Interview with John* Can you tell me a little bit about yourself?

My name is John*. I am 65 years old and in the finance industry. I am a middle child. My mom and dad are still alive, and I spend a lot of time taking care of them. I love running, food, and the outdoors. I love to fish. I love to spend time with my family and specifically my goddaughters, godsons, and nieces. I really enjoy my life now.

What has your experience with mental health been like?

I grew up in an alcoholic household. In that household, there was a lot of screaming and fighting and that frightened me deeply. Expressing feelings was in part dangerous because if I expressed upset or anger toward the parent causing me distress, I would get reprimanded and potentially hit, so I began to suppress my feelings. I had a deep-seated belief that love was earned, so I became a people pleaser. It was a very unhealthy way to live and left me exhausted and unsure of who I was.

What made you turn to drugs and alcohol?

With all the uncomfortable feelings I had as a kid, the way I sought relief was with drugs and alcohol. I became a full blown alcoholic and drug addict. In that regard, the time I finally realized I needed help occurred at 3 AM one morning in Harlem where I went to buy drugs and got robbed. I was up till about 7 or 8 AM in the morning doing the drugs.

*Names have been changed for anonymity.

I then had to call my parents to let them know that I got robbed the night before because I lost my credit card, and then proceeded to lie about how the card was lost. At that moment, I admitted, or finally said out loud, that I had an addiction problem. From that point on, I was sent to a therapist and went to a rehab program where I met my best friend.

How would you characterize addiction and being an addict?

I want people to know that I deeply understand what it's like to be an addict. It is an extremely lonely, fearful experience. There is a much better way to live. If you're reading this, know that there is a solution. Typically what's underneath is fear: fear of being abandoned or being alone. The important thing is to know that your feelings are important. Feeling will not kill you. I used to think if I felt certain ways, I would die. Drugs and alcohol temporarily took those feelings away, until the car accidents happened and my behavior changed drastically. The opposite of addiction is connection. Connection is the most important thing. Connection has the power to heal anxiety, depression, addiction, etc. There is nothing wrong about asking for help and seeking that connection. You don't have to live in isolation.

What advice would you give for young teens experimenting with drugs and alcohol?

There is a tremendous amount of peer pressure. Part of the propensity to want to drink or take drugs is seeded in wanting to fit in, perhaps in your friend circle, and that feeling is most certainly real. It is very hard to maintain individuality and walk your own path when you're insecure and uncomfortable. If you're feeling those feelings, get help. You don't have to do this alone. There is also nothing wrong with experimenting. However, if you have the emotional makeup that I have, it is very dangerous

I did not have capacity for feelings, especially uncomfortable ones, and I used drugs and alcohol to soothe myself, with a group of other people who also did that, and now four or five of my friends from high school are dead.

What are some resources/self care techniques for someone struggling with addiction?

I am a member of a number of twelve-step programs. I am also a regular meditator and pray daily. Most importantly, I am a member of a community of many like-minded people, where we share our feelings and challenges as it relates to addiction. We have a saying that a challenge shared is a challenge halved, and a joy shared is a joy doubled. This has helped me to advance in so many different ways.

Science Behind Addiction

Addiction and overdose are now the number one cause of death among people under 30 in America — far more than traffic accidents and gun violence combined. In 2017, the opioid crisis was declared a public health emergency. In order to understand why people become dependent on addictive substances and why adolescents are particularly vulnerable, we must look at the science behind addiction.

Studies have shown that 80% of adolescents experiment with drugs or alcohol before adulthood, and adolescents have higher substance use rates compared to children and older adults. Adolescents are susceptible to addiction because the developing brain consists of an inefficient regulatory system, a strong reward system, and a weak harm-avoidance system when compared with an adult's brain. These things contribute to increased engagement in substance use and other risky behaviors. Additionally, the parts of the brain that control judgment and decision-making skills, such as the prefrontal cortex, are not fully developed until people are in their 20s. This means people below the age of twenty have less of an ability to accurately assess the risks of drug experimentation, make sound decisions about drugs, and resist the vulnerable feeling whenthey experience peer pressure.

Opioids

According to the CDC, nearly 500,000 people died from opioid overdose between the years of 1999 to 2019. There are four main phases of opioid intoxication: the rush, high, nod, and “being straight.” The rush occurs within ten seconds as a wave of euphoria The high is a general feeling of well being that lasts for hours after the rush. The “nod” overlaps with the high, and describes a state of escape from reality. Finally, “being straight” is when the user is no longer experiencing the “rush,” “high,” or “nod,” but the opioid still remains in the user’s system. Withdrawal will occur around 8 hours after taking the opioid.

