Mood Charting

April 29, 2010 · Posted in · Comment 

What is Life Charting?

A life chart is a systematic collection of retrospective (past) and prospective (current) data on the course of illness and treatment recorded by a patient and/or clinician on the retrospective (by month) and prospective (by day) Life Chart Methodology (LCM) forms.

On each life chart, the horizontal line across the middle of the chart represents the baseline (euthymia, neither depressed nor hypomanic or manic) and the dateline. Retrospective life charting is done monthly and prospective ratings are done daily. Hypomania and mania are charted above the dateline, and depression is charted below the dateline, creating a graphical picture of mood fluctuations above and below normal over time. Any hospitalization (for mood) is considered a severe episode and is completely darkened for easy recognition.

Dotted lines represent estimated episodes (unsure of date). Ultra-rapid (four or more episodes per week) or ultradian (rapid mood shifts within a day) cycling is indicated by vertical lines. Treatments, including medications and psychotherapy, are charted above the top of the mania section. Comorbid symptoms, such as alcohol and/or substance abuse, anxiety, panic attacks, and others are recorded below the depression section. Significant life events are charted below the comorbidity section with an impact rating from -4 (very negative) to +4 (very positive), with 0 representing no impact.

What is the History of Life Charting?

At the beginning of the twentieth century, the German psychiatrist Dr. Emil Kraepelin first distinguished manic-depressive (or bipolar) illness from schizophrenia. His approach to recording and delineating the course of affective illness was the basis for the National Institute of Mental Health Life Chart Methodology (NIMH-LCM™).

Dr. Kraepelin’s early life chart graphs charted episodes at monthly intervals with color codes (e.g. red for mania, lighter red for hypomania, dark and light blue for severe and mild depression, respectively). Dr. Kraepelin’s early studies found that patients often undergo a progressive increase in cycle frequency, or a decrease in the well interval between episodes; that initial episodes were often triggered by external events, but later episodes emerged spontaneously; and that affective illness tended to continue in families (genetic vulnerability).

The NIMH-LCM was developed in the 1980’s based on Dr. Kraepelin’s principles of charting the course of affective illness (Roy-Byrne et al., 1985, Acta Psychiatrica Scandinavica [Suppl.] 71: 1–34; Post et al., 1988, Am J Psychiatry 145: 844–848). This method was then further developed, codified, and computerized (Leverich and Post, 1996, Current Review of Mood and Anxiety Disorders 1: 48–61; 1998, CNS Spectrums 3: 21–37). The availability of so many new medications and other treatments for bipolar disorder has made it more important than ever to track the course of illness and the response to treatment. The knowledge of a patient’s past course of illness, such as prior number of episodes, illness pattern, and treatment response, can have a significant impact on the choice of current and future treatment strategies.

Does Life Charting Work?

Hundreds of patients have used the NIMH-LCM successfully to keep track of their illness. Many different patterns of illness were unknown to both patients and their physicians before a life chart was constructed. The life chart also provides a portable psychiatric history for patients, useful when changing treatment providers or settings.

Is life charting accurate, however? In other words, is life charting consistent and dependable when repeated (reliability), and does it measure what it is supposed to measure (validity)?

Two different studies have confirmed both the validity and reliability of the NIMH-LCM. In 1997, Denicoff et al. (J Psychiatric Res; 31: 593–603) found that the Prospective Life Chart (LCM-p) reliability was extremely consistent between two different raters in 27 bipolar patients, over a two-week period of daily ratings by each rater. To assess validity, Denicoff et al. correlated LCM-p depression and mania ratings with other more established rating scales, such as the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI), the Young Mania Rating Scale (YMRS), and the Global Assessment Scale (GAS). They found statistically significant correlations between the LCM-p depression ratings and the two depression scales (HRSD and BDI), between the LCM-p mania ratings and the YMRS, and between the LCM-p average severity rating and the GAS.

