P, a 16-year-old high school student who resides with his parents and two younger siblings, ages 13 and 11 years, has been in treatment with his present psychiatrist since the age of 10 years. Upon initial presentation, history was positive for longstanding difficulty with mood shifts, oppositional behavior, and verbal and physical aggressive outbursts that have been refractory to multiple medication trials.
Despite the product of an unremarkable pregnancy and delivery, his parents felt he was somewhat different from birth. He did not like being held and was hard to soothe. Once ambulatory, P appeared very curious, overactive, and frequently into "mischief." In toddlerhood, he also began to exhibit difficulty with moodiness and oppositional defiant behaviors with peers as well as authority figures. He could be extra silly, but more often easily unhappy and angry. In nursery school, he would hit and bite peers when frustrated and was defiant with teachers. Behavioral interventions were successful.
By the time he was in the first grade, since his interactions were fraught with conflict, following evaluation, he was deemed eligible for special services in the academic setting. P was given a 1:1 aide both in school to help keep him on task and on the bus to prevent behavioral outbursts. Psychological counseling was initiated at the age of 7 years and soon thereafter a psychiatrist placed him on medication for a newly diagnosed attention-deficit hyperactivity disorder (ADHD) (see Figure 1). By the age of 10 years, despite multiple medication trials and family and individual psychotherapy, P's behavior escalated to the point that he was verbally and physically violent and uncontrollable at home. Between ages 10 and 11 years, he was psychiatrically hospitalized for more than a week on four occasions because of his aggressive threats and actions. He repeatedly stated that he wanted to kill his family and himself. Discharge diagnoses included bipolar I disorder:mixed, ADHD:combined type, and oppositional defiant disorder.
P's behavior appeared treatment resistant with minimal improvement despite multiple medication trials prior to and during hospitalizations. These included dexmethylphenidate hydrochloride extended-release tablets, methylphenidate hydrochloride extended-release tablets in a variety of preparations, mixed dextroamphetamine salts in extended release, risperidone, fluoxetine, and aripiprazole. Parents noted that he became more angry and agitated when he was on the stimulants. In an attempt to reevaluate his situation, soon after hospital discharge all psychotropic medication was stopped.
Over a 6-week period, post medication discontinuation, he started to become less volatile and violent, but exhibited rapid cycling behaviors such as laughing a lot, talking fast, exhibited increased energy, suddenly became very interested in cleaning his room, had problems falling asleep, and became preoccupied with and talked about Star Wars incessantly. He would then shift to periods of anger and destructive behavior and verbalize that he felt everything was wrong. Initiation of carbamazepine and low-dose olanzapine decreased the rapid cycling and eliminated the violent physical behavior, but his negative and critical speech at home continued. He did minimal schoolwork, was socially withdrawn, and described by mother as joyless, rarely smiling, and verbalized being unhappy. His appetite was poor. He said he hated most food, and although he grew taller he had not gained weight in 2 years.