There are four opioid receptor subtypes: μ, δ, κ, and nociceptin opioid peptide receptor. All of these opioid receptor subtypes have distinct distributions in the brain and spinal cord and mediate a wide variety of effects. Out of these receptor subtypes, the μ- receptor is responsible for mediating the reinforcing and rewarding effects of opioids. Even the distribution of these μ-receptors reflect the effects of opioids. For example, there are μ-receptors located in the medial thalamus and periaqueductal gray, which result in the analgesic, or pain-relieving, properties of opioids. Additionally, there are μ-receptors located in the ventral tegmental area and nucleus accumbens, which are involved in positive reinforcement, thus, explaining the rewarding and addictive effects of opioids.

Alcohol Withdrawal

Prolonged use of alcohol produces physical dependence, in the form of withdrawal. Withdrawal from alcohol is the most severe drug withdrawal due to the body’s adaptation to chronic use of depressants. Some symptoms of alcohol withdrawal include: tremor (the shakes), anxiety, sweating, high blood pressure, vomiting, and in the very rare case, hallucinations. These horrifying withdrawal symptoms motivate the user to take the drug again to get relief, which feeds into the awful cycle of addiction.

Narcan

Naloxone, known as Narcan, is a medicine available in the form of a nasal spray that rapidly reverses an opioid overdose by acting as an opioid antagonist. Because naloxone has a stronger affinity to the μ- opioid receptors than opioids, it binds to the μ-opioid receptors and replaces the opioids attached to the receptors. As a result, it blocks and reverses the effects of opioids and, therefore can quickly restore normal breathing to a person if their breathing has slowed or stopped because of an opioid overdose. However, it should be noted that Narcan is not a treatment for opioid use disorder.

In order to recognize when someone is experiencing an opioid overdose, we must look at the signs associated with it. A person who is experiencing an opioid overdose becomes extremely pale, their body goes limp, their fingernails or lips have a purple or blue color, they start vomiting or making gurgling noises, they cannot be awakened or are unable to speak, and their breathing or heartbeat slows or stops.

Reducing the stigma surrounding addiction begins with educating ourselves on the disease. Sometimes, addiction may feel like a never ending cycle: attempts to “get clean” may result in symptoms of withdrawal that can only be relieved by taking the drug once more. However, with resources like therapy, a strong support system, medication-assisted treatment, and knowledge of the disease, addiction is treatable.

WORKS CITED

“Opioid Overdose.” SAMHSA. Accessed March 17, 2023. samhsa.gov/medications-substance-use- disorders/medications-counseling-related-conditions/opioid- overdose.

“Naloxone Drugfacts.” National Institutes of Health. U.S. Department of Health and Human Services, January 4, 2023. nida.nih.gov/publications/drugfacts/naloxone.

Hammond, Christopher J, Linda C Mayes, and Marc N Potenza. “Neurobiology of Adolescent Substance Use and Addictive Behaviors: Treatment Implications.” Adolescent medicine: state of the art reviews. U.S. National Library of Medicine, April 2014. ncbi.nlm.nih.gov/pmc/articles/PMC4446977/.

Kane, Michael J. "Addiction." Drugs, Brain, and Mind, 7 Oct. 2021, University of Pennsylvania, Philadelphia, PA. Lecture.

Interview with Chloe Bown Community Manager at Chill Pill

Can you tell me a little bit about yourself?

I grew up in New York City and graduated from Tulane University. I very openly struggled with anxiety and obsessive compulsive disorder (OCD) in middle school and high school. My high school was an extremely stressful pressure-cooker environment. Everyone was pretending like they had it all together all the time, which felt really inauthentic to me because I was struggling so much internally. Thus, that was my avenue to trying to make a difference, and I started a student-led club to open a dialogue about mental health at school.

What were some of the symptoms associated with your anxiety or even just mental health in general?

For anxiety, I always felt a little bit on edge. I had over 60 of these what-if scenarios that were 9 out of 10 times really unrealistic. Particularly, I had a lot of anxiety around my health. I would spiral about getting sick, about germs, and anything to do with putting myself in danger. That was where the OCD came in because I felt like I needed to control things around me to make me feel like less scared of whatever the world had to throw at me. So, I developed a lot of compulsive behaviors in the form of washing my hands, flicking the light switch, or locking a door a bunch of times. I had very ritualized behaviors and patterns I knew intellectually that were not keeping me safe. But somehow internally, I felt compelled to carry out these behaviors because it made me think that I was more secure.

Was there a specific moment that motivated you to start @take.a.zen.x?

Honestly, I’ve been writing about mental health for a while before [starting @take.a.zen.x] and I would do some of it on my personal Instagram. After a while, I realized I would rather my personal Instagram be snapshots of me having fun with my friends.

The idea for @take.a.zen.x came to me in my sophomore year college. I started the account in January 2020 and I posted a couple times on it about my mental health. Then two months later [when the COVID-19 pandemic began], I was having a really hard time, and it was an important outlet to be talking about mental health. During the last two and a half years, I've been using the account to talk about my experiences and to write columns about my life as a young woman. I want to destigmatize mental health and help others in the process.

What are some coping mechanism for self-care things that you did to help your mental health?

