First, a Story
Kassia is 16. She’s a smart girl, makes mostly As and Bs with an occasional C thrown in when she isn’t showing her best effort. She’s enrolled in AP English. She belongs to a group of girls who visit the mall regularly, attend football and basketball games, and take turns sleeping at one another’s homes on the weekends. She’s been seeing a boy for several months, and is pretty caught up in the goings on of local boys – whom they like, what they’re doing, how they feel about the girls. Kassia in every respect is like most American teenage girls; her activities and interests are the standard fare. She appears functional and, on the surface, happy. Kassia was an easy baby and a happy, outgoing child. She loved to sing, dance, and play dress-up. She was curious and intelligent and loved to read and learn. Her parents divorced when she was 6, but Kassia seemed to take it fairly well, especially since her parents continued to live close to one another for a few years. There was stress in the beginning, but Kassia adapted. She liked having two bedrooms, and saw her father every week. When Kassia was around 9, her moods and disposition began to change. She began to spend long periods of time hiding in her closet. Her mother would say that she was brooding. Kassia would escape to the privacy of her closet whenever she felt the need to cry. She didn’t want anyone to see her and she especially didn’t want to be asked why she was upset. She knew she’d be told nothing was really wrong. When Kassia was 10, she became afraid enough of these feelings to tell her mother for the very first time. She revealed to her mother that she was thinking of killing herself, and that she was thinking of doing it with a long knife from her father’s kitchen. Because Kassia was only 10, her mother was taken completely by surprise. This was not her little girl, her happy, singing child. She asked Kassia if she had ever heard of someone doing such a thing, and Kassia said that she never had. Kassia could not recall any implicit memory relating to suicide; she only knew that she was hurting more than she could bear. Kassia’s parents were understandably alarmed, but likely because Kassia was so young, her anguish seemed to pass quickly. It receded into whatever formless, unknowable place from which it had sprung. They moved forward and put it out of their minds. The happy oblivion lasted two years. When Kassia turned 12, her mother’s job moved them to a new town in which they knew no one. There, Kassia would begin middle school. Middle school, as anyone knows, is the gauntlet of childhood. Any cruelty incidental to children lurks behind the faces of certain sixth-graders. A few months into Kassia’s first year of that new middle school, her mother began to notice a daughter who didn’t care at all about washing her hair; who cared nothing anymore for her new privilege of lip gloss and blush; who wore only baggy sweats every day, her hallmark style a thing of the past. This was not the daughter she knew. This was a child who had given up, a child who was clearly depressed. Kassia’s mother understood depression intimately. Kassia was being bullied but she would not talk about it to her parents. Soon, Kassia would make another phone call – this time to her mother while she was at the hairdresser. She wanted to kill herself again. This time over a boy. Kassia was voluntarily hospitalized for one week where it was learned that she had also been self-mutilating, cutting herself with knives and a pair of purple children’s scissors. One-inch cuts on the tops of her thighs, the insides of her arms, her belly. Kassia was burning inside but nobody had thought to feel for fever.
Bipolar Illness, Unipolar Depression in the Family
It has been a couple of years since the family has experienced another incident, and they are divided. Kassia’s father is certain these events were overly dramatic expressions of an immature adolescent girl, and he’s sure the episodes are behind them. Kassia’s mother is not convinced. Kassia, after all, has not been in any way dramatic since she was that bright shining child with the butterfly wings flitting about the yard in singsong. She still will not disclose her thoughts and feelings. She has never so much as raised her voice. She does not “talk back.” She hardly speaks, except to her friends, and even then she isn’t one to reveal secrets. She seems only to internalize. Consider her family tree: Kassia’s paternal grandfather and her maternal grandmother have both been diagnosed with bipolar I disorder. Her mother is diagnosed with cyclothymia, bipolar’s weaker sister. Her father has unipolar depression. On either side of her family tree, there are aunts and uncles with bipolar illness and any number of other disorders. It’s difficult not to see Kassia in clinical terms before she has had a chance to fully develop. But development is just the point.
Playing with Fire, Where STRESS is Fire
The human brain does the larger part of its development outside of a mother’s womb. Large and important components of the brain are not finished developing until adulthood. Kassia’s prefrontal lobe, for example, that part of her brain responsible for planning, decision-making, and impulse control, will not be done with its development until she’s about 25. Kassia is still very much a work in progress. When tossing around theories of causality for mental illness, many think strictly in terms of genetics. Bipolar disorder has upward of a 70 percent heritability factor to direct offspring. It’s important to recognize that Kassia is not showing the labile mood states indicative of bipolar disorder. She has a quiet, internal manner. Any frustration or pain Kassia feels is turned inward. Up to now, she has only shown a predisposition for the possibility of unipolar depression, particularly suicidal depression. But it’s dangerous to pathologize her, you think. The trouble is, it’s dangerous not to consider the possibility when so many people in Kassia’s family experience mental illness. What is a predisposition for Kassia can become destiny by virtue of the environment she experiences – specifically, the stress of her environment and her internal experience of it, which she has shown a marked tendency to suppress. A gene is like a seed for a tomato plant. If you place it in a bowl on a shelf, you no more have a tomato plant than you have a salad. You need the right environmental conditions to grow the tomatoes. It’s the same with bipolar illness, unipolar depression, and their cohorts. Supposing you have a genetic predisposition–what conditions will turn it on?
If You Can, You Must
Kindling theory evokes the image of a burned forest or field, after which so many wild seeds can truly flourish. The kindling effect was first applied to bipolar disorder by Dr. Robert Post of the National Institute of Mental Health. The idea is that if bipolar episodes are initially set off by stressors (a death, break-up, intense conflict with one’s step-parent, which Kassia experiences, over time, episodes could begin to happen even without these stressors; thus, the kindling effect. What Kassia will need is the acknowledgement and support of her family through the next crucial years. They do not need to believe she has a disorder; she does not. They need to believe she is susceptible to the disorders they and their family have without denial or stigma to dissuade them, and they need to learn positive, proactive coping mechanisms for their own stress as well as for Kassia’s. They need to work together to make their environments their sanctuaries, places of harmony and health. They need to believe it is possible. Kassia’s family must take this absolutely seriously. It could very easily determine the future health and well-being of the child. If you had the ability to turn off a potentially fatal mental illness in someone you loved, you would do it. Barring that, wouldn’t you do anything you could to ensure it never came to be?