Almost all antidepressants are broken down or metabolized in the liver. If the liver is not functioning well (Stage 4 is considered severe liver damage) then a drug such as an antidepressant cannot be metabolized and more and more will accumulate in the blood stream and could cause a toxic reaction. I would suspect her doctors are recommending she avoid any kind of medication that is metabolized in the liver. A few alternatives for treating depression are: 1. Lithium is one of the few medications that are entirely metabolized in the kidneys and not the liver. Lithium can have antidepressant properties in perhaps 40-50% of users. 2. Cognitive Behavioral Psychotherapy (CBT). This specific form of psychotherapy is considered as effective as antidepressants in moderately severe depression. 3. Electroconvulsive therapy (ECT) ECT has been and continues to be the most effective treatment for serious or severe depression and is often used when someone cannot tolerate or use antidepressants. 4. Phototherapy (light therapy). Phototherapy, using full spectrum white light, is an effective treatment for seasonal (SAD) depression and may help a small percentage of individuals with non seasonal depression and would have no untoward effects on the liver. 5. Transcranial Magnetic Stimulation (TMS) is a relatively benign treatment with no effect on the liver. Again a small percentage of patients with depression may improve. Unfortunately, this treatment is currently not covered by BC health care plans.

The vast majority of your partner's behaviors would have nothing whatsoever to do with bipolar illness. While I do not discount the possibility the he may have a bipolar illness, the only 'symptoms' or behavior that you describe that could possibly be related to bipolar illness is his depressed mood (and that may be related to other things such as substance abuse and/or substance withdrawal). 2. Most individuals who exhibit the behaviors that you have described (violence, lying, cheating, sexual addiction, substance abuse, manipulation of others) typically suffer from what are known as Cluster B personality disorders. If you review that category in the DSM IV he is exhibiting a number of characteristics associated with both antisocial and borderline personality disorders. It would be incorrect to attribute these behaviors to bipolar illness and/or any type of depressive illness. Further, it is inappropriate to try to 'explain away' these behaviors as due to someone having a traumatic, abusive childhood, etc. All the later does is reinforce the individual not acknowledging his or her difficulties and accepting responsibility for his or her actions. 3. The treatment for your partner rests solely with him. Specifically he would need to commit to regular counseling and refrain from drug abuse if those behaviors are to change. From the snippet I can get from your email, I am not optimistic at this time that he is ready to commit to change and/or as you state is ready and willing to change. 4. What this means for you is that if you are to be with him you will have to accept that he will be abusive, he will lie, he will cheat, and he will attempt to manipulate you. If you hope that with your support and love he will change, I would not be optimistic and you need to accept that only he can do the changing. 5. I regret that I cannot offer a more optimistic message, but I would not be helping you if I were not truthful in outlining what has been documented for many decades about the nature and treatment of the behaviors that you describe.

First, I am glad to hear your son is improving. Second, it is somewhere between extremely difficult to near impossible, to distinguish and diagnose schizophrenia versus bipolar mania with psychotic features during the first acute psychotic episode. The reason for this is that the symptoms or at least psychotic symptoms are indistinguishable among these illnesses. Only over time can the diagnosis be clearly made by any health care professional. One has to ascertain whether the symptoms resolve completely and your son returns to his baseline (suggesting a mood disorder). Do the psychotic symptoms persist and or return if antipsychotic agents are discontinued after 3-6 months (suggesting schizophrenia/schizoaffective disorder). Other 'clues' to a diagnosis can be a family history suggestive of a mood disorder and/or schizophrenia. In addition, a 'switch' to mania/psychosis in less than a month of an antidepressant is very strongly suggestive of a bipolar illness and/or possibly a schizoaffective disorder (if the psychotic symptoms do not resolve in 3-6 months). Thus it is paramount that all (family and physicians) keep an open mind about the diagnosis. In the first six months the goal should be to treat the symptoms and be open and flexible that the diagnosis may change or evolve. I have also attached a slide presentation I gave a few years back on schizoaffective disorder which restates some of the observations and comments I have made.

The vast majority of individuals with bipolar illness do quite well academically. Bipolar illness typically does not have an onset until at least the mid-20's, whereas learning disorders/disabilities and/or ADD typically has an onset during the elementary shcool years. My suspicion is that, unfortunately, you have two different disorders - a mood disorder (bipolar illness) and a childhood learning disorder or ADD. The treatment for each is quite different. I do not think they are inter-related in any way.