Going to therapy was obviously a big part of my getting better. My therapist gave me a lot of resources for self-care. In terms of my own coping mechanisms, I've always been really content when I'm outdoors and surrounding myself with nature, so doing more of that has helped me when I'm feeling really out of control or anxious. I like hanging out with friends or watching a funny TV show that can take my mind off of whatever is triggering my anxiety. I would say continually and openly talking about my mental health with friends and family and actively working on it in therapy have been the most helpful.

What's one piece of advice we give to a teen who is struggling with mental health?

You're not alone. I've done work and research on this through my psychology degree, and struggling with mental illness in your teenage years through your early twenties is such a common phenomenon. I think 9 out of 10 times, the person you are speaking to will be able to relate to you and make you feel less alone. As soon as you connect with someone else about your experiences with mental health, it starts to feel much less scary and isolating. But the first step is talking to someone.

Any resources that can help a teen who is struggling with their mental health?

I’m currently working as a Community Manager at an app called Chill Pill, which is an amazing resource. Chill Pill is a virtual and honest forum for mental health where you can engage with other teens who are going through similar experiences as you. It has all the non-toxic parts of social media. It's a safe space to get things off of your chest. The app also offers these peer support audio groups on a variety of topics, whether it be friendship, anxiety, family relationships, or struggling with vulnerability. You can share your experiences, or you can just listen to others in the community. It’s a really validating environment to talk about my experiences and realize that you're not alone in whatever you're struggling with.

In addition to Chill Pill, I would say that there are so many good books, podcasts, and articles out there that can inform you about what goes on in our minds. Learning about my mental health has helped me because knowledge is power. The more that you know, the more that you're capable of experiencing. Always studying up on the things that you want to understand about yourself can be really helpful.

Science Behind Anxiety

As of 2019, an estimated 275 million people suffer from anxiety disorders. There is no particular reason why anxiety is so common. Still, to understand what is happening on a neurobiological level, we must look at three regions of the brain: the amygdala, central nucleus, and prefrontal cortex. The amygdala detects stress in the environment and plays a significant role in emotion processing. The central nucleus is located within the amygdala. Within the amygdala lies the central nucleus. The central nucleus is activated in response to sudden unpleasant events and mediates the fear response. Brain imaging studies have shown an increased amygdala volume in patients with Generalized Anxiety Disorder (GAD) due to greater activity of the central nucleus. Lastly, we must look at the prefrontal cortex, which is involved with executive functioning and develops later in life. The prefrontal cortex has an inhibitory function over responses of subcortical brain regions, including the emotional responses by the amygdala. However, with GAD, there is an imbalance between emotion-generating centers such as the amygdala and higher cortical control from the prefrontal cortex.

There are many neurotransmitters that play a role in either the upregulation or downregulation of anxiety. These neurotransmitters include Norepinephrine (NE), GABA, and Serotonin (5-HT).
First, let's look at Norepinephrine or NE. Locus Coeruleus, a small brainstem nucleus, produces NE in the brain. Increased firing of the Locus Coeruleus is involved with physiological responses to stress and panic. Excess NE activity is associated with symptoms like palpitations, flushing, and tachycardia.

WORKS CITED

Kane, Michael J. "Anxiolytic Drugs and Anxiety Disorders." Drugs, Brain, and Mind, 18 Nov. 2021, University of Pennsylvania, Philadelphia, PA. Lecture.

Fleming, Sean. "This is the world's biggest mental health problem - and you might not have heard of it." World Economic Forum, Jan

14,2019, weforum.org/agenda/2019/01/this-is-the- worlds-biggest-mental-health- problem/#:~:text=goes%20to%20anxiety.-,An%20estimated%20275 %20million%20people%20suffer%20from%20anxiety%20disorders., with%20105%20million%20male%20sufferers.

Interview with Kirby

Can you tell me about yourself?

I work a lot. I put a lot of my time into my future, but this is how I grew up and how I was raised. I also make TikToks every so often (that's just a hobby I've had since Musically was a thing) and the more I've got into social media it helped me realize what I want to do with my life: helping others realize the normality of what they go through and not feeling alone.

Can you tell me a little bit about your experiences with mental health?

I've gone through it a lot with its negative and positive sides to it. I dealt with a lot of different diagnoses and a lot of medications, along with all different types of therapy. It's been a rollercoaster of trying to figure out what has affected me and what is going to be affecting me. The first diagnosis I dealt with was anxiety back after I moved out of my mother's house because she was very against the “mental illness thing”. Not specifically mental illness, but her belief of what it meant for the person. It was a struggle to get the help that I really wanted while I was in high school, but when I moved out I had gone to a psychiatrist and wanted to get tested for more things. TikTok was also a big influence in getting the help I needed. I was worried that my diagnosis would affect me getting jobs. I found out that I was dealing with eating disorders all throughout high school. Even after high school I am still struggling a little bit with one, just because of the job I used to do. It has all been really hard to try and navigate in dealing with all of it because, like I said, it's just a roller coaster of how the day is going to go.

