Pre-pubertal Bipolar Disorder with Rapid Cycles— a Case Report

An 11 year boy presented with periods of lethargy, poor appetite and diminished interest in normal activities alternating with periods of overactivity, reduced sleep and unruly behaviour. The symptoms started after a temporary separation from home when the boy became quieter and displayed easy fatiguability, crying spells and no initiative to go to school. Fifteen days later, he suddenly became boisterous and abusive and talked incessantly. The episodes continued to occur in the same sequence every 15 days for the next 8 months. He was prescribed Imipramine 75 mg/day which switched him into a prolonged manic phase. When examined, he was restless, distractable and had elated mood, racing thoughts andgiandiose delusions. Physical examination revealed no signs of puberty. There was no history of affective disorders in any relative. He was diagnosed as Bipolar disorder (Type I) and put on intramuscular haloperidol 20 mg/ day as he was uncooperative for oral medications. His haematological and thyroid function tests as well as EEG were normal. His symptoms did not subside and as there was risk of exahaustion, three modified electroconvulsive therapies (ECTs) were given. His symptoms abated and he was put on lithium (Li) 900 mg/day for 2 weeks (plasma Li levels 0.82 mmol/1) without further benefit. Garbamazepine (GBZ) 600 mg/day was then substituted and clinical euthymia was achieved in ten days. His remission was maintained for about a year on the same dose of GBZ (plasma GBZ levels 8.94 ug/ml), without any side effects.