Abstract
To The Editor:
A
Case Report
A 10-year-old male patient presenting with attention deficit, forgetfulness, difficulty in memorizing, and low school success underwent a Wechsler Intelligence Scale For Children-Revised (WISC-R) test to assess his mental capacity. The test revealed that his verbal subtest score was 64, performance subtest score was 68, and total subtest score was 63. According to observations of the psychologist applying the test, attention deficit and performance anxiety affected the test result unfavorably. In addition, it was determined that the patient could not express himself properly in social settings, avoided activities requiring performance, such as not attending classes out of fear of making mistakes, and was usually quiet and shy; therefore, his daily functions were unfavorably affected by his condition.
Assessment with respect to ADHD revealed that his time spent studying was limited. In addition, he made careless mistakes in homework, was easily distracted, forgot daily activities easily, and, hence, was frequently warned by his family and teacher. The assessment indicated no activity or impulsivity that had an impact on functionality. He had been advised to take methylphenidate for similar symptoms at the age of 7, but the treatment had been stopped by the family because of side effects such as marked sedation, appetite loss, and irritability. The teacher notification form that was sent via the family also supported these findings.
For diagnosis, semistructured interviews based on the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnostic criteria were conducted with the child and his parents (American Psychiatric Association 1994). Moreover, Conners' Parent and Teacher Rating Scales (Goyette et al. 1978; Conners 1997) were applied. According to the evaluation of the patient, it was determined that he fulfilled the diagnostic criteria for ADHD—attention-deficit subtype and social anxiety disorder—common type. The patient was also evaluated through a semistructured interview based on the DSM-IV diagnostic criteria for any symptoms of other anxiety disorders, mood disorder, and oppositional defiant disorder/conduct disorder, as well as tics and elimination disorders; no signs of these psychiatric disorders were observed. He was begun on atomoxetine 10 mg/day (body weight 36 kg) with gradual dose increases. Special educational support was postponed until a repeat WISC-R test could be administered at 6 months after the treatment.
The patient was brought to our polyclinic with nervousness, defiance to parents, and overactivity on 7th day of atomoxetine treatment. A repeat evaluation revealed that his self-esteem increased; he also developed behavioral and emotional changes in the form of occasional anxiety and irritability, and sometimes excessive joy, restlessness, impatience, pugnaciousness, pressured speech, speech interruption behavior, tendency to commit violence against friends, one attempt to kiss one of his friends on her cheeks, and very frequent and irritating kissing behavior toward his mother. His sleep time and appetite, on the other hand, did not change significantly. His simultaneous clinical evaluation showed that he had a slightly increased amount of speech, although he sometimes had difficulty in responding to questions properly, as a result of impatience and hastiness, could hardly sit still during the interview, and tended to wander around frequently. His affect was considered euphoric, and his spontaneous and voluntary attention and concentration were found to be reduced. His thought content was considered normal, whereas his thought flow partly accelerated.
According to the abovementioned findings, he was considered to have a hypomanic shift, and atomoxetine treatment was stopped. Upon cessation of treatment, his behavioral changes abated at the psychiatric evaluation performed 5 days later.
The patient had no family history of any psychiatric diseases. He was not born to a consanguineous marriage.
Discussion
Hypomania-like symptoms in this case were related to atomoxetine use, as this patient had previously had no clinical symptoms or signs of mania or hypomania-like disorder, no similar history of a different drug use, and hypomania-like symptoms started shortly after beginning of atomoxetine treatment and improved shortly after stopping the treatment. In the literature there are two case reports describing manic symptoms with atomoxetine use. Henderson (2004) reported the case of an adolescent with a history of drug-induced mania and a family history suggestive of bipolar disorder (Henderson 2004). Bahali and colleagues (2013) reported the case of an adolescent with ADHD and oppositional defiant disorder, with atomoxetine-induced mania-like symptoms, who had no history of mood disorder, and a family history positive only for major depression in the mother (Bahali et al. 2013). In the available literature we found a study, which we will mention later, including preadolescent children as well. However, no study or case reports in this age group only were encountered.
Henderson and Hartman (2004) evaluated 153 patients with a mean age of 10.5±3.74 years who were begun on atomoxetine treatment. They observed extreme irritability, aggression, and mania or hypomania induction in 51 cases (33%). Of these 51 cases, only 6 (11%) were reported not to have a personal history of mood instability or a family history of bipolar disorder. Based on these results, the authors concluded that the factor most closely related to “an increased risk of mania or hypomania induction or mood dysregulation” was the presence of personal or family history of a mood disorder (Henderson and Hartman 2004). In our case, on the other hand, there was no personal or family history with a risk for bipolar disorder. Therefore, explaining the mania-like picture also to the relatives of patients with no family history while informing them about the drug, may be beneficial for early detection of symptoms.
It has been reported that atomoxetine treatment can be safely employed in the treatment of anxiety disorders accompanying ADHD (Christman et al. 2004). Our patient also had social anxiety disorder accompanying ADHD diagnosis. It has been suggested that co-occurrence of anxiety disorders and bipolar disorder is quite common, and the rate of anxiety disorder is higher in bipolar disorder compared with in the general population (Bauer et al. 2005); however, it is difficult to determine which type of anxiety disorder is most common in bipolar disorder (Tamam 2007). It has been suggested that in most patients with an additional diagnosis of bipolar disorder, the social phobia antedates the bipolar disorder (Perugi et al. 1999). Himmelhoch (1998) has argued that a group of phobic patients composed of social phobia patients may be on the bipolar disorder spectrum. It has been suggested that patients with social phobia assessed in these subgroup especially, show difficulty in inhibition after antidepressant treatment, and their bipolar disorder II appears at this stage (Himmelhoch 1998). Valença and colleagues (2005) defined a subgroup of patients with social anxiety disorder that had never experienced spontaneous hypomania over a lifetime but exhibited a clear hypomanic phase (at the mild-to-moderate level), despite an improvement of signs and symptoms of social anxiety disorder with the use of antidepressant drugs (Valença et al. 2005). Analysis of our patient in light of the literature data suggests that the presence of comorbid social anxiety disorder in addition to ADHD and the development of hypomania-like symptoms during atomoxetine treatment may be interrelated.
Conclusions
Based on these findings, it was considered that studies also including adolescent and preadolescent age groups, which scrutinize the relationship between atomoxetine use and hypomania/mania-like symptoms, are needed, especially in cases with concurrent ADHD and social anxiety disorder.
Footnotes
Disclosures
No competing financial interests exist.