I have never heard the term 'hypermanic' and could not find this term in any medical dictionary. Hypomanic or hypomania is a lesser degree of mania. A diagnosis of bipolar I disorder is made if there are manic and depressive episodes while a diagnosis of bipolar II disorder is made when there are hypomanic and depressive episodes. Manic symptoms include an elevated or irritable mood, decreased need for sleep, inflated self confidence or grandiosity, being more talkative or pressured speech, distractibility, agitation, and involvement in pleasurable activities that have a high potential for painful consequences (e.g. buying sprees, gambling, substance abuse, sexual indiscretions, foolish business ventures). Mania (versus hypomania) is typically diagnosed when psychotic (delusions, hallucinations) symptoms are present, when the individual requires hospital care, or there is severe impairment in judgment affecting one’s social or occupational functioning.

In my opinion, I only use the atypical antipsychotics to treat bipolar mania in the short term and then I suggest tapering off these medications unless there are no alternative treatments for the individual. I do this because there is a very high risk of significant weight gain with these agents (except for ziprasodone/Zeldox which is not covered under most BC health care plans and is quite expensive and aripiprazole/Abilify which is not commercially available in Canada) as well as a long term risk of developing high cholesterol and/or type 2 diabetes mellitus with the uses of these medications- diseases that have a very high risk of serious morbidity and mortality. While many of my colleagues do use these medications for long term treatment, I believe there may be many other alternative medical treatments (e.g. older typical antipsychotics, other mood stabilizers) that while not without potential side effects, have side effects that I believe are not so potentially dangerous. Further, I still remain a bit skeptical of research sponsored predominantly by the companies that make the drugs. If you are taking these medications it is prudent that your doctor weighs you every 3-6 months, and that he keep a record of these values. In addition you should do blood tests on an annual basis to check for high cholesterol and diabetes.

Olanzapine is one of several medications known as atypical antipsychotics. Others include risperidone (Risperdal), quetiapine (Seroquel), ziprasodone (Zeldox) and aripiprazole (Abilify; which is not commercially available in Canada). All antipsychotic medication, whether the older 'typical' or the newer 'atypical' medications are effective at quelling or settling the manic symptoms of agitation, hyperactivity, rapid pressured speech, delusions and other psychotic symptoms as well as insomnia. While olanzapine (Zyprexa) is sedating that is not the reason for its effectiveness in bipolar illness. In addition to the positive antipsychotic effects on mania, research has suggested that these 'atypical' medications may also have both mood stabilizing and antidepressant effects as well. This is likely due to its myriad of neurochemical actions in the brain which are different than the older typical antipsychotic medications. However, I would caution that the vast bulk of the research that has shown that these medications are effective has been supported by the pharmaceutical companies that produce the drugs. I would suggest that we are careful not to jump on the bandwagon by prescribing these drugs too quickly. These agents have a number of serious long term side effects. Please read more Ask the Professional questions for further information on these medications.

There is actually quite a high rate of adult attention deficit disorder (ADD) in bipolar illness. Some studies suggest that 20% of bipolar patients also suffer from a concurrent diagnosis of ADD. Many of the symptoms in ADD and bipolar depression appear to be similar including poor concentration at work, being forgetful, inattentive, and irritable. ADD symptoms include often being late and being 'unable to focus.' One can often distinguish to two with ADD often having an onset (whether diagnosed or not the symptoms are present) in childhood, while bipolar illness seldom appears before early adolescence. Further, ADD and/or bipolar illness will often have family members with a similar disorder. The rule of thumb in terms of treatment is to treat the illness causing the most difficulties as a first priority.

