Onset of Abnormal Movements and Cardiovascular Symptoms after Acute Change in Complex Polypharmacy in a Child with Attention-Deficit/Hyperactivity Disorder and Mood Symptoms

Abstract

T. was being treated in the community for diagnoses of attentiondeficit/hyperactivity disorder (ADHD) and bipolar disorder, not otherwise specified (BD-NOS). T.’s mother reported that T. had had many ADHD symptoms present since kindergarten, including difficulty with concentration and completion of tasks, inattention, restlessness, impulsivity, frequent interruption of conversations, and need for constant redirection. T. also was reported to have other behavioral problems, including refusal to follow directions and aggressive behavior toward family members, including slamming or punching objects. In the previous few months, he was reported to have become more oppositional and more disrespectful, and he had attempted to set fires and been cruel to animals. T.’s mother also reported that T. had experienced difficulty with emotional regulation, and had threatened to hurt himself in the past when angry. He also reportedly had had brief crying spells when he was upset. His mood was reported to be irritable when he did not have his desires fulfilled; T. himself reported his mood as ‘‘sad and mad’’ most of the time. His mother reported that he had experienced difficulty sleeping, typically going to bed at 1:30 a.m. and waking up at 6:30 a.m. T. was reported to have nightmares at times, but he was not able to recall the content. His mother denied that he had demonstrated grandiosity, elevated mood, racing thoughts, or pressured speech. There was no history of suicidal ideation, suicide attempts, or psychotic symptoms. There was no history of abuse, trauma, tics, obsessive compulsive and anxiety symptoms, or use of substances. T. had been treated for his aggressive behavior by an outpatient child and adolescent psychiatrist with aripiprazole 5mg by mouth (p.o.) daily for a total of 1.5 years. Two months prior to his ED presentation, aripiprazole had been discontinued because of reported weight gain (1.81 kg in 1.5 years) and ineffectiveness at decreasing aggressive episodes. Lithium CR 300 mg p.o. daily was subsequently started to address the continued aggressive behavior to self and others. One month prior to the ED presentation, guanfacine extended release 2 mg p.o. daily was started. Four days prior to his ED presentation, T.’s psychiatrist had recommended several changes in his medication regimen to target what his mother called ‘‘spasm attacks.’’ These attacks were described by mother as T. hitting and slamming objects, punching holes into walls, attempting to physically harm family members with knives and shovels, and attempting to harm himself by placing his head outside or attempting to get out of a moving car. These symptoms had been escalating over the past few months. Recommended medication changes included discontinuation of guanfacine extended release 2 mg, an increase in lithium CR to 450 mg from 300 mg, and initiation of risperidone 1 mg and lisdexamfetamine (LDX) 50 mg. T.’s mother reportedly did not feel comfortable with the multiple medication changes recommended, so she only stopped the guanfacine extended release and increased the lithium CR. In the 2 days following the lithium CR increase and guanfacine extended release discontinuation, T. reportedly experienced no adverse effects. On the day of his ED presentation, his mother had started the LDX 50 mg in the a.m.; 45 minutes after starting the medication, T.’s mother reported that T. was rubbing his chest and complaining of chest pain. He would not eat, which was very unusual for him, and he reportedly started to gasp for air. T. was taken to a nearby family practice clinic for evaluation. There had been no past history of abnormal movements, shortness of breath, or chest pain.