so disgusting that I needed to purify myself. It was like an act of redemption. Other times, I was too depressed to do anything about my eating. I didn’t have enough energy."

As you can see, Cynthia mainly suffered from her bulimia during a manic stage, whereas during a depressive episode, she was too lethargic to binge or purge. I generally find that bipolar clients suffer from self-destructive behaviors during manic states.

♦ 2. Self-Mutilation
The second self-destructive behavior common in bipolar children is self-mutilation.Commonly, many bipolar children scratch themselves with their own nails and knives. Many clients describe the urge to self-harm as being trapped inside their own body with a snarling creature. One theory about self-mutilating impulses is that a powerful urge to discharge aggression meets a client’s attempt to inhibit the urge. The stress created culminates to an unbearable point and physical pain towards the self is the only relief. Many self-harming clients believe that this method is a cathartic way to relieve tension.

Brittany, age 13, talked candidly about her self-mutilation. Brittany stated, "I dig into my heels with my nails and rip layers and layers of skin off. While I’m doing it, I’m not thinking. I feel as though there’s an animal rage inside me—it’s like a super-electrically charged thing…like voltage. And when I see the blood, I stop feeling this horrible rage and come out of this stage." To learn more about self-harm, see the Healthcare Training Institute’s course entitled "Treating Teen Self Mutilation," or the DVD course entitled "Substituting Self-Control for Self-Mutilation."

♦ 3. Substance Abuse
In addition to eating disorders and self-mutilation, a third destructive behavior is substance abuse. Generally, adolescents are more likely to abuse drugs and alcohol, again a result of peer pressure, but also a result of their manic, risk-taking moods. Many teens with early onset bipolar disorder will abuse alcohol during both their manic and depressive states because while it will augment a manic client’s inhibitions, it will also numb a depressive client and worsen their condition. During manic states, client’s tend to prefer stimulants, while during depressive states, clients favor opiates. Opiates produce a numbing effect. Unfortunately, many bipolar clients mix alcohol and drugs that increase their risk of overdosing. 

Kevin, age 14, related his encounter with substance abuse, "I used to take so many hyper drugs like cocaine and speed, which I got on the playground. My school was not in a good neighborhood at all. When I was in my high state, they helped me get higher. Even though my friends took the drugs too, they said I had the most severe effects. Then, when I was in my low stage, I would break into my dad’s liquor cabinet and drink whatever I could find." 

As you can see, the particular substance that a bipolar client chooses is directly affected by what mood he or she is in.

Borderline Personality Disorder
Many times, when such self-destructive behaviors are evident, along with bipolar disorder, I find that a minor borderline personality disorder may also contribute to these habits. I find that clients with this disorder have a history of unstable and tempestuous interpersonal relationships, impulsive behaviors, frequent displays of temper, marked shifts of mood, and frantic efforts to avoid real or imagined abandonment. Dr. Hagop Akiskal and his colleagues performed a study of one hundred clients diagnosed with Borderline Personality Disorder. Almost half were found to also have a mood disorder. 

Twenty-nine developed unmistakable major depression with melancholic symptoms, eleven had brief hypomanic episodes, four others had psychotic mania, and eight developed mixed states. Dr. Akiskal believes that there is a strong link between the two disorders, perhaps a subclinical manifestation. To learn more about Borderline Personality Disorder and its treatment, you might consider referring to the Healthcare Training Institute’s course entitled "Borderline Personality Impulse Control with Schema Therapy".

Technique:  Recording Positive Self-Talk
I have found that child clients suffering from bipolar disorder who carry out self-destructive behaviors are reacting to negative self-talk. These clients react on their emotions and first impressions rather than on their knowledge of what is good for their bodies and social lives. 

Ethan was a 13 year old bipolar client of mine who had taken up sneaking alcohol from his parents’ cabinets. Ethan stated, "At first, I was just sipping. You know, to see what it was like.  Then I thought, ‘That makes me feel pretty good.  Maybe more will make me feel better.’ It was worse when I was depressed. I wasn’t really thinking. All I had in my head was that I was in pain and that the rum helped me." 

Ethan had become so consumed by his depression that he would shut out the reasoning factors in his mind. To help Ethan resist his urge to heal himself with alcohol, I asked Ethan to try "Recording Positive Self-Talk".

First, I asked Ethan to write down all the phrases he wished people had told him while he was depressed. Ethan wrote, "Hang in there, buddy. It will all pass. You’re going to be fine. You can get through this. You’re a strong person." Ethan even included one of his favorite jokes on the paper. I then asked Ethan to record these phrases onto a tape. 

Next, I told him that when he again felt the need to drink alcohol, he play the tape instead.  I asked him to attach the tape to the front of the cabinet so that would be the first thing he’d see when he went to drink.

Obviously, just this technique will not completely stop a teenage client from abusing substances.  However, Ethan did state, "It was nice to have an alternative. Even when I wasn’t feeling the need to drink, but I was depressed, I’d play the tape and suddenly I didn’t hurt so much."  Think of your "Ethan". Could he or she benefit from "Recording Positive Self-Talk"?

In this section, we discussed three self-destructive behaviors commonly practiced by bipolar child clients. These three self-destructive behaviors were eating disorders; self-mutilation; and substance abuse.

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