Also, the industry I work in now has given me, surprisingly, a lot of healthy coping mechanisms for a bunch of different disorders.

When did you first start experiencing an unhealthy relationship with food?

My eating disorder started senior year of high school. I fell into this really bad depression. That's something for me that started a lot of the kind of eating disorder coming back into my life. I'll get into a depression and all either start eating more or I won't eat it all. One of the things that I noticed fluctuated was that I started getting extremely tired. For about six months, I danced as an entertainer at a gentlemen's club. The first four months I was doing really well, even though I wasn't eating right. I was doing okay, but I was doing a lot of physical activity to where whenever it hit that third or fourth month, and I still wasn't taking care of my body right, I was getting fatigued by 11 and that's just the start of a 8- 10 hour shift, which I was able to work before.

Often people try to hide their eating disorders, is this true in your case?

Back in high school, yes, when I was dealing with it I didn't want to bring anybody into it because personally I had grown up being told you don't do it right you get yelled at or punished. So I never really went to anybody for help because I was terrified of that suggestion. But now I have a lot of people supporting me saying, "Hey, did you make sure you ate at least a meal today or something?” I have at least four or five girls who will make sure I'm okay. I definitely feel like if someone is not given the right idea of communication it can be very hard to communicate mental illnesses.

Did you experience a desire to stay in control?

Definitely. My boyfriend about 2 months into my eating disorder noticed and said, “You're not eating right? You're starting to get slimmer in the waist, are you eating?” I didn't want to talk about it. It was a hard thing to bring up because before this relationship I'm in now I had not had any healthy communication. I feel like that's a big thing that goes into mental health and trauma is if someone isn't taught how to communicate those feelings correctly they're going to hide it and it's a hard thing to fight with by yourself. You're so used to having to hold it in and when people offer you that help you reject it.

What's one piece of advice you would give to a teen who is struggling with an eating disorder?

Honestly, just eat the comfort foods. Don't hold back on yourself because your mind is telling you need to do this diet. If you're dealing with an eating disorder, do what you feel is best for your body. Choose the comfort food that you know is going to get you the help you need to build back into eating meals today.

What are some coping mechanisms or self-care techniques that you use for your mental health?

I'm still learning on my own because I'm 20, I'm still pretty young! I've just been through a decent amount of stuff on this Earth. I know it can be hard to find someone that will be there for you to hold you accountable but find that person that can really help you and hold you accountable. I also found that journaling works well for me. I'll keep a journal on me and write everything that I do in it so if I'm researching a book or if I'm writing down a to-do list I keep it all in that journal so whenever I'm flipping through those pages it reminds me, “Hey, make sure you eat this or make sure you drink that protein shake.” Whatever it is, you can have it all there in a little booklet on you. It may be hard to build a habit, but that habit is going to help you in the future.

Science Behind Eating Disorders

Imagine biting into your favorite food. What do you feel? For most people, craving their favorite food activates the brain's reward system - called the mesolimbic dopamine system. When the reward system fires, it reinforces behaviors- making it more likely for us to carry out these actions again. There are two phases during food intake: cognitive and consummatory. The cognitive phase is associated with the experience of desire or craving. Dopamine is associated with “wanting,” or the drive to approach a reward. In the consummatory phase, you experience pleasure. Opioid system activity is associated with “liking” or the pleasure associated during food consumption.

There are three manifestations of eating disorders: anorexia nervosa, binge eating, and bulimia nervosa. Dopamine activity is altered in both bulimia and anorexia, but in opposite ways. Studies have shown that women with bulimia have a weaker-than-normal response in brain regions that are part of dopamine-related reward circuitry, whereas these reward circuits in women with anorexia are hypersensitive to food-related stimuli. Let's take an individual look at each of these eating disorders.

Those struggling with anorexia usually experience low body weight, persistent restriction of food intake, increased energy expenditure, intense fear of gaining weight, and distorted body image. Only 30% of adults achieve full recovery. In a brain imaging study from 2011, Bailer et al. found that the release of dopamine in the dorsal caudate after administration of amphetamines in individuals with anorexia geared anxiety. In contrast, healthy individuals experienced pleasure and euphoria when dopamine was released.

This result suggests that restriction of food may be a coping mechanism for anorexic patients to regulate their anxiety, which then feeds further into their disorder.

The second manifestation is binge eating disorder (BED), in which binge eating occurs in the absence of compensatory behaviors such as fasting, excessive exercise, or self-induced vomiting. Binge eating is defined as consuming an unusually large amount of food in a short period of time, accompanied by a sense of loss of control. For people with BED, there is a decrease in dopamine at the nucleus accumbens when fasting and enhanced levels when they are binging. The dopamine release causes pleasures which incentives them to binge more. People with BED show altered brain activation in regions associated with impulsivity and compulsivity.

Bulimia nervosa is when binge eating is followed by compensatory behaviors. Cognitive behavioral therapy is the leading evidence- based treatment. In people with bulimia, reduced dopamine activity results in increased episodes of binging and purging. During a binge-purge cycle, there is often a period of restricted caloric intake followed by an impulsive binge episode.