In a second study (Psychological Med 2000; 30: 1391–1397), Denicoff et al. compared LCM-p ratings in 270 bipolar patients to the Inventory of Depressive Symptomatology-clinician rated (IDS-C) scale, the YMRS, and the Global Assessment of Functioning (GAF) scale. Again, the validity of the NIMH-LCM was confirmed, this time in a study with a much larger number of patients. Statistically significant correlations were found between severity of depression ratings on the LCM-p and the IDS-C, between LCM-p mania ratings and the YMRS, and between LCM-p average severity of illness ratings and the GAF.

A study of the NIMH-LCM in the Netherlands found that most of the patients found it worthwhile, and were able to complete their life charts with minimal outside assistance (Honig et al., 2001; Patient Education and Counseling 43: 43–48).

Track Your Moods with Life Charting

January 14, 2011 · Posted in Resources · Comment 

If you have unipolar depression or bipolar disorder and are having trouble stabilizing your mood, we recommend nightly charting of mood, medications and side effects on the easy-to-use Monthly Mood Chart Personal Calendar (pictured below) or the National Institute of Mental Health Life Chart (NIMH-LCM), both of which are available for download.

Sample Mood Chart

Sample Mood Chart

Click on the Life Charts tab above to download the personal calendar, which includes space for rating mood, functioning, hours of sleep, life events, side effects, and other symptoms such as anxiety.  Then bring the chart to each visit with your physician to help in the assessment of treatments.

Life charting can help determine which medications are working partially and need to be augmented further, and which need to be eliminated because of side effects.  Since there are now many potential treatments for depression and bipolar disorder (some FDA-approved and some not), a careful assessment of how well each new treatment works for a particular patient is essential to finding the optimal treatment regimen.

Ziprasidone Improves Mood With Possible Weight Loss Side Effects

September 28, 2011 · Posted in Current Treatments · Comment 

weight lossIn an open study of bipolar disorder treatment, Shefali Srivastava, Terence Ketter and colleagues at Stanford University evaluated ziprasidone as an aid to patients unresponsive to other medications. This study was part of the multi-center research program Systematic Treatment and Evaluation Program for Bipolar Disorder, or STEP-BD. During naturalistic treatment, ziprasidone was added to an average of 3.6 other psychotropic medications and 1.2 other nonpsychotropic medications patients had already been prescribed. The researchers found substantial improvement in mood with ziprasidone, particularly in the patients who had symptomatic levels of depression at baseline. The research team also observed a mean weight decrease from 195 + 50lbs at baseline to 183 + 47lbs at the final visit, with 34.3% of the patients achieving at least a 7% weight loss with ziprasidone.

Mean trial duration was 860 + 700 days, with no subsequent psychotropic agents added in 51.2% of the patients who had a mean trial duration of 221 + 272 days. Ziprasidone was discontinued in 57.3% of the 82 trials after a mean of 208 + 364 days. This was due to side effects in 26.8% of the participants and due to inefficacy for mood in 23.2%.

The investigators concluded that in bipolar patients treated naturalistically with complex pharmacotherapy, ziprasidone decreased overall bipolar illness severity, was helpful in patients with substantial depression at baseline, and also yielded clinically significant weight loss in about one-third of the patients.

Editor’s note: These data are notable because they support ziprasidone’s pattern of weight neutrality and because of the overall improvement in mood symptomatology the drug brought about. Read more

New, More User-Friendly Mood Chart!

October 11, 2010 · Posted in About the BNN, Resources · Comment 
Sample Mood Chart

Sample Mood Chart

We’ve just posted a more attractive and user-friendly mood chart you can use to keep track of your illness, how you respond to your medications, and any side effects you may experience.  See Life Charting for Patients, or download the chart here:

Monthly Mood Chart

You can print extras of pages 5 and 6 for each following month.

What is Life Charting?

May 19, 2010 · Posted in · Comment 

What is Life Charting?

A life chart is a systematic collection of retrospective (past) and prospective (current) data on the course of illness and treatment recorded by a patient and/or clinician on the retrospective (by month) and prospective (by day) Life Chart Methodology (LCM) forms.

On each life chart, the horizontal line across the middle of the chart represents the baseline (euthymia, neither depressed nor hypomanic or manic) and the dateline. Retrospective life charting is done monthly and prospective ratings are done daily. Hypomania and mania are charted above the dateline, and depression is charted below the dateline, creating a graphical picture of mood fluctuations above and below normal over time. Any hospitalization (for mood) is considered a severe episode and is completely darkened for easy recognition.

