Diagnostic and Therapeutic Challenges in an Adolescent with Comorbid Oppositional Defiant Disorder and Bipolar Disorder

Abstract

Oppositional defiant disorder (ODD) is often found to be comorbid with bipolar disorder (BD) in children and adolescents. Both disorders are characterized by chronic irritability, emotional dysregulation, and behavioral problems. These overlapping symptoms often lead to diagnostic difficulty. In addition, ODD-BD comorbidity also presents multiple therapeutic challenges. Here, we describe the case of an adolescent male, who presented with comorbid ODD and BD, along with multiple diagnostic and therapeutic challenges.

Introduction

Oppositional defiant disorder (ODD) is characterized by “a pattern of angry/irritable mood, argumentative/defiant behavior or vindictiveness lasting for at least six months.” ¹ It is commonly found to be comorbid with pediatric bipolar disorder (BD). In a meta-analysis by Van Meter and colleagues, the prevalence of ODD in children and adolescents with BD was found to be 42%. ² The overlap of symptoms between ODD and hypomania/mania with the persistence of irritability or defiance often results in diagnostic and management difficulties. ODD has varyingly been discussed as a disorder of deficient emotional regulation or as being on the spectrum of chronic irritability. ³ Disruptive Mood Dysregulation Disorder (DMDD) is also associated with persistent irritability and severe recurrent temper outbursts. The diagnosis of DMDD was introduced to reduce the overdiagnosis of BD. In addition, DMDD and ODD are not diagnosed simultaneously, and the diagnosis of DMDD takes precedence. ¹ Chronic irritability was also given close attention in the development of the Mental, Behavioural, and Neurodevelopmental Disorders (MBND) chapter in ICD-11. ⁴ In this case report, we describe an adolescent male with comorbid ODD and BD leading to diagnostic and therapeutic challenges.

Case Summary

X, a 14-year-old boy, was brought to the child psychiatry outpatient clinic by his parents with complaints of frequent and severe temper tantrums (3–4 times per month), which were out of proportion to the situation. At the age of around 8, patient started displaying irritable mood and he had frequent anger outbursts on trivial issues. He would often be argumentative and disobedient towards his parents. In the next 1–2 years, complaints started coming from his school that he refuses to comply with the teacher’s instructions, often troubles other children, and picks up fights with them. When confronted, he would often blame his classmates for initiating the fights. His biological functions like sleep and appetite were within normal limits. Though these issues started around 8 years of age and caused significant distress to his parents, they did not seek any professional help due to lack of awareness regarding the availability of child mental health services.

A detailed assessment revealed that the patient was born out of normal vaginal delivery at term, without any perinatal complications. He achieved all developmental milestones as per age. He had a difficult temperament. and his parents had frequent interpersonal issues between them, resulting in inconsistent parenting. In addition, there was a family history of BD in multiple second and third-degree relatives on the paternal side (paternal uncle, grandfather, and great grandfather). No history of childhood trauma or abuse was reported by any of the informants or the patient. There was no history of substance use. Parental conflict in the form of dispute over roles and responsibilities about household work and child rearing, contrasting styles of parenting, and frequent interpersonal issues were elicited. Inconsistent parenting was also elicited in the form of fluctuations in rewarding and reinforcing behavior, incorporating disciplinary routines alternating with overlooking of maladaptive behavior and use of harsh punishments. However, there was no history of any mental illness or substance use in the parents.

ODD and conduct disorder (CD) were considered as the differential diagnoses. After detailed exploration, CD was ruled out, as there was no history of violation of the basic rights of other people, serious violation of age-appropriate rules and norms, destruction of property, deceitfulness, or theft. Owing to the relatively less severe nature of the behavioral disturbances and presence of emotional dysregulation, he was diagnosed with ODD. DMDD was ruled out as the temper tantrums were less frequent (4-6 times per month) than the threshold required for diagnosis of DMDD (ie, 3 or more times per week). His parents were educated about the illness. In addition, parent management training and behavioral therapy were initiated. Psychotherapy for addressing the marital conflict was also initiated. However, patient’s father had to frequently travel due to his business. As a result, regular sessions could not be held. Pharmacologically, tab. aripiprazole up to 10 mg/d and risperidone 2 mg/d were tried sequentially. However, the conflicts between his parents persisted, which resulted in inconsistent parenting. As a result, no significant improvement was noticed in his behavior.