This is unfortunately a difficult and tragic situation that we face far too often. What I often suggest to families is: 1. Be informed as family members. Be clear about the diagnosis (i.e. you concur that the diagnosis is bipolar illness) and what the appropriate treatment interventions are. Be aware of who will treat your loved one if and when they seek professional help. 2. Approach your loved one as a unified group i.e. siblings, spouse, parents, friends, etc and say something like, " We are all here because we are concerned about you and we love you. All of us perceive that you are not yourself, and we believe you need specific medical treatment." This does not always work at first but it is important that a unified front be presented. 3. Get support for yourself (e.g. use MDA support groups; use MDA website/lecture series to get informed) as this is a long and arduous process. 4. If you feel your family member needs urgent care or hospital care (e.g. suicidal thinking is present, the mania is becoming increasingly destructive) then your relative may meet the criteria for an involuntary hospital care. This can be discussed with your doctor, a crisis line, the psychiatric charge nurse in a hospital emergency room, or in Vancouver you could call Car 87 (604.874.7307 )which is a service with a police officer and a mental health worker who (if deemed appropriate) will go the person's home and do a evaluation as to whether hospital care is indicated. 5. Do not give up. Sometimes it takes many many interventions before your relative finally realizes the destructive nature of his bipolar illness both for himself and the entire family.

Mania would definitely be classified as a mood disorder. The specific classification is that of a bipolar disorder. It is most rare (less than 10%) for someone only to suffer from episodes of mania (so called 'unipolar mania') without some depressive episodes but is does infrequently occur.

Dementia is a category of diseases characterized by progressive loss of cognitive functioning in a variety of areas (e.g. memory, use of language, ability to plan sequentially and use judgment, ability to recognize common objects, etc) with associated behavioral (e.g. loss of initiative) and emotional symptoms (e.g. labile or depressive affect). The most common form of dementia is Alzheimer’s disease but there are several other types of dementia as well. There is no known relationship between depressive illness (e.g. unipolar disorder) and developing a dementia later in life. However, perhaps up to 25% of patients with a dementia have depressive symptoms in the year or two before the diagnosis of dementia is actually made, suggesting that for some this may be an early symptom of the illness. Persons who have a depressive illness that develops before the age of fifty have no more risk of developing a dementia than anyone else, so unfortunately, I suspect you have developed two different discreet illnesses--a depressive illness earlier in your life and a dementia later in your life.

It is suggested that normal adult requirements for sleep are between seven and nine hours per night. It is also known that in North America sleep deprivation is an unrecognized and very common problem with far too many (including myself!) not meeting this sleep requirement, resulting in a significant health cost in terms of heart disease, motor vehicle accidents, poor job performances and other medical problems. Sleep requirements vary widely and certainly there is a minority if 'normal' individuals who need a few hours more or less than the norm. Among the most common symptoms of depression is a sleep disturbance (insomnia or too little sleep; hypersomnia or too much sleep). Hypersomnia (typically greater than 10hours per night on a consistent basis) may be a symptom of depression, but unfortunately it is, in my opinion, far too brief a "haven" from the torment of a depressive illness.

Alcoholics Anonymous (AA) is the ‘gold standard’ in terms of an effective treatment fro alcohol abuse. Far too many people with alcohol abuse problems do not give AA a good try, rationalizing their non involvement with ‘it’s a cult’, ‘it is too religious’,etc which in my opinion is most unfortunate. I recommend AA to any and all patients with alcohol problems. Emotions Anonymous (EA) is based on a similar ‘recovery through support’ model. Unfortunately, there are far too few EA chapters in British Columbia. Patients of mine who have been able to access and attend an EA chapter typically have found it to be very helpful and supportive. I am unaware of any medical evidence that EA has specific effectiveness in the treatment of depressive disorders. I am aware of countless testimonials from individuals with depression who find EA offers them enormous benefit and support when in the midst of a depressive episode. While AA can offer a support network for dealing and treating alcoholism, it is not a treatment for depression.

I am aware that many take a variety of vitamin supplements and are quite certain that they have a beneficial effect. Indeed, for specific individuals this may be so. However, at this time there is no good medical evidence that vitamin supplements (e.g. vitamin B,C,D,etc) will have any beneficial effect on improving depressive symptoms and/or stabilizing bipolar mood swings.I would comment that there is a small amount of research that omega 3 fatty acids can have some mood stabilizing antidepressant effects in some patients. This compound, found in fish oil (“brain food”), is one I recommend patients consider trying for a 3 month trial and then decide whether this non insured compound is worth the price. It is suggested that the component of omega 3 fatty acid, EPA (look at the ingredients label on the bottle before purchase), is the important mood stabilizing factor and 1000mg or more per day of EPA (usually 2-3 capsules) is required.

