Byline: Amlan. Jana, Samir. Praharaj, Vinod. Sinha
Obsessive compulsive disorder and bipolar affective disorder in the pediatric population show a bidirectional overlap. Few studies that have addressed this issue show that the prevalence of obsessive compulsive disorder in bipolar affective disorder patients ranges from 0 to 54%, and 1.85 to 36% of the obsessive compulsive disorder patients have a comorbid bipolar affective disorder. We report a case of a patient with an onset of obsessive compulsive disorder at two-and-a-half years of age, who developed mania after exposure to escitalopram. We suggest that in pediatric obsessive compulsive disorder cases, antidepressants be used with caution, especially in cases with a positive family history of bipolar affective disorder.
Childhood mental disorders are known for their associated comorbidities; childhood bipolar affective disorder and obsessive compulsive disorder are no different. They are marked with multiple comorbid anxiety disorders, mood disorders, and disruptive behavior disorders. It was once considered that bipolar comorbidity in obsessive compulsive disorder was rare and a systematic investigation in this area was not done until recently. [sup] Even today, there is a dearth of literature in this area, when childhood population is considered. We report the case of a child presenting with obsessive compulsive disorder and bipolar disorder at a very young age. A review of the relevant literature has been undertaken, to compile the information on comorbidity of bipolar disorder and obsessive compulsive disorder in childhood. A Pubmed search was done using the keywords, 'childhood', 'adolescent', 'obsessive compulsive disorder', 'bipolar disorder', 'antidepressant-induced mania / hypomania,' and relevant articles were retrieved supplemented with a manual search of cross-references.
The index patient, a four-year-old male, from a rural background of eastern India, presented with irritability for 18 months. He would frequently gesticulate as if he was brushing something off his clothes. He would say, "chhiya gaya hai" (local dialect of Hindi, meaning: "there's filth on my clothes and body") whenever someone would touch him and would be irritated. In the seven months prior to presentation he used to urge his family members to wash his dresses with detergent repeatedly. After being touched by someone he would insist on getting bathed, using an unusually excessive amount of water, and taking a long time before he would let the attendant take him out of the bathroom. He would also repeatedly touch the private parts of the female members of the family. Another noted feature was his habit of repeatedly hitting himself or biting his body parts. On asking about these he would not provide any explanation, but would say that he did not like doing these. There was a family history of bipolar disorder in the maternal grandfather. However, the birth, prenatal, postnatal, and developmental history was unremarkable. When admitted in hospital, there were few occasions of tearfulness. He would often demand that the bed sheets and linens be washed several times a day, as they were not satisfactorily clean. The self-injurious behaviors also continued. Entertaining a diagnosis of obsessive compulsive disorder he was started on escitalopram 5 mg per day and behavioral intervention was done for the self-injurious behaviors. He showed improvement in his overall condition and was discharged on that regime. At follow-up after four months, he showed increased goal-directed behaviors, an unusual cheerful mood, and the parents reported increased socialization. The diagnosis of obsessive compulsive disorder with mania was made; he was re-admitted, escitalopram was stopped and tablet lithium 600 mg per day was started, and was increased to 750 mg (serum level 0.92 mmol / l) along with tablet risperidone 1 mg per day. On this regime the manic symptoms improved significantly. …