One brain imaging study from 2013 found that brain volume could be used to identify individuals with EDs, as well as to distinguish between patients with anorexia and bulimia. Researchers found that there was a larger orbitofrontal cortex gyrus rectus in ED patients. The orbitofrontal cortex gyrus rectus functions to control food intake, specifically by regulating satiety. One potential explanation for this finding is that the larger orbitofrontal cortex gyrus rectus is associated with stronger sensory experience of food and related stimuli. However, one caveat to brain imaging studies of eating disorders is that any observed neural changes may not have a causative role in the eating disorder; rather, the changes in neurobiology may be a result of the eating disorder. Thus, we should consider brain imaging studies with the understanding that any observed changes may have a correlative, and not a causative, role.

WORKS CITED

Bulik CM, Coleman JRI, Hardaway JA, Breithaupt L, Watson HJ, Bryant CD, Breen G. Genetics and neurobiology of eating disorders. Nat Neurosci. 2022 May;25(5):543- 554. doi: 10.1038/s41593-022-01071-z. Epub 2022 May 6. PMID: 35524137; PMCID: PMC9744360.

McShane M, Ozbolt L. Neurobiology of Eating Disorders and the Use of Psychotropic Medications. Psychiatric Annals. 2018 Oct; 48 (10): 468-472. DOI: 10.3928/00485713-20180912-01

Kaye WH, Wierenga CE, Bailer UF, Simmons AN, Bischoff-Grethe A. Nothing tastes as good as skinny feels: the neurobiology of anorexia nervosa. Trends Neurosci. 2013 Feb;36(2):110-20. doi: 10.1016/j.tins.2013.01.003. Epub 2013 Jan 18. PMID: 23333342; PMCID: PMC3880159.

.Bailer UF, Narendran R, Frankle WG, Himes ML, Duvvuri V, Mathis CA, Kaye WH. Amphetamine induced dopamine release increases anxiety in individuals recovered from anorexia nervosa. Int J Eat Disord. 2012 Mar;45(2):263-71. doi: 10.1002/eat.20937. Epub 2011 May 3. PMID: 21541980; PMCID: PMC3151352.

Frank GK. Advances from neuroimaging studies in eating disorders. CNS Spectr. 2015 Aug;20(4):391-400. doi: 10.1017/S1092852915000012. Epub 2015 Apr 23. PMID: 25902917; PMCID: PMC4989857.

Kerr KL, Moseman SE, Avery JA, Bodurka J, Zucker NL, Simmons WK. Altered Insula Activity during Visceral Interoception in Weight-Restored Patients with Anorexia Nervosa. Neuropsychopharmacology. 2016 Jan;41(2):521-8. doi: 10.1038/npp.2015.174. Epub 2015 Jun 18. PMID: 26084229; PMCID: PMC5130127.

Frank GK, Shott ME, Hagman JO, Mittal VA. Alterations in brain structures related to taste reward circuitry in ill and recovered anorexia nervosa and in bulimia nervosa. Am J Psychiatry. 2013 Oct;170(10):1152-60. doi: 10.1176/appi.ajp.2013.12101294. PMID: 23680873; PMCID: PMC3789862.

Berridge KC. 'Liking' and 'wanting' food rewards: brain substrates and roles in eating disorders. Physiol Behav. 2009 Jul 14;97(5):537-50. doi: 10.1016/j.physbeh.2009.02.044. Epub 2009 Mar 29. PMID: 19336238; PMCID: PMC2717031.

Interview with Veronica Grace

Can you tell me a little bit about yourself?

Being raised by my parents, who are both in the military, in conjunction with their strict religious beliefs and a genetic predisposition for bipolar disorder (and that in line with some of the complex trauma I experienced growing up), has resulted in this “cocktail of mental illnesses” that I'd end up dealing with on a daily basis. In high school, I enjoyed doing track and cross-country, and one of my biggest passions that would end up making my career is singing and being in film and television. I've been training towards that my whole life, supporting myself because my parents didn't necessarily want me to pursue it. So I grew up to be a strong confident individual that can actually perform and hold my own on a stage. From there, I ended up going to college because I wanted to pursue marketing full-time. My mindset there was to craft a brand around myself, around who I wanted to be, so that I could not only understand the financial bearings and background of a certain business venture but also fund myself because I have the knowledge to do so.

What were some of the symptoms associated with your bipolar disorder or your mental health in general?

I was first diagnosed with anxiety in 2019 when I was studying in New York. I didn't see a psychiatrist, I didn't see a therapist. Six months after I’m diagnosed with anxiety [by my general practitioner], I had my first major manic episode.
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Some of the triggers for mania include a break up, a big blow up argument, or the loss of someone. All of this happened to me. I had a break up, I had a huge blowout fight with a couple friends, my mom was diagnosed with cancer, in addition to feeling like a lot of change was happening. I was in the state of not being in control of the people I love and things were rocky in my academic and career pursuits, so I felt threatened. I felt isolated. And I was absolutely alone in this manic episode. I wasn’t diagnosed, I didn’t get medications.