We do know that there is no serious 'bad news' about the long term use of antidepressants. There are eight, older tricyclic antidepressants, the most familiar names being Elavil, Tofranil, amitriptyline, and imipramine and two MAO Inhibitors, Parnate and Nardil. These drugs have been available and now used for more than forty years and there have been no reports of serious or dangerous long term effects. Specifically, they do not cause cancer, heart disease, liver or kidney disease, etc. Side effects that occur early in treatment (dry mouth, sedation, etc) may continue, but new or more ominous problems do not arise. The newer antidepressants are the serotonin reuptake inhibitors like Prozac and Celexa. Some of these drugs have been commercially available for more than twenty years. Once again, there would appear to be no 'surprises' or new side effects later in treatment in those persons taking these drugs for several decades.

I am glad to hear that you are progressing well with your recovery. Seroquel (generic name is quetiapine) is one of the several drugs in a class called the atypical antipsychotics. Others in that family include Zyprexa (olanzapine), Risperdal (risperidone), and Clozaril (clozapine). These medications are used primarily to treat psychotic illness such as schizophrenia or psychotic mania. However, in smaller doses (the typical Seroquel dose for schizophrenia is 400 - 1200 mg/day); they can be quite helpful at controlling anxiety, irritability, and insomnia which would not be uncommon symptoms in someone suffering from borderline personality disorder.

Higher doses of these atypical antipsychotic medications can cause muscle spasms and restless legs, and often, as in your case, a dose reduction resolves the problem. Seroquel (and all of this class of medications) should have no effect on your thyroid gland so I suspect this is just a secondary medical problem; goiter is more common in women, runs in families and perhaps 10% of women develop a similar problem.
The biggest concern about the long term use of Seroquel and medicines in this class is the risk of weight gain, the risk of developing high cholesterol or the risk of developing type 2 diabetes mellitus (type 1 requires insulin, type 2 requires antidiabetic medication). Because of the long term health consequences of developing any of these three medical problems, I often recommend that atypical medications only be used when there are no alternative treatments that would cause less risk of side effects. Most medical organizations recommend ( and this is certainly my practice) that anyone taking these medications, have their weight and abdominal circumference measured twice per year, and on an annual basis blood tests for diabetes (fasting blood glucose) and high cholesterol (fasting cholesterol and 'lipid' panel) be completed. If any of these measurements are worsening then a serious review with your doctor should be done as to (determine) the advantages and risks of using these medications on a long term basis; safer alternatives should be reviewed.

In your specific case, the primary treatment for borderline personality disorder is specific psychotherapy (known as dialectical behavioural therapy) which you suggest has been most helpful. Medication can be an effective adjunctive treatment as it appears to have been in your case, and you should continue to review with your doctor the long term benefits and possible risks of using the Seroquel.

The vast majority of bipolar patients will experience many more depressive than manic or hypomanic episodes. Mood disorders are recurring illnesses with relapses and remissions. On average a bipolar patient will experience 9 or 10 cycles (either mania or depression) in their lifetime. On average a depressive episode will last 2-3 months while a manic or hypomanic episode will last 1-2 months. Sixty per cent of bipolar patients will notice an increase in the frequency of their episodes as they get older, while forty percent will continue to 'cycle' (e.g. have a relapse rate every 1, 3, 5 years, etc) at the same frequency throughout their lives.

As depression is clearly the more frequent (and typically the more problematic) in bipolar illness, this is why many of you have heard me emphasize that while doctors need to be cautious about mania, they should not do so at the expense of treating the depression. Aggressive treatment of the depression (cognitive therapy or antidepressants) in bipolar disorder will result in less overall impairment for the individual.
One last note, 'unipolar' mania patients who suffer only manic episodes without depressive relapses, is extremely rare - afflicting perhaps only 1-2 % of bipolar patients.

The general 'rule' would apply much more to the treatment of someone with an acute mood disorder rather than someone with a mood disorder who is stable and/or in remission for several months or years. The 'rule' should always include the caveat that all non prescription or non psychiatric prescription medications (often prescribed by another doctor) should be approved for use in combination; make sure your doctor knows everything you are taking.

Marijuana (MJ) use, while still illegal in Canada, is a commonly used recreational drug. The most common sensations experienced with MJ use, in addition to a sense of well being and/or mild euphoria can include fatigue, apathy and drowsiness. A small, but significant, number of MJ users (~10-15%) experience a paradoxical sense of agitation, anxiety and paranoia and should completely cease all future MJ use. There is growing evidence that heavy MJ use (defined as > 3 'joints' per week for three months or more) in a small percentage of adolescents/young adults can precipitate a psychotic state. So once again, heavy MJ use (which is more aptly termed misuse or abuse) should be avoided in this group of individuals.