Dotted lines represent estimated episodes (unsure of date). Ultra-rapid (four or more episodes per week) or ultradian (rapid mood shifts within a day) cycling is indicated by vertical lines. Treatments, including medications and psychotherapy, are charted above the top of the mania section. Comorbid symptoms, such as alcohol and/or substance abuse, anxiety, panic attacks, and others are recorded below the depression section. Significant life events are charted below the comorbidity section with an impact rating from -4 (very negative) to +4 (very positive), with 0 representing no impact.

What is the History of Life Charting?

At the beginning of the twentieth century, the German psychiatrist Dr. Emil Kraepelin first distinguished manic-depressive (or bipolar) illness from schizophrenia. His approach to recording and delineating the course of affective illness was the basis for the National Institute of Mental Health Life Chart Methodology (NIMH-LCM™).

Dr. Kraepelin’s early life chart graphs charted episodes at monthly intervals with color codes (e.g. red for mania, lighter red for hypomania, dark and light blue for severe and mild depression, respectively). Dr. Kraepelin’s early studies found that patients often undergo a progressive increase in cycle frequency, or a decrease in the well interval between episodes; that initial episodes were often triggered by external events, but later episodes emerged spontaneously; and that affective illness tended to continue in families (genetic vulnerability).

The NIMH-LCM was developed in the 1980’s based on Dr. Kraepelin’s principles of charting the course of affective illness (Roy-Byrne et al., 1985, Acta Psychiatrica Scandinavica [Suppl.] 71: 1–34; Post et al., 1988, Am J Psychiatry 145: 844–848). This method was then further developed, codified, and computerized (Leverich and Post, 1996, Current Review of Mood and Anxiety Disorders 1: 48–61; 1998, CNS Spectrums 3: 21–37). The availability of so many new medications and other treatments for bipolar disorder has made it more important than ever to track the course of illness and the response to treatment. The knowledge of a patient’s past course of illness, such as prior number of episodes, illness pattern, and treatment response, can have a significant impact on the choice of current and future treatment strategies.

Does Life Charting Work?

Hundreds of patients have used the NIMH-LCM successfully to keep track of their illness. Many different patterns of illness were unknown to both patients and their physicians before a life chart was constructed. The life chart also provides a portable psychiatric history for patients, useful when changing treatment providers or settings.

Is life charting accurate, however? In other words, is life charting consistent and dependable when repeated (reliability), and does it measure what it is supposed to measure (validity)?

Two different studies have confirmed both the validity and reliability of the NIMH-LCM. In 1997, Denicoff et al. (J Psychiatric Res; 31: 593–603) found that the Prospective Life Chart (LCM-p) reliability was extremely consistent between two different raters in 27 bipolar patients, over a two-week period of daily ratings by each rater. To assess validity, Denicoff et al. correlated LCM-p depression and mania ratings with other more established rating scales, such as the Hamilton Rating Scale for Depression (HRSD), the Beck Depression Inventory (BDI), the Young Mania Rating Scale (YMRS), and the Global Assessment Scale (GAS). They found statistically significant correlations between the LCM-p depression ratings and the two depression scales (HRSD and BDI), between the LCM-p mania ratings and the YMRS, and between the LCM-p average severity rating and the GAS.

In a second study (Psychological Med 2000; 30: 1391–1397), Denicoff et al. compared LCM-p ratings in 270 bipolar patients to the Inventory of Depressive Symptomatology-clinician rated (IDS-C) scale, the YMRS, and the Global Assessment of Functioning (GAF) scale. Again, the validity of the NIMH-LCM was confirmed, this time in a study with a much larger number of patients. Statistically significant correlations were found between severity of depression ratings on the LCM-p and the IDS-C, between LCM-p mania ratings and the YMRS, and between LCM-p average severity of illness ratings and the GAF.

A study of the NIMH-LCM in the Netherlands found that most of the patients found it worthwhile, and were able to complete their life charts with minimal outside assistance (Honig et al., 2001; Patient Education and Counseling 43: 43–48).

