Bipolar mood disorder: different occurrences of the same disease

Abstracts

O presente relato tem por objetivo acompanhar a evolução de um caso que se apresentou como mutismo seletivo e evoluiu para transtorno de humor bipolar e chamar atenção para a diversidade de sintomas possíveis no transtorno de humor. Em geral, o mutismo seletivo tem início na idade pré-escolar, porém os sintomas chamam mais atenção na idade escolar. A importância do diagnóstico e tratamento precoces reside na prevenção das complicações, tais como distúrbios no desenvolvimento social e acadêmico e na auto-estima, além da possibilidade de evolução para outros transtornos de ansiedade. O transtorno de humor bipolar é uma doença mental caracterizada por variações extremas no humor. Na criança, prejudica o crescimento emocional e seu desenvolvimento. É confundido com transtorno de déficit de atenção/hiperatividade e transtornos de comportamento, tais como transtorno de conduta e desafiador opositivo. A paciente do sexo feminino, quando avaliada, estava com 5 anos e 9 meses de idade. Concluiu-se o diagnóstico como mutismo seletivo. Foi indicada psicoterapia, com orientações aos pais e à escola, e iniciado o uso de inibidores seletivos de recaptação da serotonina, com boa resposta aos sintomas de ansiedade, mas passou a apresentar piora significativa do comportamento. Foi levantada a hipótese diagnóstica de transtorno de humor bipolar de início precoce. Medicada com estabilizador, apresentou adequação na terceira medicação e evolução satisfatória. O mutismo seletivo, considerado um transtorno de ansiedade na infância, pode ser pródromo para outros quadros psiquiátricos na infância. Há necessidade que os pediatras, médicos que primeiro acessam essas crianças, assim como os psiquiatras da infância, estejam atentos à riqueza de sintomas que pode dar seguimento ao quadro.

Criança; mutismo; transtorno bipolar; terapia cognitiva

CASE REPORT

Bipolar mood disorder: different occurrences of the same disease

Audrey Regina Magalhães Braga^I; Lia Silvia Kunzler^II; Feng Yu Hua^III

^ISpecialist in Health and Education. Physician, State Department of Health, Brasília, DF, Brazilian

^IISpecialist in Psychiatry, Associação Brasileira de Psiquiatria and Associação Médica Brasileira. Cognitive therapist, Beck Institute, Philadelphia, USA. Psychiatrist, Medical Care Service, Deanship of Community Services, Universidade de Brasília (UnB), Brasília, DF, Brazil

^IIISpecialist in Neuropsychology. Neuropsychologist, Mental Help - Clínica de Psiquiatria e Psicologia, Brasília, DF, Brazil

Correspondence

ABSTRACT

The purpose of the present case report is to follow the evolution of a child who presented selective mutism and evolved into bipolar mood disorder, and also to draw attention to the diversity of possible symptoms of mood disorders. In general, selective mutism starts at preschool age, although the symptoms are more evident at school age. The importance of an early diagnosis and treatment lies in the prevention of some complications, such as social and academic development and self-esteem, besides the possibility of the development of other anxiety disorders. Bipolar mood disorder is a mental disease characterized by extreme mood variations. In childhood, it hinders the child's emotional growth and development. Selective mutism is mistaken by attention deficit hyperactivity disorder, and behavioral disorders, such as conduct disorder and oppositional defiance disorder. The present case report is about a female patient evaluated at 5 years and 9 months of age. We concluded the case as being a selective mutism disorder. Not only psychotherapy, with parent and school orientation, but also medication was prescribed. The first prescribed medication was use of selective serotonin reuptake inhibitors with good results regarding anxiety symptoms, although the patient started to present significant deterioration in behavior. Because of that, the diagnostic hypothesis came to be bipolar mood disorder with an early start. The patient presented satisfactory evolution only after given a third option of mood stabilizer medication. Selective mutism, which is an anxiety disorder in childhood, can be prodromus to other psychiatric conditions at the same age. It is necessary for pediatricians, who are the doctors that first assess these children, and also child psychiatrists, to be aware of the wealth of symptoms that can give continuation to the condition.

Keywords: Child, mutism, bipolar disorder, cognitive therapy.

