Abstract
To The Editor:
A
Case Report
The case presented here was a 14-year-old boy, referred to our outpatient clinic from a pediatric emergency room with excessive anger, irritability, and assaults on staff or other patients. During the interview, he said that he wanted to die and planned to kill himself. He also stated that he would cut himself and showed razor blade wounds on his wrist and neck. His self-destructive behavior was related to suicidal ideation. This patient was being treated in the another child and adolescent psychiatry clinic for his generalized anxiety disorder with alprazolam 1 mg/day. The suicidal ideation and self-destructive behavior started on the 10th day of treatment. Parents reported that the boy had been a peaceful, well-adjusted, and happy child before the start of alprazolam treatment. He was diagnosed as having generalized anxiety disorder according to the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision (DSM-IV-TR) criteria (American Psychiatric Association 2000). Alprazolam was reduced and stopped over 3 days. He was evaluated daily, and his parents were warned to monitor his suicidal ideation. His symptoms disappeared by the third visit. Complete blood count, biochemical analysis, toxic screening, thyroid function tests, electroencephalogram (EEG) and cranial MRI revealed no abnormality. The patient had no other disorder and was on no other medication. Sertraline 25 mg/day was initiated 2 weeks later. One week later, the sertraline dose was increased to 50 mg/day. After 8 weeks, the patient's anxiety symptoms completely improved. Follow-up visits made periodically during 6 months revealed no recurrence of symptoms.
Discussion
To our knowledge, this is the first report that describes a child with excessive anger, irritability, suicidal ideation, and self-destructive behavior as a result of the use of alprazolam. Although alprazolam-related violence and aggression is relatively rare, it can be of a high severity. Dietch and Jennings (1988) found that out of 11,717 patients receiving alprazolam, only 4 reported paradoxical reactions. Paton (2002) suggested that risk factors for paradoxical reactions include the presence of central nervous system degenerative disease, a learning disability, or difficulty with impulse control. Other authors suggested that alcohol use and borderline personality disorder have increased alprazolam-related paradoxical reactions. Further research is required to clarify the mechanism of paradoxical reactions.