Life Charting for Patients

May 19, 2010 · Posted in · Comment 

About Life Charting

Would you like to be able to keep track of all aspects of your bipolar illness on one simple form?  Life charts have proven to be invaluable aids in managing bipolar illness for thousands of patients.  Download them below.

In the past you have probably been asked many questions about your illness by doctors and/or therapists, and by family members or friends who were concerned about your well-being. It can be difficult, however, to remember things on the spot, and important facts could be left out that would be useful for your doctor or therapist to know when trying to decide on a next step for treatment. You already know that you benefit from being an informed and knowledgeable participant in your treatment process. We think that the life chart can be a valuable tool in helping you organize and visually present the past course of your illness.

By constructing your own life chart, you are creating a portable psychiatric history of your illness in the form of an easily understandable graph or picture that you and your physician can review together, change where necessary, consult when important decisions about your treatment are being made, and continue to use as a way of monitoring your current course of illness and treatment response through daily prospective life-charting.

Downloading Life Chart Forms and Manuals:

The patient life chart manuals and forms are in Adobe Acrobat *.pdf form. Adobe Acrobat Reader is a free program that you can download from the internet at: http://www.adobe.com/products/acrobat/readstep2.html

Patient Prospective Forms and Manuals, for charting your current illness and medications:

The most user-friendly version of the mood chart for charting your ongoing illness, medications, and any side effects: Monthly Mood Chart Personal Calendar

Sample Mood Chart

Sample Mood Chart

 

The National Institute of Mental Health Life Charting Method Forms:

Patient Prospective Form

Patient Prospective Manual

Patient Retrospective Forms and Manuals, describing your past history of illness:

Patient Retrospective Form

Patient Retrospective Manual

Preventing Illness in the Offspring of a Parent with Bipolar Disorder

April 18, 2019 · Posted in Potential Treatments · Comment 

family with boy

A 2018 article by researcher Robert Freedman and colleagues in the American Journal of Psychiatry reported that prenatal nutritional supplements can reduce mental illness in at-risk offspring. The article made a good case for supplementation with folate, phosphatidylcholine, and vitamins A and D.

Here we describe some additional ways to minimize risk of mental illness in children who are at risk for bipolar disorder or other mental illnesses.

Some efforts at prevention can begin even before a child is conceived. Avoiding smoking or drinking alcohol and maintaining a nutritious diet to prevent inflammation and excessive weight gain before conception could reduce adverse epigenetic effects on the offspring. Epigenetics refers to environmental influences on gene transcription. The impact of life experiences such as a mother or father’s substance use is not registered in their child’s DNA sequence, but can influence the structure of the child’s DNA or its packaging.
Maternal good health and wellbeing during pregnancy has also been shown to improve neonatal health and functioning.

Once a child is born, they can be encouraged in healthy habits, including a nutritious diet, good sleeping habits, regular vigorous exercise, and mindfulness/meditation training (which pediatric psychiatrist James Hudziak has suggested should be universal).

For a child who is beginning to develop mood or behavioral symptoms, more intensive intervention may be prudent. Research supports the effectiveness of family interventions such as family-focused therapy (FFT) for youth with depression, cyclothymia, or bipolar disorder not otherwise specified (BP-NOS) and a family history of bipolar disorder. Researcher David J. Miklowitz described the effects of this intervention in a 2013 article in the Journal of the American Academy of Child and Adolescent Psychiatry.

Depression in children 3 to 6 years of age is as common as depression in older children (with rates around 1–2%), and robust improvements have been observed when families engage in parent child interaction therapy (PCIT) with a focus on emotional development. In PCIT, parents are coached while interacting with their children and encouraged to establish warm interactions while setting appropriate limits. In a study by Joan L. Luby and colleagues published in the American Journal of Psychiatry in 2018, using PCIT modified to include an emotional development component improved depression and associated symptoms in children aged 3 to 11, and it also improved mothers’ mood and behavior. Read more

Treatment Approaches to Childhood-Onset Treatment-Resistant Bipolar Disorder

May 14, 2018 · Posted in Potential Treatments · Comment 

Dear readers interested in the treatment of young children with bipolar disorder and multiple other symptoms: In 2017, BNN Editor Robert M. Post and colleagues published an open access paper in the journal The Primary Care Companion for CNS Disorders titled “A Multi-Symptomatic Child: How to Track and Sequence Treatment.” The article describes a single case of childhood-onset bipolar disorder shared with us via our Child Network, a research program in which parents can create weekly ratings of their children’s mood and behavioral symptoms, and share the long-term results in graphic form with their children’s physicians.

