Rask Olof, Suneson Klara, Holmström Eva, Bäckström Beata, Johansson Björn Axel
Department of Clinical Sciences, Division of Pediatrics, Lund University, Lund, Sweden.
Office for Healthcare 'Sund', Child & Adolescent Psychiatry, Unit for Pediatric Bipolar & Psychotic Disorders, Lund, Sweden.
J Med Case Rep. 2017 Dec 12;11(1):345. doi: 10.1186/s13256-017-1508-8.
Comorbidity of bipolar disorder and obsessive-compulsive disorder is common in adolescence. Obsessive-compulsive disorder symptoms may be episodic and secondary to alterations in mood, and display specific features. Management of pediatric bipolar disorder-obsessive-compulsive disorder is challenging, as pharmacotherapy of obsessive-compulsive disorder may induce or exacerbate manic episodes and there is limited evidence of treatment efficacy. Electroconvulsive therapy is sparsely used in children and adolescents, but is documented to be a safe and efficacious intervention in adults with bipolar disorder. In view of the severity of symptoms in juvenile mania, studies on treatment strategies are warranted. We report a case of an adolescent with bipolar disorder-obsessive-compulsive disorder who was successfully treated with electroconvulsive therapy during an episode of severe mania.
A 16-year-old girl of Middle East origin first presented to us with depressed mood, irritability, and increased obsessive-compulsive disorder symptoms, which were initially interpreted in the context of acute stress secondary to migration. She had been diagnosed with bipolar disorder and obsessive-compulsive disorder in her previous home country, but had difficulties in accounting for earlier psychiatric history. During hospitalization her mood switched to a manic state with mixed and psychotic features, at times showing aggression toward others. Interruption in her lithium treatment for a short period and possibly the introduction of an atypical antipsychotic could in part have been triggering factors. After 8 weeks of in-patient care and psychotropic drug trials, electroconvulsive therapy was initiated and administered every second or third day for 4 weeks, with marked positive response. No apparent side effects were reported.
This case demonstrates the need for a detailed medical history, taking special note of periodicity and character of obsessive-compulsive disorder symptoms, in adolescents with mood disorders. When treating culturally diverse patients, extra consideration should be taken. Special concerns in the pharmacological treatment to avoid the patient's condition from worsening must be addressed, including giving priority to mood stabilization before obsessive-compulsive disorder symptoms. There are potential benefits in considering electroconvulsive therapy in young patients with severe mania where first-line treatment options have failed.
双相情感障碍与强迫症的共病在青少年中很常见。强迫症症状可能是发作性的，继发于情绪变化，并具有特定特征。小儿双相情感障碍合并强迫症的治疗具有挑战性，因为强迫症的药物治疗可能诱发或加重躁狂发作，且治疗效果的证据有限。电休克治疗在儿童和青少年中使用较少，但有文献证明其对双相情感障碍成人患者是一种安全有效的干预措施。鉴于青少年躁狂症状的严重性，有必要开展治疗策略的研究。我们报告一例患有双相情感障碍合并强迫症的青少年患者，在严重躁狂发作期间成功接受了电休克治疗。
一名来自中东的16岁女孩首次就诊时表现为情绪低落、易怒，强迫症症状加重，最初这些症状被认为是移民继发的急性应激反应。她在原籍国被诊断患有双相情感障碍和强迫症，但难以说明早期的精神病史。住院期间，她的情绪转变为具有混合和精神病性特征的躁狂状态，有时对他人表现出攻击性。锂盐治疗短期中断以及可能引入非典型抗精神病药物可能是部分触发因素。经过8周的住院治疗和精神药物试验后，开始进行电休克治疗，每隔一天或第三天进行一次，共进行4周，取得了明显的积极效果。未报告明显的副作用。
该病例表明，对于患有情绪障碍的青少年，需要详细了解病史，特别注意强迫症症状的周期性和特征。在治疗文化背景多样的患者时，应给予额外考虑。必须解决药物治疗中的特殊问题，以避免患者病情恶化，包括在治疗强迫症症状之前优先稳定情绪。对于一线治疗方案失败的严重躁狂年轻患者，考虑电休克治疗可能有益。
