Abstract
Harpreet S. Duggal, Siddhartha Dutta and Vinod K. Sinha, Central Institute of Psychiatry, Ranchi, India:
Among the affective disorders associated with Asperger's syndrome (AS), depression is the commonest with syndromal mania and bipolar disorder being anecdotally reported [1]. Little information is available on the management of manic symptoms in AS. We report a case of AS whose comorbid mania responded to a combination of two mood stabilisers.
S., a 22-year-old male, presented with a history of poor socialization, circumscribed areas of interest, oddities of speech, repetitive patterns of behaviour and an awkward gait since early childhood. Besides these symptoms, the patient, since the age of 4 years, had displayed obstinacy, irritability, anger outbursts and talkativeness. Over the years, violence towards animals, beating small children and family members, and increased appetite were added to his repertoire of symptoms. Two months before consulting us, his symptoms worsened so that at presentation he had hyperactivity, pressure of speech, elated affect and grandiose delusions.
The patient was a product of uneventful pregnancy and delivery with normal developmental milestones. Family history revealed affective illness in maternal grandmother. In view of this presentation, a diagnosis of Asperger's syndrome with comorbid manic psychosis was made according to ICD-10.
At intake, the patient had a score of 37 on the Young Mania Rating Scale (YMRS). He underwent routine blood investigations, which were normal. Though his electroencephalogram and brain magnetic resonance imaging were unremarkable, a detailed neuropsychological testing using Luria Nebraska Neuropsychological Battery suggested temporo-parietal and right frontal lobe dysfunction. Considering these observations, patient was started on valproate along with risperidone at 4 mg/day. The valproate was gradually increased to a maximum tolerable dose of 2000 mg/day (25 mg/kg/day), which was continued for another 4 weeks without any effect. It was then decided to add lithium, which was increased to 1200 mg/day with serum levels at 1 mEq/L. Within 2 weeks of this combination, the patient showed a dramatic response in his affective symptoms with the score on YMRS coming down to 12, a drop of 67%. Significant improvement occurred in the domains of elevated mood, irritability, speech and biological functions.
There are reports associating bipolar disorder with AS [2–4]. Patients with AS with a family history of affective illness may show a propensity to develop antidepressantinduced hypomania [5]. However, not much literature is available on the treatment of either spontaneous or druginduced affective disorders in AS. In the above-cited case series [5], three patients with AS who developed fluoxetine- induced hypomania were adequately treated with valproate. This did not occur in our case as our patient responded only after lithium was added. There is evidence supporting the use of lithium on a long-term prophylactic basis in autistic patients with manic-like symptoms [4].
In conclusion, authors highlight that chronic mania may be common in some subsets of patients with AS, which may be mistaken as a manifestation of the behavioural dysreguation and mood swings associated with autistic syndromes. Making a diagnosis of comorbid mania in these patients and treating it with mood stabilizers may, thus, be a more pragmatic approach. At the same time, some patients with AS, although asymptomatic, are vulnerable to antidepressant-induced hypomania, especially those having family history of affective illness. Hence, caution needs to be exercised while prescribing antidepressants to such patients. Concurrent use of mood stabilisers can be explored as an alternative in these cases. That some cases of AS may be aetiologically related to bipolar disorders [3] may explain the response to mood stabilizers. Finally, neurobiological correlates of vulnerability for developing mania, either spontaneous or drug-induced, and the predictors of response to mood stabilizers in AS require further elucidation.