Here we summarize potential treatment approaches for this child, which may be of use to other children with similar symptoms.

We present a 9-year-old girl whose symptoms of depression, anxiety, attention-deficit hyperactivity disorder (ADHD), oppositional behavior, and mania were rated on a weekly basis in the Child Network under a protocol approved by the Johns Hopkins School of Medicine Institutional Review Board. The girl, whose symptoms were rated consistently for almost one year, remained inadequately responsive to lithium, risperidone, and several other medications. We describe a range of other treatment options that could be introduced. The references for the suggestions are available in the full manuscript cited above, and many quotes from the original article are reprinted here directly.

As illustrated in the figure below, after many weeks of severe mania, depression, and ADHD, the child initially appeared to improve with the introduction of 4,800 micrograms per day of lithium orotate (a more potent alternative to lithium carbonate that is marketed as a dietary supplement), in combination with 1 mg per day of guanfacine, and 1 mg per day of melatonin.

mood chart

Despite continued treatment with lithium orotate (up to 9,800 micrograms twice per day), the patient’s oppositional behavior worsened during the period from November 2015 to March 2016, and moderate depression re-emerged in April 2016. Anxiety was also generally less severe from December 2015 to July 2016, and weekly ratings of overall illness remained in the moderate severity range (not illustrated).

In June 2016, the patient began taking risperidone (maximum dose 1.7 mg/day) instead of lithium, and her mania improved from moderate to mild. There was little change in her moderate but fluctuating depression ratings, but her ADHD symptoms got worse.
The patient had been previously diagnosed with bipolar II disorder and anxiety disorders including school phobia, generalized anxiety disorder, and obsessive compulsive disorder.
Given the six weeks of moderate to severe mania that the patient experienced in October and November 2015, she would meet criteria for a diagnosis of bipolar I disorder.

Targeting Symptoms to Achieve Remission

General treatment goals would include: mood stabilization prior to use of ADHD medications, a drug regimen that maximizes tolerability and safety, targeting of residual symptoms with appropriate medications supplemented with nutraceuticals, recognition that complex combination treatment may be necessary, and combined use of medications, family education, and therapy.

Mood Stabilizers and Atypical Antipsychotics to Maximize Antimanic Effects

None of the treatment options in this section are approved by the US Food and Drug Administration for use in children under 10 years of age, so all of the suggestions are “off label.” Further, they may differ from what other investigators in this area of medicine would suggest, especially since evidence-based medicine’s traditional gold standard of randomized placebo-controlled clinical trials is impossible to apply here, given the lack of research in children with bipolar disorder.

As we share in the original article, reintroducing lithium alongside risperidone could be effective, as “combinations were more effective than monotherapy in a study [by] Geller et al. (2012), especially when they involved an atypical antipsychotic such as risperidone. This might include the switch from lithium orotate to lithium carbonate,” the typical treatment for bipolar disorder, on which more research has been done. “Combinations of lithium and valproate were also more effective than either [drug alone]…in the studies of Findling et al. (2006),” and many patients needed stimulants in addition.

“Most children also needed combinations of mood stabilizers (lithium, carbamazepine, valproate) in the study [by] Kowatch et al. (2000).” In a 2017 study by Berk et al. of patients hospitalized for a first mania, randomization to lithium for one year was more effective than quetiapine on almost all outcome measures.

Targeting ADHD

“[The increased] severity of [the child’s] ADHD despite improving mania speaks to the…utility of adding a stimulant to the regimen that already includes…guanfacine,” which is a common non-stimulant treatment for ADHD. “This would be supported by the data of Scheffer et al. (2005) that stimulant augmentation for residual ADHD symptoms does not [worsen] mania, and that the combination of a stimulant and guanfacine may have more favorable effects than stimulants alone.”

