Abstract
A patient with a history of autism spectrum disorder and epilepsy was hospitalized for management of acute onset psychosis and agitation. The acuity of his behaviors warranted abrupt shifts in treatment and multiple pharmacologic interventions were ineffective. The atypical nature of his presentation and intense pressure from ancillary staff to consider organic etiologies drove frequent transitions of care within the hospital setting. Multiple diagnoses were considered including a primary psychosis, excited catatonia and antiepileptic drug-induced psychotic disorder. Ultimately the patient was diagnosed with bipolar disorder and effectively treated with quetiapine and valproic acid. The authors suggest that rapid consideration of comorbid bipolar disorder in autism spectrum disorder patients presenting with affective dysregulation may expedite trial of an anticonvulsant with mood stabilizing properties, which would have simplified this patient’s clinical course and limited potential for iatrogenic harm. This course of treatment should especially be considered when a history of epilepsy is present.
Highlights
Autism spectrum disorder (ASD) is a neurodevelopmental condition broadly characterized by deficits in social interaction and restrictive patterns of behavior[1]
A patient with a history of autism spectrum disorder and epilepsy was hospitalized for management of acute onset psychosis and agitation
The authors suggest that rapid consideration of comorbid bipolar disorder in autism spectrum disorder patients presenting with affective dysregulation may expedite trial of an anticonvulsant with mood stabilizing properties, which would have simplified this patient’s clinical course and limited potential for iatrogenic harm
Summary
Autism spectrum disorder (ASD) is a neurodevelopmental condition broadly characterized by deficits in social interaction and restrictive patterns of behavior[1]. This case study describes a patient with ASD, active epilepsy, and severe episodic affective dysregulation whose clinical course was confounded by diagnostic uncertainty and notable for symptomatology recalcitrant to several psychotropic trials His symptoms, which were favored to be etiologically related to comorbid bipolar disorder, remitted on a combination of VPA and quetiapine. Over the course of these hospitalizations he was trialed on low-dose risperidone and quetiapine, in addition to replacement of topiramate with lacosamide, re-initiation of valproic acid as his primary anti-epileptic None of these interventions had been effective in ameliorating the patient’s agitation or psychosis and the family presented to the emergency department in a state of ongoing crisis. This is interpreted by the authors as a measure of adherence and tolerability of these medications
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