Hypomania?

[tictoc]

Hi,
Bug's neuropsychologist raised the possibility of bipolar disorder recently and I'm trying to learn as much about it as I can. Right now, his diagnoses are Tourette Syndrome, ADHD, Obsessive Compulsive Disorder (OCD), Generalized Anxiety Disorder (GAD), and Sensory Integration Disorder (SID). He also shows some signs of NLD. He is almost 7 yo.

Bug has always been a very hyper child, even before he was born. I swear, he was trying to find the exit months before he was born. He has never slept well (Naps? What are those?) and has always had trouble with self-regulation. He started having tics at 3.5 and they got much worse when he started kindergarten last year. He had done well in a wonderful preschool program, but kindergarten was a disaster (lots of tantrums, violent language, parents wanting him kicked out...). He now has an IEP, an has a one-on-one aide, social skills therapy, Occupational Therapist (OT), and adaptive PE through the school. He takes clonidine, Prozac, and imipramine (a tryicyclic antidepressant).

So, I'm wondering if Bug's hyperactivity could be hypomania. Our neuropsychologist says that he sees two warning signs for BiPolar (BP): 1) Zoloft was EXTREMELY activating for Bug. He took two doses of 12.5 mg over two days and was the most hyper I have ever seen him. Our pediatrician said it could have been much worse...Bug was in the early days of taking clonidine then and it was still causing a lot of sedation, so presumably that took some of the edge off the hyperactivity. 2) Bug is very irritable, in addition to hyperactive and impulsive. I would say that the irritability is the most difficult symptom for our family to deal with and it also has a serious impact on his interactions with peers.

He is currently on a very low dose of Prozac and imipramine and a fairly high dose of clonidine. He started with 6.25 mg of imipramine and did well. The first time we tried to increase imipramine, he became very hyper so we lowered the dose again. The second time we tried increasing it, he seemed sedated. We have maintained the original dose now for about a month and I'm not sure what to think about it. Last week, he had several days of extreme hyperactivity, coupled with extreme irritability. He had periods of calm where he played happily with his sister, but then he would return to being hyper and irritable. He did very well at school during this time. The problems were only at home. This extreme hyperactivity/irritability passed after about 5 days and he returned to his usual levels of hyperactivity and irritability.

Overall, Bug is a very loving little boy. He is extremely bright (most likely "gifted") and creative. We know that he loves us dearly (as we do him), but that sometimes his emotions overwhelm him and he lashes out, both physically and verbally. He adores his sister and has several close friends. Last year, he did not make many friends in kindergarten, but this year is going much better. He has a "modified day" and leaves school after lunch and recess and is doing very well on the playground.

Right now, our neuropsychologist and pediatrician have us watching Bug closely and keeping track of his mood and other symptoms. We are also trying to get him into a child psychiatry clinic through a nearby medical school.

I would appreciate your thoughts.

 

[gcvmom]

It very well could be bipolar. His response to Zoloft is very similar to what happened with my difficult child 2 in first grade. Have you checked out any of the books on pediatric bipolar?

"The Bipolar Child" by Papolos
"Bipolar Disorder in Childhood and Early Adolescence" edited by Geller & DelBello

Another good one is:

"Misdiagnosis and Dual Diagnoses of Gifted Children and Adults" by Webb et al

If he doesn't already have a 504 plan or IEP you should be talking to the school about it. He will likely benefit from some kind of social skills intervention to help with the peer interactions. We found that to be a huge problem for difficult child 2 and his social life suffered greatly over the years. The social skills classes have helped him quite a bit. I'm glad to hear that this year is going better so far for him on the playground. I hope that continues. Recess and lunch were always difficult times for difficult child 2.

Depending on where you live, there are number of universities conducting pediatric bipolar studies. I'm on the west coast and know of two really good centers if you're interested.

 

[crazymama30]

I agree with gcv mom, there are so many symptoms that go with more than one diagnosis. It could be bipolar. Read and educate yourself. I do like that you are getting him in to be seen at the psychiatric dept of a university, they should do a thorought evaluation.

 

[rlsnights]

you might take a look at the NIMH website especially if you are open to participating in research and travelling to NIMH in Bethesda. I have talked to them in the past and they were willing to pay for travel from California and lodging while there if I was able to bring my son for assessment and/or treatment.

Here's a link to the patient recruitment page at NIMH.

http://patientinfo.nimh.nih.gov/

i thought of this because your child is a complex case due to his multiple neurological and psychiatric conditions. you will not get a better assessment and treatment process anywhere and may get the fastest and most definitive (if there is one) answer going that route.

otherwise i would to talk to all the docs about the pros and cons of a trial of mood stabilizer. depending on outcome, then gradually wean imipramine, then the zoloft. if it's bipolar, the AD's are much more likely to be triggering increased severity than not particularly without a mood stabilizer on board. while I am an adult etc. imipramine (unopposed by a mood stabilizer) provoked mania with psychosis for me but it took a long time to build up to therapeutic levels and thus to mania. i knew I was getting worse but my then psychiatrist wouldn't listen until i flipped out - at which point i went off it cold turkey.

a website I have found helpful (though oriented toward adults) is

http://www.psycheducation.org/

lots of good info about different ways to think about bipolar; social rhythm therapy; light and dark therapy as treatment; and he generally keeps up with the most current research and findings. in particular you may find his page about mixed states and rapid cycling helpful.

http://www.psycheducation.org/depression/Waves.htm

 

[smallworld]

Many kids with NLD (which some believe falls on the autistic spectrum) have mood dysregulation. That doesn't necessarily mean full-blown bipolar disorder. Furthermore, it's very, very difficult to diagnose bipolar disorder in a 6-year-old. I'm not saying he has it, or doesn't, just that it's very hard to settle on a differential diagnosis at his age.

I happen to live in NIMH's backyard in Maryland and have had the opportunity to speak with several NIMH researchers. One told me that a bad reaction to an AD within one to two days does not necessarily point to bipolar disorder. It is inidicative of a bad reaction to an AD. What is more consistent with bipolar disorder is a manic reaction (pressured speech, decreased need for sleep, mission mode) that occurs at the three-week or three-month mark and does not disappear once the AD is discontinued. Even that is not diagnostic in and of itself. The diagnosis is made as the episodes of the patient's moods are observed clinically over time.

That is not to say that medications that are activating your son should not be removed. And others like mood stabilizers might be trialed. My younger daughter, who does not have a diagnosis of BiPolar (BP), has symptoms of mood dysregulation and has done very well on a low dose of Lamictal (100 mg). So it is something to consider, even if the full-blown diagnosis is not there.

Good luck.