In terms of the recreational use of MJ (e.g. less than 6 times a month) I would suggest it be avoided during the acute treatment of a depressive or manic episode as some of the 'symptoms' with MJ use will cloud and confuse your doctor (and yourself) with how well or not well the treatment is progressing. While I would again emphasize that MJ is illegal, I am unaware of any serious or significant effects from its long term recreational use.

With stabilized mood disorder patients, I would state something different. If any treatment in medicine is to be successful, it has to be a treatment that the patient will accept in the long term. This means that the treatment would not have significant adverse effects on one's lifestyle; whether or not that lifestyle includes recreational alcohol and/or MJ use. My experience is that if I suggest to a stabilized patient that they avoid all use of alcohol and/or MJ while receiving long-term treatment, they will typically stop their treatment rather than their recreational drug use. Accordingly, in stabilized mood disorder patients, I encourage them to return to their normal lifestyle. If that includes the recreational use of alcohol or MJ, I do not admonish or forbid such usage.

Antidepressants do not commonly cause weight gain. There are indeed a number of antidepressants, the one you have mentioned, Elavil (amitriptyline) as well as Remeron (mirtazepine) appear to be the worst offenders in terms of weight gain. However, the majority of the 22+ antidepressants commercially available in Canada do not cause weight gain. While weight gain can certainly increase the risk of developing heart diseased and/or diabetes, I am unaware of any of the 22 currently available antidepressants directly causing either heart disease and/or diabetes with either short or long term use of these medications.

Sexual difficulties with antidepressants are not a side effect of most of the available antidepressants. All of the serotonin antidepressants (e.g. Prozac, Paxil, Zoloft, Luvox, Celexa, Effexor, Cipralex) have a risk of causing sexual dysfunction (decreased libido or sexual interest, difficulty obtaining or maintaining erection, difficulty with achieving orgasm) in 50% of the users, but most of the other antidepressants do not cause this side effect.

With bipolar I disorder, 30% of sufferers can expect full, sustained recovery so there would be no reason the bipolar illness should negatively effect their ability to return to work. 30% of bipolar I patients show marked or significant improvement in their symptoms (i.e. symptoms become mild, episodes occur less frequently, and are less severe in intensity). The vast majority of those individuals could return to full time or near full time work. Accordingly, I would estimate that the prognosis for recovery and return to work would be somewhere around 65%.

Electroconvulsive therapy (ECT) has been and continues to be one of the most effective treatments in all of medicine. Psychiatrists consider ECT to be the 'gold standard' in terms of effective treatments for depression. Whereas, 60% of patients with depression respond to either an antidepressant and/or a course of cognitive psychotherapy, 80% of depressed patients respond to ECT. Further, patients with refractory or treatment resistant depression can still expect a 50-60% chance of recovery with ECT. ECT is a modern medical procedure and nothing like what has been portrayed by Hollywood and some lay press. Typically, a course of 6 to 12 ECT treatments are administered (usually 2-3 treatments per week), done in a day care surgery center. All general hospitals have the facilities to administer ECT and do so. Most now do ECT as a day care/outpatient procedure. UBC Hospital now has a specific day care ECT program available to all (upon physician referral) in the province. Side effects from ECT are minimal (headache, nausea, muscle aches) and typically resolve within 24 hours after the treatment. Concerns about long term irreversible memory impairment are simply not true with current ECT administration and technique. For any patient with depression who cannot tolerate antidepressant medications and/or is not improving with medication and/or psychotherapy, ECT should be a consideration. If you are interested in finding out more about ECT click on the Link below or you may contact the clinic by phone at 604.822.7702. ECT Information Booklet