What events led up to your first hospitalization for bipolar disorder?

In 2020, I went back to college in the fall. My mom was diagnosed with a new type of cancer. In addition, I was doing a Title IX case against a professor from my university. That was very tough, to have to recount my experiences. I had also started dating someone new and was just making a lot of impulsive, unrealistic decisions. I spiraled out of control. I started doing a lot of drugs. I wasn't going to my classes as frequently and I wasn't paying attention in my classes. It just shows the extent to which an individual with bipolar disorder can lose control and things get so out of hand. It's unbearable. It feels like someone else is taking over your life and in all facets–financial, personal, spiritual, mental, everything–your life becomes a mess.

In the fall of 2020, I was hospitalized because I had a couple friends report me through our confidential counseling service. I ended up being in the hospital for 2 days and when I got out, I had my first therapy appointment with my therapist. She said, “you're bipolar and we need to get you to a psychiatrist who can prescribe you the medications that will be suitable for chemical imbalance in your brain.” Since getting the right diagnosis and the right prescriptions, I've been relatively stable. I've been able to maintain two separate jobs in the marketing realm.

Some of the triggers for mania include a break up, a big blow up argument, or the loss of someone. All of this happened to me. I had a break up, I had a huge blowout fight with a couple friends, my mom was diagnosed with cancer, in addition to feeling like a lot of change was happening. I was in the state of not being in control of the people I love and things were rocky in my academic and career pursuits, so I felt threatened. I felt isolated. And I was absolutely alone in this manic episode. I wasn’t diagnosed, I didn’t get medications.

What events led up to your first hospitalization for bipolar disorder?

In 2020, I went back to college in the fall. My mom was diagnosed with a new type of cancer. In addition, I was doing a Title IX case against a professor from my university. That was very tough, to have to recount my experiences. I had also started dating someone new and was just making a lot of impulsive, unrealistic decisions. I spiraled out of control. I started doing a lot of drugs. I wasn't going to my classes as frequently and I wasn't paying attention in my classes. It just shows the extent to which an individual with bipolar disorder can lose control and things get so out of hand. It's unbearable. It feels like someone else is taking over your life and in all facets–financial, personal, spiritual, mental, everything–your life becomes a mess.

In the fall of 2020, I was hospitalized because I had a couple friends report me through our confidential counseling service. I ended up being in the hospital for 2 days and when I got out, I had my first therapy appointment with my therapist. She said, “you're bipolar and we need to get you to a psychiatrist who can prescribe you the medications that will be suitable for chemical imbalance in your brain.” Since getting the right diagnosis and the right prescriptions, I've been relatively stable. I've been able to maintain two separate jobs in the marketing realm.

What are some resources you would recommend for a teen who is struggling with BPD?

Depression and Bipolar Support Alliance. They have hundreds of chapters across the country and what they specifically focus on is depression and bipolar neurodivergence. This organization reached out to me recently and I'm actually going to do a podcast with them. In looking at what they actually do and the resources that they have on their website, there are real accounts from family members, from actual people with these illnesses, and testimonials from doctors and psychiatrists to help get the full picture of what a mental illness might look like.

Science Behind BPD

Bipolar disorder manifests in two types, bipolar I and bipolar II, and the difference lies in the severity of the manic episodes caused by each type. A person with bipolar I will experience an episode of mania, whereas a person with bipolar II will experience a hypomanic episode, a period less severe than a full manic episode. It is important to note that hypomanic symptoms do not lead to the major problems in daily functioning that manic symptoms commonly cause. “Mania”, a period where a person's mood and behavior changes abnormally elevate. Some symptoms of mania include decreased need for sleep, increased speech, uncontrollable racing thoughts, distractibility, increased activity, and increased risky behavior. The key difference is that a person with bipolar I may or may not experience a depressive episode, while someone with bipolar II will experience a major depressive episode.

Although there is a general lack of consensus on causes and underlying biology of bipolar disorder, research has shown that bipolar disorder is highly heritable, with genetic influences explaining 60–85% of risk. A large number of family studies have consistently concluded that BPD aggregates in families. For example, studies published since 1960 suggest that the recurrence risk for BPD in first-degree relatives of BPD patients is approximately 9%, nearly ten times that of the general population!

Mood changes, feelings of highs and lows, as well as changes in motivation and exercise patterns, are the main indicators of people with bipolar disorder.

Dopamine, more than other neurotransmitters, has been implicated in the transition of depression to a manic episode in bipolar disorder because of the essential role that the dopamine system plays in activity level, motivation control, and compensation circuit in the midbrain. Even though the evidence is scarce, there has been some research that suggests Manic episodes typically occur at the time of administration of the dopamine precursor L-dopa. In addition, amphetamine, which triggers the release of dopamine, causes hypomanic episodes in patients with bipolar disorder and hypomania-like episodes in healthy controls. Lastly, antipsychotics, which block the dopamine receptor, are effective in treating manic episodes.