Introduction

Bipolar mood disorder (BMD) has been described since the mid-19th century, but over the past decade it received more attention by the scientific community and was recognized as a pathology present in the younger population.¹

The clinical presentation of BMD in childhood and adolescence is different from its manifestation in the adult life. There are controversies regarding the characteristic symptoms of BMD in that population,^2,3 which contributed to a disagreement as to its existence.¹ Prepuberal BMD can be presented as follows: irritable moodPrepuberal BMD can be presented as follows: irritable mood⁴ with affective storms, chronic course,⁵ mixed symptoms of depression and mania,² fast cycles, low recovery between episodes,⁶ emotional lability and irritability during all episodes.^7-9 The child is active and impulsive, explosive and irritated, talks in excess, quickly changes the subject, and has little need of sleep. They believe having special skills and/or being able to perform unreal things.^10,11 Children at school age and adolescents in general have irritable mood, mixed mania, fast cycles, delusions of grandeur, emotional lability, and anger attacks. In the current literature, the data show equal prevalence of psychotic phenomena in children and adolescents,¹² with high rates of suicide,¹³ school failure, aggression, high risk behaviors, such as sexual promiscuity and substance abuse, and high recurrence rates.⁶

The complexity and variety of symptoms delay and confound diagnosis, resulting in delay of specific and proper treatment.^5,6,14

BMD often overlaps or occurs combined with other disorders: attention-deficit/hyperactivity disorder (ADHD) in 80-90% of children; and in 30% of adolescents,^1,15 depression with very intense symptoms, high risk of suicide,¹ and anxiety.^4,6,16-19

Incorrect diagnosis exposes the patient to use of psychostimulants and/or antidepressants, and late diagnosis may make them resistant to treatment, which aims at the patient's social and academic inclusion when applied properly.²⁰

Selective mutism (SM) was described in 1877 by Kussmaul as voluntary aphasia in people who could not speak under some situations, despite having the ability of doing so. It was initially believed that people chose not to speak under given circumstances. In 1934, Tramer used the term elective mutism to describe children that only communicated under certain situations or with a few people, but did not speak in most social situations. It has been suggested that this was a refusal to speak, which characterizes an opposition behavior.²¹ After a better understanding of the disease, SM started being recognized as an anxiety disorder in childhood²² that has as main characteristic the persistent failure in talking in specific social situations, unfamiliar environments,²¹ at school and with friends, where they could be expected to speak, despite speaking in other situations.^23-25

Comorbidity with social phobia (SF) is frequent. This disease is characterized by intense anxiety generated by situations that generate avoidant behaviors toward them.²¹ Although refusing to talk, children with SM - a term adopted after the publications of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) - have interest in communication, and try to establish it through gestures, drawings, waves and head movements. Subtypes include timid, phobic or anxious, hostile or aggressive, as well as a reactive, hysterical or traumatic subtype.²⁶

The social and academic functioning of these children can be impaired if not properly treated, even if there is some improvement with time.^27,28

It has been associated with several other psychiatric pathologies in childhood, developmental changes, especially language, encopresis, enuresis and sensory integration dysfunction, diagnosis found in autistic children.^{21,26 The first symptoms are manifested between 3 and 8 years, although the child does not often receive clinical care before the school period.26} It is more frequent in girls, in a 2:1 ratio.²¹

Early diagnosis allows therapeutic interventions with the aim of reducing symptoms, improving quality of life and preventing anxiety disorders in adult life.²¹ Behavioral modification and psychopharmacotherapy with selective serotonin reuptake inhibitors (SSRI) are treatment options.²⁸

The present report describes a case of SM as part of the diversity of BMD presentation with onset in childhood.

Case report

Female patient, refereed for assessment at 5 years and 9 months, with complaint of absence in verbal communication when outside the family environment. Parents denied any difficulty in receptive and/or expressive language. She is the first born of two siblings, and the second is a boy with no changes in physical and/or mental health. The child was described as very intelligent, strong personality and oppositional behavior that did not meet the diagnostic criteria for oppositional challenging disorder.