For any medication to be effective it has to get into the blood stream and make its way to the targeted area. In the case of antidepressants this would mean the blood circulation of the brain. Medication, once swallowed, is broken down in the stomach and small intestines and then absorbed from this area (gastrointestinal tract) into the bloodstream. How much or how little is absorbed is very much a genetic factor which is one reason that some people need very high doses of a drug before effect and others are extremely intolerant of even very small doses of a drug. Other factors affecting absorption are what you eat or do not eat at the time you take a medication, whether you are taking other medications that either block or increase how much medication is absorbed in the intestines, and/or whether you have other medical problems that would affect absorption (for example, colitis). Once a drug is absorbed into the blood stream it is transported through the liver where much of it is broken down or metabolized and then excreted. So only a small amount of drug is eventually available to get into the circulation of the brain and offer an effect. Rapid or slow metabolism of drugs is also genetically determined (i.e. runs in families) but can be speeded up or slowed down by taking other medications at the same time. Your pharmacist or a drug printout you receive when you get your prescription will tell you if there is an interaction with your antidepressant and any other medications you are currently taking. Other factors that can effect metabolism are concurrent other medical illnesses and indeed the aging process. While aging can increase drug absorption and slow metabolism (so that less drug is necessary to get the same effect), more often than not the other factors that I have mentioned are more important in determining how much medication will get into your blood stream.

Poor or decreased sleep (insomnia) is a common symptom associated with depression. However, insomnia is also a very common symptom in many other medical disorders, both psychiatric (e.g. anxiety disorders, substance abuse) and non psychiatric. I would recommend you start by consulting with your family physician. See if you can describe the specific nature of your sleep problem (e.g. difficulty falling asleep or frequent awakenings throughout the night or awakening in the early morning hours) to your doctor. In addition, if you have a bed partner who can comment on your sleeping behavior (e.g. loud snoring, restless tossing and turning, talking, teeth grinding, periods where you appear not to breath regularly, etc) you will be a long way toward diagnosing your sleep problem and getting the proper treatment.

Orthomolecular therapy is based on the theory that many psychiatric disorders (depression, schizophrenia) are caused by changes or deficiencies in certain brain chemicals or alterations in certain brain chemical pathways. The theory is that the illness can be corrected by ingesting specific vitamins and/or nutrients to correct these altered pathways or deficiencies. While psychiatrists and all physicians hold a similar view of 'altered brain chemistry' playing a primary role in psychiatric disease, there still has been no good medical evidence that orthomolecular treatments are effective. I personally do not recommend orthomolecular treatment to my patients when there are so many effective proven medical and psychological treatments available.

Low self esteem and indecisiveness are very common symptoms in the depressive phase of bipolar illness; whereas, overinflated self esteem leading to poor judgment (and often regrettable decisions) are hallmarks of the manic phase of the illness. This is why we strongly recommend mood disorder patients not to make major decisions (e.g. job changes, relationship changes) in the midst of a significant depressive or manic episode.

The best place to look for self-help CBT related techniques for teens is in the Dealing with Depression: Antidepressant Skills for Teens, which is available free, online at, www.mcf.gov.bc.ca/mental_health/teen.htm. Experts at the Mood and Anxiety Disorders Clinic at Children's Hospital developed this guide in association with the Ministry of Children and Family Development. The guide can be used by a teen on their own and can be used online. Printed copies can be ordered. Teens have found it helpful to review this manual with their doctor or counsellor to help them stay on track while recovering from depression. Self-regulation of mood refers to the capacity to manage our tendency to "react" to situations with negative (eg. sad, anxious, angry) moods and also to repair a negative mood if it has occured. Effective self-regulation involves many different skills and strategies ranging from getting enough sleep to eating well and excercising, using effective self-talk and building a practical support network. Medications can help with the neurochemical regulation. New research is indicating that throughout our lives we can continue to train ourselves in more effective self-regulation, and that cognitive and behavioural coping strategies assist with this continued learning process. Regarding tapping and EMDR, there is no research evidence that these methods are helpful for depression.

There are many factors which may contribute to depression in later adolescence, around the time that they are transitioning out of high school into post secondary training. This is a time of life when the first episode of depression often naturally occurs, independent of specific stressors. Secondly, it is a time of life filled with many of the kinds of stressors which may contribute to a depressive reaction. As people move out of home and into new settings, there may be a loss of their friendships and family support. There may be a loss of confidence as they are challenged by more demanding academic expectations. In addition, it is a time when there is commonly a great deal of social experimentation with substances such as alcohol and marijuana which have negative effects on mood. This is a time when healthy peer support, such as the MDA youth support group, can be very beneficial. The issue of the pressure of "not meeting expectations" is a factor throughout the teen years, and encompasses both academic expectations and social expectations.