Atomoxetine-Induced Hypomania-Like Symptoms in a Preadolescent Patient

Abstract

[Author Affiliation]Esra Guney. Ankara Pediatric & Pediatric Hematology Oncology Training and Research Hospital, Child and Adolescent Psychiatry Department, Ankara, Turkey.Ozden Sukran Uneri. Ankara Pediatric & Pediatric Hematology Oncology Training and Research Hospital, Child and Adolescent Psychiatry Department, Ankara, Turkey.Address correspondence to: Esra Guney, MD, Ankara cocuk sagligi ve hastaliklari egitim arastirma hastanesi, Ziraat Mah, Irfan Bastug Cad. Kurtdereli Sk. No: 10, Diskapi-Ankara, Turkey, E-mail, : dresraguney@gmail.comTo The Editor:Atomoxetine, a selective noradrenaline reuptake inhibitor, is the first nonstimulant drug approved by the Food and Drug Administration for the treatment of attention- deficit/hyperactivity disorder (ADHD) (Kaplan and Newcorn 2011). It has been reported that atomoxetine can be safely used in comorbid anxiety disorder and tic disorders (Christman et al. 2004). In this article, we aimed to report hypomania-like symptoms triggered by atomoxetine in a patient with ADHD and social anxiety disorder.Case ReportA 10-year-old male patient presenting with attention deficit, forgetfulness, difficulty in memorizing, and low school success underwent a Wechsler Intelligence Scale For Children-Revised (WISC-R) test to assess his mental capacity. The test revealed that his verbal subtest score was 64, performance subtest score was 68, and total subtest score was 63. According to observations of the psychologist applying the test, attention deficit and performance anxiety affected the test result unfavorably. In addition, it was determined that the patient could not express himself properly in social settings, avoided activities requiring performance, such as not attending classes out of fear of making mistakes, and was usually quiet and shy; therefore, his daily functions were unfavorably affected by his condition.Assessment with respect to ADHD revealed that his time spent studying was limited. In addition, he made careless mistakes in homework, was easily distracted, forgot daily activities easily, and, hence, was frequently warned by his family and teacher. The assessment indicated no activity or impulsivity that had an impact on functionality. He had been advised to take methylphenidate for similar symptoms at the age of 7, but the treatment had been stopped by the family because of side effects such as marked sedation, appetite loss, and irritability. The teacher notification form that was sent via the family also supported these findings.For diagnosis, semistructured interviews based on the American Psychiatric Association, Diagnostic and Statistical Manual of Mental Disorders, 4th ed. (DSM-IV) diagnostic criteria were conducted with the child and his parents (American Psychiatric Association 1994). Moreover, Conners' Parent and Teacher Rating Scales (Goyette et al. 1978; Conners 1997) were applied. According to the evaluation of the patient, it was determined that he fulfilled the diagnostic criteria for ADHD--attention-deficit subtype and social anxiety disorder--common type. The patient was also evaluated through a semistructured interview based on the DSM-IV diagnostic criteria for any symptoms of other anxiety disorders, mood disorder, and oppositional defiant disorder/conduct disorder, as well as tics and elimination disorders; no signs of these psychiatric disorders were observed. He was begun on atomoxetine 10 mg/day (body weight 36 kg) with gradual dose increases. Special educational support was postponed until a repeat WISC-R test could be administered at 6 months after the treatment.The patient was brought to our polyclinic with nervousness, defiance to parents, and overactivity on 7th day of atomoxetine treatment. A repeat evaluation revealed that his self-esteem increased; he also developed behavioral and emotional changes in the form of occasional anxiety and irritability, and sometimes excessive joy, restlessness, impatience, pugnaciousness, pressured speech, speech interruption behavior, tendency to commit violence against friends, one attempt to kiss one of his friends on her cheeks, and very frequent and irritating kissing behavior toward his mother. …