However, the consensus in the field is that mood stabilization should be achieved first, before low to moderate (but not high) doses of stimulants are added. “Thus, in the face of an inadequate response to the lithium-risperidone combination in this child, stimulants could be deferred until better mood stabilization was achieved.”

Other Approaches to Mood Stabilization and Anxiety Reduction

“The anticonvulsant mood stabilizers (carbamazepine, lamotrigine, and valproate) each have considerable mood stabilizing and anti-anxiety effects, at least in adults with bipolar disorder. With inadequate mood stabilization of this patient on lithium and risperidone, we would consider the further addition of lamotrigine.

Lamotrigine appears particularly effective in adults with bipolar disorder who have a personal history and a family history of anxiety (as opposed to mood disorders), and it has positive open data in adolescents with bipolar depression and in a controlled study of maintenance (in teenagers 13–17, but not in preteens 10–12) (Findling et al. 2015). With better mood stabilization, anxiety symptoms usually diminish…, and we would pursue these strategies [instead of using] antidepressants for depression and anxiety in young children with bipolar disorder.”

“Carbamazepine appears to be more effective in adults with bipolar who have [no] family history of mood disorders,” unlike lithium, which seems to work better in people who do have a family history of mood disorders.

“While the overall results of oxcarbazepine in childhood mania were negative, they did exceed placebo in the youngest patients (aged 7–12) as opposed to the older adolescents (13–18) (Wagner et al. 2006).

“There are long-acting preparations of both carbamazepine (Equetro) and oxcarbazepine (Oxtellar) that would allow for all nighttime dosing to help with sleep and reduce daytime side effects and sedation. Although data [on] anti-manic and antidepressant effects in adults are stronger for carbamazepine than oxcarbazepine,” there are good reasons to consider oxcarbazepine. First, there is the finding mentioned above that oxcarbazepine worked best in the youngest children. Second, there is a lower incidence of severe white count suppression on oxcarbazepine. Third, it has less of an effect on liver enzymes than carbamazepine. However, low blood sodium levels are more frequent on oxcarbazepine than carbamazepine.

Other Atypical Antipsychotics That May Improve Depression

Read more

Preventative Treatment Should Begin After First Manic Episode

March 8, 2017 · Posted in Current Treatments · Comment 

teen with bipolar disorder

Evidence from multiple studies has indicated the importance of beginning preventative treatment, particularly with lithium, early in the course of bipolar disorder. A 2016 comprehensive literature review by researcher Katie Joyce and colleagues in the International Journal of Bipolar Disorders concluded that psychoeducation and medication are more effective in bipolar disorder when applied in earlier stages of the illness rather than later stages.

Several  studies suggest that treatment for bipolar disorder should be started specifically after the first manic episode.

A 2014 study by researcher Lars Kessing and colleagues in the British Journal of Psychiatry examined 4,700 patients treated with lithium in Denmark. Kessing and colleagues found that those who started treatment after one manic episode were less likely to find lithium ineffective than those who started later.

Another study by researcher Michael Berk and colleagues presented at the International Society for Bipolar Disorders found that after a first manic episode, a year of treatment with lithium was much more effective on all measures of outcome, including mania and depression ratings, brain imaging, and neuropsychological functioning, than a year when patients were randomized to quetiapine (Seroquel).

Researcher Lakshmi Yatham and colleagues presented research at the International Society for Bipolar Disorders showing that patients recovered from the neuropsychological deficits associated with a first episode of mania if they were well treated and had no further episodes, while those who had new episodes did not return to their baseline capabilities. This suggests that early treatment that prevents future episodes helps maintain a healthy brain.

Kessing and colleagues previously reported in the British Journal of Psychiatry in 2013 that patients randomized to two years of treatment in an outpatient clinic specializing in mood disorders following a first hospitalization for mania had 40% fewer recurrences of bipolar episodes over the next six years than those who received treatment as usual. These data indicate that early treatment, which may include psychotherapy, medications, mood charting (i.e. keeping a daily record of symptoms) and illness education, can improve the long-term course of illness. Lithium is often a key component of such treatment.

