psychotic disorder, and 12-17 % among autism spectrum disorder .5,6 It is associated with significant ... her manic symptoms with Young Mania Rating Scale 30.
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Title: Electroconvulsive Therapy Induced Mania in A Child with Catatonia: Case Report and Review of literature
Authors: Khairkar Praveen, Ransing Ramdas ,Sarkar Dipayan, Sakekar Gajanan
Affiliations: Department of Psychiatry, Mahatma Gandhi Institute Of Medical Sciences, Sevagram , India .
Corresponding Address : Department of Psychiatry, Mahatma Gandhi Institute Of Medical Sciences, Sevagram , India .-442102
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Title: Electroconvulsive Therapy Induced Mania in A Child with Catatonia: Case Report and Review of literature
Abstract Introduction: Despite of controversial history in paediatric population, ECT has been found effective treatment in psychiatric disorders including Catatonia with fewer side effects. Mania or hypomania has been reported as one of the rare side effect of ECT in adult population and discussed well. We report case of ECT induced mania in paediatric patient. Case report: A 14 yrs old right handed female child presented with sudden onset of catatonic symptoms of 1 month duration. She developed manic episode after three cycles of ECT as a treatment module for Catatonia. She was treated successfully with combination of antipsychotics and mood stabiliser. Conclusion: Clinician should consider mania as rare but possible side effect in paediatric population while treating catatonia. Lithium may be considered as one of the treatment option for such manic switch. Keywords: Catatonia, ECT, Mania, Mood Stabiliser.
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Introduction: Kahlbaum described catatonia for unique clinical presentation of motor, vocal and behavioural abnormalities in 18741. Catatonia has been recognised as predominant feature of affective disorder than schizophrenia 2 along with several medical, neurological and drug induced condition in adult population3. Besides adult population, few studies reported catatonia has been reported in paediatric population with psychotic , affective , drug induced , neurological , autistic disorders 4 with prevalence ranging from 5% among outpatients with (17 %-33%) among subgroup of psychotic disorder, and 12-17 % among autism spectrum disorder .5,6 It is associated with significant morbidity and mortality if not treated promptly and adequately . Paediatric catatonia responds well with benzodiazepines and electroconvulsive therapy. Benzodiazepines are treatment of choice for catatonia. Those unresponsive or insufficient responsive to benzodiazepine needs electroconvulsive therapy. However, ECT is known to cause certain side effects including cognitive dysfunction, cardiovascular problems and in rare case mania7. Most of cases were reported among adult population with discussion of possible underlying mechanisms. The guideline for continuation of ECT and selection of Mood stabiliser is still unclear. We report case of childhood mania following ECT in patient of Catatonia and successful management with mood stabilisers. Case vignette: A 14 years old right handed female child with premorbid hyperthymic temperament was presented with abrupt onset of Mutism, staring look, withdrawal, posturing, psychomotor retardation and waxy flexibility of 1 month duration. Extensive search for causality revealed no underlying structural lesion. There were no psychotic and mood symptoms prior to presentation. Neither past nor family history was suggestive of psychiatric illness including bipolar disorder, schizophrenia, seizure, autistic spectrum disorder and attention deficit hyperactivity disorder. Her CT head, complete blood count, renal function test, thyroid function test, Electroencephalography were within normal limit. She received Risperidone 2 mg per day prior to admission from previous hospital without extrapyramidal symptoms and no improvement in her symptoms. She was diagnosed as “Catatonic Associated with schizophreniform disorder” as clinical picture is dominated by three symptoms – Waxy flexibility, Mutism, Negativism required for diagnosis according to DSM-5. Her score on the 23 items Bush-Francis Catatonia Rating Scale was 23. She was started on Inj. loarazepam 2 mg slow IV thrice a day .Antipsychotics was planned to start after catatonic phase resolves. However there was no significant improvement was observed in catatonic symptoms after five days and ECT was planned She received 4 cycles of modified ECT with anaesthesia during hospitalisation after written informed consent from her father. She received Bilateral ECT twice a week with standard bifrontotemporal electrode placement. Initial dose of 80 mc (miliCoulombs) was applied with
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an ECT range from 80 mc to 150 mc) for 0.6 sec resulted into 25-30 sec of motor seizure with uncomplicated postictal recovery. After every cycle of ECT she was showing improvement as her score was dropped to 6 after three cycles. After three cycles her catatonic symptoms were resolved. However, she developed symptoms in the form of over familiarity, excessive talking, dancing and was restless, roaming in ward continuously. Her Young Mania Rating Scale score was 24. As there was no specific guideline 4th cycle of ECT was given. It resulted in further increase in her manic symptoms with Young Mania Rating Scale 30. Then it was planned to stop ECT and started on mood stabiliser lithium 300 mg per day which was gradually increased to 600 mg per day. She responded well with Risperidone 2 mg, lithium 600 mg and lorazepam 4 mg in divided dose over three to four week. Discussion: Discussion of index case has been organised in following headings -1) Mechanism producing Catatonia 2) Mechanism of action of ECT in Catatonia 3) Possible mechanism producing manic switch 4) Selection of mood stabilisers. 