Data collection should include information about parents and/or caretakers, child and, whenever necessary, professors and other professionals providing care to the child.²⁹ Academic information can be useful to assess treatment progress and general functioning.²⁹

In this case, medical assessment consisted of two meetings with the parents, four sessions with the child, case discussion with the professional who referred her, school assessment and observation of the child in social situations: school recess and her graduation party. Diagnostic conclusion was SM.

A weekly follow-up was indicated, which consisted of 60-minute sessions each, based on cognitive-behavioral therapy (CBT). This technique has favorable evidence for the treatment of many disorders, including anxiety disorders.^30-32 During the first 3 months of follow-up, the patient had no oral communication, using her mother as mediator, and communicating through whispers. Her visual contact was timid, but consistent. She started using written communication, and then came the whispers directed to the professional, with progressive increase in tone of voice. The main focus to approach the patient was a common interest by horses, used in games, and found by the patient as a sportive practice - horse riding. At school, she remained without impairment in academic functioning.

During the follow-up, her parents reported intense emotional suffering due to situations of social exposure, which was perceived by skin paleness, sweating, resistance against participating in some social situations, and complaint of tachycardia. Based on the reports and on diagnosis, antidepressant drugs were prescribed - SSRI.^28,30 After clinical and laboratory evaluation of the patient, whose objective was discarding possible medical conditions and establishing the basal metabolic profile for further periodic control examinations with normal results,²⁹ paroxetine 10 mg was administered in the morning until a maximum dose of 20 mg/day - with no collateral effects. The patient had good response to the medication, with more adequate social behaviors.

After 6 months taking the medication, her parents reported significant worsening of oppositional behavior, mood lability, with anger attacks that could be long and due to banal reasons, verbal and eventually physical aggressiveness, distractability and unstable attention, more energy, more self-centered, in addition to grandiosity and egocentrism in some situations. During the session, these symptoms were also observed, and her interest in sex subjects,³³ boys and dating drew attention, since it was not compatible with her age and previous behavior. When asked, her parents reported the same concern and confirmed the absence of such behavior in other times. There was no evidence suggesting sexual abuse.

During the treatment, her father was assessed and diagnosed with ADHD, and her mother with recurrent and resistant depression; both started drug therapy. The following data can be added to family history: maternal grandfather described as impulsive and verbally aggressive, with no psychiatric treatment; paternal grandfather was alcoholic and abusive, also without treatment.

There was diagnostic hypothesis of BMD, early onset, more clearly defined after use of antidepressants, compatible with the current literature.^5,7,34

A mood stabilizer was indicated, opting for oxcarbazepine, which did not have expected response up to a daily dose of 900 mg. The second drug, sodium divalproate 500 mg/day, triggered a major hair loss; it was then replaced by carbamazepine, which proved to be adequate starting at 600 mg/day.

One of the interventions performed with the patient was the identification of her mood states.^29,34 Their representation is shown in the figures below, performed during a therapy session, and systematize the cognitive model of depressive and hypomanic symptoms (Figure 1).

In CBT, psychoeducation and cognitive conceptualization are essential. In this report, these techniques were applied using drawings as an instrument to understand cognitive distortions. In Figure 1, the patient drew how she represents herself when in hypomania and depression. Cognitive conceptualization, in the form of drawings, allows identification of the problems faced by the patient and that caused referral for treatment, as well as determination of specific objectives.

Discussion

SM, which is an anxiety disorder in childhood, can be prodrome to other psychiatric conditions. Physicians, both pediatricians and psychiatrists, have to be alert to the symptomatology, maintaining a proper follow-up of the child to provide a healthy mental development and ensure the best pharmacological choice. It is important to stress that children can be particularly sensitive to the development of SSRI-induced mania, which is more common in mixed cases associated with higher risk of suicide.³⁵

The patient developed important functional improvement, manifested by quality of social, relationship and family life adequacy. There is indication of treatment maintenance, since in the literature there is a report that an association between anxiety and bipolar mood in childhood predicts a more severe condition of BMD.³⁶

References

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Publication Dates

• Publication in this collection
  01 Dec 2008
• Date of issue
  Apr 2008

History

• Accepted
  10 Mar 2008
• Received
  04 Nov 2007