After around 6 months of starting consultation, he developed an episode of illness characterized by irritable mood, overtalkativeness, excessive activity, overfamiliarity, aggressive behavior, decreased sleep, and sexual disinhibition. A diagnosis of mania without psychotic symptoms was made, considering the severity of symptoms and socio-occupational dysfunction caused by the sexual disinhibition and aggressive behavior. Routine blood investigations (including complete blood count, liver function tests, kidney function tests, thyroid function tests, fasting blood glucose, and serum electrolytes) were within normal limits. He was started on tab. valproate sodium 1000 mg/d, olanzapine 10 mg/d, and clonazepam 0.5 mg/d. However, there was no improvement in his symptoms even after 6 weeks. Hence, olanzapine was cross-tapered with haloperidol 10 mg/d. He achieved remission with valproate sodium and haloperidol (YMRS score reduced from 22 to 6). However, the earlier behavioral symptoms persisted.

After 6 months of continuing treatment, he refused to come for follow-up or take his medications, despite multiple efforts by his parents. He remained off medications for 1 year, during which he developed 2 self-limiting episodes suggestive of hypomania around 6 months apart. At 16 years of age, he had another episode of illness characterized by persistent and pervasive low mood, pessimistic thoughts related to his career, death wishes, anhedonia, irritability, multiple somatic symptoms along with a disturbance in sleep and appetite. The diagnosis of bipolar depression (moderate in severity) was made. Subsequently, quetiapine up to 400 mg was started. In addition, behavior therapy, anger management, stress management, social skills training, and parent management training were continued for ODD. With the combination of these pharmacological and psychological interventions, there was significant improvement in the depressive symptoms as well as behavioral disturbances. After six months, he developed another episode of mania. Quetiapine was gradually hiked to 800 mg. After 6 weeks, valproate sodium 750 mg/d was added because of persisting symptoms and behavioral disturbances. He achieved remission on these medications within a month and is maintaining well for the last 2 years. Gradually, quetiapine was tapered to 400 mg/d (with a plan to gradually taper and stop) and valproate sodium 750 mg/d was continued. With the above treatment, his irritability and anger outbursts have reduced significantly.

Due to the frequent episodes of illness, he was frequently absent from the school. Although there was no history of frequent change of school, there were multiple complaints from his teachers regarding school absenteeism. His grades declined gradually and he was not able to pass 10th class examination. Subsequently, he dropped out of school despite the persuasion by his parents to continue. Currently, he is 19 years old and is working in a factory. He comes for regular consultation and is adherent to the pharmacological treatment.

Discussion

The index patient had irritability, frequent anger outbursts, and behavioral problems since early childhood. As a result, it was difficult to elicit history of hypomania or depression from the parents. Additionally, many of the mood symptoms were initially considered to be a part of ODD by the treating team. Retrospectively, it can be speculated that these factors might have obscured initial symptoms of hypomania or mild depression. Further, the diagnosis of BD could be established only after the patient developed overt symptoms of mania like overtalkativeness, excessive activity, overfamiliarity, aggressive behavior, and sexual disinhibition. Apart from these diagnostic challenges, there were multiple therapeutic challenges, including marital discord between his parents, poor engagement in psychological interventions, and irregular follow-up.

Chronic irritability in children and adolescents cuts across multiple diagnoses. It is seen in multiple disorders, including ODD, BD, DMDD, CDs, Attention Deficit Hyperactive Disorder (ADHD), and Autism Spectrum Disorder (ASD). In some of these disorders (eg, ODD, BD, and DMDD), irritability is considered one of the core features, often leading to diagnostic difficulties. In BD, irritability occurs only during the episodes of mania or hypomania, as compared to the more chronic nature of irritability in ODD, CDs, or DMDD. Although in children and adolescents, discreet episodes may not be seen, they are often accompanied by other symptoms of mania or hypomania. On the other hand, irritability in ADHD and ASD is situational and can often be predicted. Also, the severity of irritability in different disorders varies. For example, the irritability seen in DMDD and BD is often comparable, while patients with ODD often present with less severe irritability. ⁵

Emotional (dys)regulation is another multidimensional and transdiagnostic construct across various disorders. In addition, temper tantrums and defiance may be the presenting feature in both BD and ODD. Another related disorder is DMDD, and available evidence supports similar treatment recommendations—behavioral parent training and/or cognitive behavior therapy for ODD as well as DMDD.^6,7

Hence, both differentiating or concurrently diagnosing ODD and BD often becomes a contentious task. Often long-term follow-up is needed for the clarification of diagnosis, as seen in the index case. The episodic nature of BD, noticeable change in mood, and response to psychotropic medications are essential factors for differentiating between these 2 conditions. ODD-BD comorbidity in the adolescent population is a challenging presentation. Both disorders have the potential to significantly hamper the long-term growth of the individual besides having implications on the quality of life and functioning of the family. Hence, it requires both pharmacological and psychological therapy for optimum outcomes. In addition, further well-designed studies should be performed to establish nosological stability and utility and identify appropriate interventions in such cases.