Expert: Ivan Goldberg, M.D. - 5/3/2006

Question
My 13-year old son has been treated for OCD and ADHD. Before being treated for both, had only a few unusual anger outbursts a year, but the reason I took him to a psych and therapist was mainly for his OCD and extreme disorganization. It took him hours and hours to get started on homework, he'd have infinite delaying activities and it was impossible for him to get started. He started on Zoloft, which helped with his mild OCD, but when it made him indifferent about school deadlines and anything requiring organization or attention, his psychiatrist added Ritalin LA and Focalin in the evening for concentration.

For a while, things really seemed to be improving for my son, but sporadically, and now over the past two weeks, something's dramatically different. Mornings are nearly impossible for him to get up, and he gets caught up in various strange activities, (i.e. bus about to come, and he's still in boxers, inappropriately calm, drumming in room or wrapping tape around something.) In the afternoon, he's been having major agitated fits every afternoon. He's not necessarily even yelling, just kicking things, and not even provoked. His personality isn't always angry, it's just this fog-type physical fit he has. Yesterday, he told me he punched a couple of kids at two separate times in the day, saying they'd shoved/punched him first. The smallest things are setting him off. Last night, he worked on a class project that required cutting and there were hundreds of pieces of confetti all over his carpet (again, he's 13). His sense of time has become extremely skewed recently.

Our psychiatrist is now having us wean him off the Zoloft, and she told us she's considering that his reaction to it may be an early indicator of bipolar disorder. (I do have an aunt with bipolar disorder, so it has appeared in family history.) For now, she's going to leave him on the Ritalin and see how he does on it alone.

My question is this: If she's correct, and the Zoloft has "revealed" an underlying bipolar disorder, would would similar cases show happens to the bipolar symptoms once he's off the Zoloft (assuming that's the inducing drug)? In other words, if Zoloft contributed to the bipolar-like behavior, then once he's off it, would the symptoms perhaps go away? Or do SSRI's trigger bipolar cycling that just stays?

I realize one can't determine which came first, the chicken or the egg, here, but I wonder what studies show happens once most kids have the symptom-provoking trigger removed. Do the medication-induced symptoms tend to linger or fade?

Also, I'm having real difficulty understanding the difference between a teenage anger fit and a bipolar episode. As much info as you have on this would be extremely helpful.

Thank you so much.

-E.

Answer
Hi . . .

I am not an expert when it comes to children and adolescents.

It has been my experience that one of the most common misdiagnoses in psychiatry is for bipolar disorder to be diagnosed as ADD/ADHD. This frequently leads to a worsening of the situation by antidepressants that have a capacity to worsen manic/irritable/angry/impulsive behavior. Such behavior often disappears when the offending medication(s) have been stopped.

Best regards . . .

Ivan
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