Editor’s Note: This type of intensive, ongoing treatment is not the norm after a first manic hospitalization in the United States, but it should be. Given the new data on the impact of starting lithium after a first episode of mania, and lithium’s superiority over quetiapine in the year following a first episode, lithium treatment should be standard following a diagnosis of bipolar disorder.

In the past, sometimes doctors have recommended waiting until a patient has had multiple episodes of mania before beginning preventative treatment with lithium. This now appears to be a mistake.

Lithium protects against depressive as well as manic recurrences, and there is also evidence that it increases hippocampal and cortical volume, helping prevent cognitive deterioration in those with mild cognitive impairment. Lithium is also the most effective mood stabilizer for preventing suicide, and it increases the length of telomeres (caps on the end of DNA strands), thus preventing a wide range of medical and psychiatric illnesses. Lithium may need to be combined with other drugs to achieve a complete remission, but using it after a first mania is a good place to start.

A PANS Case Study, Immune Treatment Reduced Psychiatric Symptoms

October 14, 2015 · Posted in Diagnosis · Comment 

infection in a young child

Pediatric acute neuropsychiatric syndrome (PANS) is a little-known syndrome in which a child has an acute onset of psychiatric symptoms following a bacterial or viral infection, when the antibodies generated to fight the infection instead attack neurons in the brain. The behavioral alterations can be severe and resistant to the usual psychotropic drug treatments. PANS often requires antibiotics and immune-targeted therapies.

The following is a case report of a real child who had a sudden onset of depression and violence after getting sick with the flu, pneumonia, and a strep infection at the age of 4. (Names have been changed for privacy.)

Anne contacted this editor (Robert M. Post) seeking a consultation on her 6-year-old son, Jake. Two years earlier, he had suddenly become difficult—depressed, angry, and even violent. This coincided with the emergence of obsessive compulsive symptoms and urinary incontinence. He went from being able to read short sentences in pre-kindergarten, to being cognitively dull and not even able to recognize letters of the alphabet. He had been diagnosed with a mood disorder, and Anne was told it was probably bipolar disorder. But he didn’t respond to any of the typical medications, and suffered side effects including hallucinations, nightmares, bowel accidents, and worsening depression.

The best results came with the atypical antipsychotic risperidone. While it didn’t reduce all of Jake’s symptoms, Anne described it as “heaven” compared to earlier treatments. But Jake’s levels of prolactin started to increase, and he lost bladder control, so he had to stop taking risperidone. Jake’s doctor tried 18 different medication regimens with 8 different medications in less than a year without finding one that worked well. Jake had a horrible time in school, and Anne fretted about the lack of an effective, stable medication, saying, “He’s actually worse than I’ve ever seen him.”

Dr. Post recommended that they consider using high doses of quetiapine and valproate for Jake’s aggression and behavioral dyscontrol, along with the antioxidant N-acetylcysteine and vitamin D3. However, given that Jake’s symptoms were severe, involved cognitive and neurological abnormalities, and had begun after a flu-like illness, and was unresponsive to conventional treatment, Dr. Post suggested that Anne get Jake checked out for PANS and start charting Jake’s mood on a daily basis.

Jake began taking higher doses of quetiapine and valproate, and improved to the point that Anne said they restrained him only once a day, rather than four times per day. But his behavioral dyscontrol continued. In one memorable incident, after feeling picked on by other children at a baseball game, he lashed out at Anne, kicking her in the face with his cleats and punching her glasses off her face.

Anne told Dr. Post that the family had visited a neurologist, who said that she had never heard of PANS and suggested that Anne would have to travel across several states to see Dr. Post if she wanted to pursue that diagnosis.

Dr. Post encouraged Anne to keep looking for a doctor who would take the PANS idea seriously. He sent her a comprehensive review article about PANS by Dr. Kiki Chang and colleagues published in the Journal of Child and Adolescent Psychopharmacology in 2014.

This past June, Anne found a doctor who understood PANS and was willing to run the appropriate tests on Jake. The tests revealed that Jake had at one time been infected with the bacteria mycoplasma. Read more

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