Brain imaging studies comparing patients with bipolar disorder and healthy controls consistently demonstrate smaller cortical volumes in the insula, anterior cingulate cortex, and prefrontal cortex. In addition, these studies consistently report loss of gray matter in primarily frontal regions such as prefrontal and anterior cingulate cortex (Lim et al., 2013). Since frontal regions in the brain, like the prefrontal cortex, play an important role in mood-related disorders and are responsible for cognitive control, impulsivity, and attention, the loss of gray matter in these regions are in line with the frequently observed impairments in executive function (impaired planning, prioritization, memory, execution, emotional regulation, etc.) in bipolar disorder.

Cross-sectional studies have shown that higher numbers of manic episodes in bipolar patients have been associated with less gray matter volume in prefrontal brain areas. Although those cross- sectional studies can be interpreted as manic episodes resulting in decreased gray matter volume (or vice versa), they also suggest that less gray matter volume is a premorbid condition that increases the risk of mania. To determine if manic episodes are actually associated with changes in frontal brain regions, a longitudinal study design is needed, where gray matter changes and manic episodes are prospectively investigated over time. 

WORKS CITED

Roland J. "Bipolar 1 and Bipolar 2: What Are the Differences?" Healthline, Jan 10, 2019, healthline.com/health/bipolar-disorder/bipolar-1-vs- bipolar-2.

Barnett JH, Smoller JW. The genetics of bipolar disorder. Neuroscience. 2009 Nov 24;164(1):331-43. doi: 10.1016/j.neuroscience.2009.03.080. Epub 2009 Apr 7. PMID: 19358880; PMCID: PMC3637882.

Lee JG, Woo YS, Park SW, Seog DH, Seo MK, Bahk WM. Neuromolecular Etiology of Bipolar Disorder: Possible Therapeutic Targets of Mood Stabilizers. Clin Psychopharmacol Neurosci. 2022 May 31;20(2):228-239. doi: 10.9758/cpn.2022.20.2.228. PMID: 35466094; PMCID: PMC9048001.

Murphy DL, Brodie HK, Goodwin FK, Bunney WE., Jr Regular induction of hypomania by L-dopa in "bipolar" manic-de-pressive patients. Nature. 1971;229:135–136. doi: 10.1038/229135a0.

Jacobs D, Silverstone T. Dextroamphetamine-induced arousal in human subjects as a model for mania. Psychol Med. 1986;16:323–329. doi: 10.1017/S0033291700009132.

Christoph Abé, Carl-Johan Ekman, Carl Sellgren, Predrag Petrovic, Martin Ingvar, Mikael Landén, Manic episodes are related to changes in frontal cortex: a longitudinal neuroimaging study of bipolar disorder 1, Brain, Volume 138, Issue 11, November 2015, Pages 3440–3448, doi.org/10.1093/brain/awv266.

Pratt E. "How does bipolar disorder affect the brain?" Medical News Today, May 12, 2022, medicalnewstoday.com/articles/bipolar-disorder- and-the-brain#affected-structures.

Interview with Jennifer*

Can you tell me a bit about yourself?

I am sixteen years old. In my free time, I like to play tennis and hang out with my friends. I prioritize my school work, but my happiest times are spent with friends and family. I also love to dance and listen to music. In terms of school, my favorite subjects are English and history. Math and science have never really been my thing. I love learning new things, but sometimes the environment at my high school can be so competitive that learning becomes secondary to “getting good grades”. I also love the beach and my favorite season is summer!

When did you start experiencing stress in a negative way?

The first time I knew it was bad was the night before a biology test of freshman year. When preparing for the test, I kept discovering new material that I just did not understand. By the time I had gotten 3⁄4 of the way through studying the material, the clock had just hit 1:30 AM. I had to be up for school by 7 AM. I began to panic. Suddenly I found myself lightheaded, dizzy, and struggling to breathe. After a few moments, I calmed down and decided to call it quits for the night. The next day, I felt completely unprepared and honestly depleted. All in all, I ended up with a B on the test, which wasn't even bad. But from there, I felt like I was living in a constant state of anxiety. Hearing that we had an upcoming test or quiz instantly made me very anxious. I knew it was bad when that one instance started haunting me with my other assessments.

*Names have been changed for anonymity.

What are some symptoms of your chronic stress?

One important factor is that the stress I feel is not a one time thing. It's more like a feeling that I live with that I have to work to overcome. Sometimes it can be almost irrational, but nevertheless, the feeling is still there. It kind of just feels like you live in a consonant state of panic, and your heart is almost always beating. Some times are more intense than others, like that panic attack in ninth grade.

What are some self care techniques/ coping mechanisms that help you deal with the stress you face from school?