1).Mechanism of Catatonia: The exact mechanism of catatonia is still unknown. But several hypotheses have been postulated. Imbalance between excitatory and inhibitory neurotransmitter of brain may be considered basic mechanism for production of motor symptoms of catatonia and has been supported by therapeutic effect of benzodiazepines. 8 9 Clozapine induced catatonia is supposed due to rebound cholinergic and serotonergic hyperactivity10. Interestingly, Moskowitz (2004) postulated the catatonia as evolutionary fear response11. Sudden blocked of dopamine has been postulated by Osman & Khurasani (1994) and associated with worsening of condition with use of antipsychotics12. In our case, unresponsive to benzodiazepine might be against imbalance between excitatory and inhibitory neurotransmitter. Sudden onset of catatonia symptoms may be explained by sudden blockade of dopamine or rebound serotonergic hyperctactivity. In case of serotonergic hyperactivity one may consider as risk factor for development of ECT induced mania. 2 ) Mechanism of action of ECT ECT is a rapid, effective treatment for catatonia and thus helpful in preventing related life threatening complications. Mechanism of action of ECT is unclear though several theories have been proposed to explain. Neurotransmitter theory suggest ECT works by changing the way receptors receive neurotransmitter like serotonin and nor epinephrine.13 Induction of seizure generates counter mechanism that resists seizures in the brain .This counter mechanism also dampens
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abnormally active brain circuits that stabilizes mood which is the basis of anticonvulsant theory15. Whereas neuroendocrine theory suggest seizure causes the hypothalamus to release chemical that causes changes in throughout the body14 . ECT may affects the brain by increasing metabolism and blood flow to certain parts of the brain however it’s not known how this blood flow alleviates depression.13 ECT may enhances expression of neuroprotective protein, brain derived neurotropic factor [BDNF] which antagonizes the neurotoxic effects of brain. 15 3) Possible Mechanisms for Manic Switch Till date five studies examined the incidence of manic switch in patient with bipolar depression beyond case reports which ranges from 6.7 % to 38.6 % among adult population. Most recent study by Bost-Baxter et al. (2012) found the incidence of hypomania or mania was 24.8 % among his 105 patients after overcoming the previous studies limitation such as small sample size, availability of fewer medicines to treat mania.16 Henry et al 2001 studied risk factors for antidepressant induced switch which includes sex , age , diagnosis (bipolar I and Bipolar II ) number of previous manic episodes were not associated with switching . Number of ECT cycles and Hyperthymic temperament was associated with a greater risk of switching.20 Switch rate in Angst’s study is mainly explained by polarity; patient with previous history of mania or hypomania have switch rate of 21% (mania to depression) to 29 %( depression to mania) 17 .In our case there was no significant past or family history suggestive of any polarity. Younger age, female sex has been studied as important risk factor in contradictory to previous study13. Manic switch in our case may be excessive limbic stimulation that exceeded affective target resulting mania besides other risk factors18. Presence of hyperthymic temperament may be due to serotongeric hyperactivity. However further research is indicated for exploration of risk factor in adolescent population. 4) Selection of Mood Stabilizers: Our case was treated with lithium successfully. Interestingly, Even though manic switch following ECT is common among adult population, still there is no specific treatment guideline. Most of medication used in studies includes mood stabilisers and antipsychotics with immediate discontinuation of ECT. Treatment of catatonia can improves as few as 1 to 4 cycles of ECT in adult population.So one should be vigilant in deciding total number of ECT cycles. 13 Studies finding suggests concurrent use of lithium therapy may prevent ECT induced switch manic switch.18 Lewis and Winkour et al confirmed the efficacy of lithium and neuroleptic medication in antidepressant induced mania. 19 However Henry et al were failed to notice significant difference among patient receiving mood stabilizers and those not. No study has compared the efficacy of lithium with other mood stabilisers. 20 Selection of mood stabilisers remains unclear in ECT induced mania in both adult and paediatric age group.
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Conclusion: The ECT is no doubt useful for effective and successful management catatonia in paediatric age group despite of controversies and Mental Health Care Bill, 2013. We suggest consideration of ECT induced Mania as rare but important side effects among children. ECT induced switch is one of the important poor prognostic factor among children.So, regarding decision of ECT as treatment option one must weigh risk and benefits of same. Lithium may be used as mood stabilizers in ECT induced manic switch with discontinuation of further cycles of ECT. However there is need to study underline possible mechanism of ECT induced mania and to compare effectiveness of lithium with other mood stabiliser in prospective study.
Conflict of Interest: None
Abbreviations: ECT: Electroconvulsive therapy, YMRS – Young Mania Rating Scale.
Acknowledgement: Author is thankful to patient and her parents for providing their consent for publication of this case report.
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