A 13-year-old Asian, boy, from urban area of East India, with normal birth and developmental history, past history of febrile convulsions till the age of 6 years, medical history of bronchial asthma and ankyloglossia, family history of single manic episode in father and dissociative convulsions in mother, presented in November 2003 to the Outpatient Department (OPD) of Centre for Child and Adolescent Psychiatry, Central Institute of Psychiatry, Ranchi, India with reduced interest in studies, episodes of sudden unarousable "sleep," lasting as long as 14-16 h and sudden awakening for 2 weeks. Simultaneously, there are periods of unresponsiveness for 16-18 h starting and ending abruptly with no response to noxious stimuli and complete amnesia. An initial impression of hypersomnia unspecified with a possibility of dissociative disorder was made, and he was admitted for investigation and management. He was responsive to behavioral management comprising of the problem behavior extinction and differential reinforcement of alternative behavior. Fluoxetine was started as he was noted to be sad and disinterested.
Pentothal interview was unremarkable, and Video electroencephalogram with quantitative analysis during apparent period of unresponsiveness showed no sleep changes or abnormal focal or generalized discharges. Polysomnography was also unremarkable except for increased rapid eye movement latency and relatively increased percentage of Stage 3 and 4 sleep in total sleep time. Mental status did not reveal any depressive cognition. With the above regimen, he showed good response and a diagnosis of dissociative disorder unspecified was kept at discharge. He came for regular follow-up till 1 year, but thereafter did not report till 3 years, a period in which he had stopped his medicines, maintaining well. He reported again in November 2007 with a 3 months history of low mood, irritability, poor concentration, difficulty in studying and two suicidal attempts. He was admitted with a diagnosis of severe depressive episode without psychotic symptoms. Fluoxetine was increased to 40 mg but he developed significant deterioration with hyperactivity, decreased need for sleep, anger outbursts and grandiose claims. An impression of antidepressant-induced manic switch was made and he was put on electroconvulsive therapy as he also expressed significant suicidal ideations and attempted once in the ward to hang himself during the course. With this he had good response and after 8 sessions he was put on lamotrigine considering family history of mania, high impulsivity, and age of onset, and it was increased up to 200 mg/day on which he attained remission over 4 weeks and was discharged from hospital.
This can be observed as an absorbing case considering the way the clinical presentation evolved over a period of 5 years. To the best of our knowledge, there is no similar presentation and evolution of psychopathology in children and adolescents. There were genetic vulnerabilities to both bipolarity and dissociative disorder, which may have been exposed to an examination failure stress and brought about the symptoms in the child. Draijer and Langeland have noted that severity of dissociation could be predicted by maternal dysfunction; in our case we could speculate that the maternal dissociation was a response to escape some overwhelming stress and the patient having witnessed these attacks took a similar route to escape his stressor.
About the periods of unresponsiveness and "sleep" noted in our patient, it has been noted by Putnam et al. that the young patients may recurrently cycle through sleep and drowsy states more than the older population. Our subject had displayed symptoms of depression in the first episode of illness itself- as per Hornstein and Putnam there may be a number of clusters within which dissociative behavior can overlap with a number of internalizing disorders like depression, anxiety etc. This patient demonstrated gradual response to psychotherapeutic interventions, although a pentothal interview interestingly revealed the persistence of amnesia for the month in which he did not pass his examinations, a psychological and social stressor as per Srinath et al., who noted academic pressures to be an important underpinning among Indian children attending psychiatric OPD with features suggestive of "hysteria." The switch induced by the antidepressant added yet another facet to the case as there have been observations of selective serotonin reuptake inhibitor-induced hypomanic switch in patients of dissociative disorder.
There have been proposed hypotheses of dissociative identity disorders (DIDs) and bipolar disorder as been lying on a continuum based on the phasic alterations of the DID patient's personalities and the bipolar subject's affective changes. On a similar note, our subject's longitudinal course of illness gave an opportunity to observe the evolution of this process. Thus, our patient was a candidate who fell into the bipolar spectrum constellation with age of onset added to his predisposing factors. In a Norwegian sample, it was noted that there is a significantly higher prevalence of dissociative symptoms in bipolar II subjects when compared to MDD patients. Long-term outcome and prognosis of dissociative disorder with onset in childhood or adolescence in a large German sample revealed that more than 50% of the patients went on to develop anxiety or somatoform disorder over a clinical course of around 10 years but mood disorder was not reported. This makes a strong point toward the possible common lineage between these two groups of disorders and may raise a theoretical possibility of dissociation being a forerunner to bipolarity in clinical populations and thus helping clinicians' pickup occult bipolarity in dissociative disorders and instituting early treatment. Further research in the coming years may help shed light on this interesting probability.