It really helps me to do things that I actually enjoy so I can get my mind off of the negative things. For example, I like to put on face masks and paint my nails as a form of self care. I also enjoy going on long walks, listening to music, and detaching from reality. Another thing I have been really into recently is working out. Whether it be dancing, tennis, or even a workout class, getting my blood pumping and endorphins flowing really makes the biggest difference in raising my mood and getting my mind off of the stress. I would say the most important thing, though, is surround yourself with the people you love. For me, I know I can always count on my grandma to make me feel better, so I normally spend time with her when I need an escape. However, I do feel like it's important to note that, in some ways, you must face the stress head on. If I only do things to avoid the stress and not actually study/look over the test, by the time the assessment comes, I will be more anxious than ever. So, I must also be proactive about it and study while still focusing on the good and fun things. It's this happy medium that I feel like I have definitely improved at finding throughout my years in high school, but to this day, I am still working on perfecting it.

Science Behind Stress

Suppose you just found out you have a huge test coming up. You panic, anticipating the amount of work that will be coming up. According to Hans Selye, an endocrinologist who pioneered research on the stress response in the 1950s, this acute distress marks the alarm phase of the “General Adaptation Syndrome.” After this first stage, there is a resistance phase: the acute manifestations of your stress subside, and you learn how to cope with the upcoming test by studying. Eventually, you burnout and your body becomes exhausted of its ability to deal with the stressor; Selye called this the final exhaustion stage.

Selye’s theory of “General Adaptation Syndrome,” which described the three universal stages of dealing with a stressor, was analogous to the “fight or flight response” proposed earlier by the physiologist Walter Cannon in 1915. Cannon described the “fight or flight response” as an automatic physiological reaction to a perceived stressor; these bodily changes, in turn, allow for potential escape or defense from the stressor.

The stress system integrates a wide diversity of brain structures that are able to detect events and interpret them as either a real or potential threat. In general terms, the stress response can be characterized by an initial perception of a real or potential threat, which leads to the release of mediating molecules, and these molecules then interact with their corresponding receptors in the brain.

Specifically, the hypothalamic-pituitary-adrenal (HPA) axis mediates our bodies’ stress response. In response to stress, the hypothalamus secretes a hormone called corticotropin releasing factor (CRF). CRF triggers the release of adrenocorticotropic hormone (ACTH) from the anterior pituitary. Finally, in response to the ACTH, the adrenal cortex in the kidney will release glucocorticoids like cortisol. Cortisol is the body’s primary stress hormone that increases levels of glucose in the bloodstream, enhances your brain's use of glucose, and increases the availability of substances that repair tissues. Cortisol also curbs functions that would be harmful in a fight or flight response, such as digestive, reproductive, and growth processes.

The sympathetic-adrenal-medullary (SAM) axis is another stress response pathway. While the HPA axis requires a continuous stressor to be activated, the SAM axis is activated instantaneously. In the SAM axis, the hypothalamus activates the sympathetic branch of the autonomic nervous system, which triggers the “fight or flight response.” As a result, the adrenal medulla secretes adrenaline and noradrenaline.

Adrenaline and Noradrenaline function as both neurotransmitters and hormones. The main difference between hormones and adrenaline is that hormones are transmitted through blood, whereas neurotransmitters are transmitted across the synaptic cleft between neurons. The body's ability to feel pain decreases as a result of adrenaline, which is why you can continue running from or fighting danger even when injured. With the help of adrenaline, norepinephrine also increases heart rate and blood pumping from the heart. It also increases blood pressure, helps break down fat, and increase blood sugar levels to provide more energy to the body. This is why you may often find yourself performing better than you thought in high stress situations like a sports race or math test: because the adrenaline and noradrenaline pumping through your blood and traveling between synaptic clefts is providing more energy to your body.

WORKS CITED

Godoy LD, Rossignoli MT, Delfino-Pereira P, Garcia-Cairasco N, de Lima Umeoka EH. A Comprehensive Overview on Stress Neurobiology: Basic Concepts and Clinical Implications. Front Behav Neurosci. 2018 Jul 3;12:127. doi: 10.3389/fnbeh.2018.00127. PMID: 30034327; PMCID: PMC6043787.

Godoy LD, Rossignoli MT, Delfino-Pereira P, Garcia-Cairasco N, de Lima Umeoka EH. A Comprehensive Overview on Stress Neurobiology: Basic Concepts and Clinical Implications. Front Behav Neurosci. 2018 Jul 3;12:127. doi: 10.3389/fnbeh.2018.00127. PMID: 30034327; PMCID: PMC6043787.

"Chronic stress puts your health at risk." Mayo Clinic, July 8, 2021, mayoclinic.org/healthy-lifestyle/stress- management/in-depth/stress/art-20046037.

Flanagan C. "Stress: Which comes first, SAM or HPA?" Oxford Education Blog, Jan 29, 2009. educationblog.oup.com/secondary/psychology/which- comes-first-sam-or-hpa.

"Sympathomedullary Pathway (SAM Pathway)". Tutor2U, tutor2u.net/psychology/topics/sympathomedullary- pathway-sam-pathway.