Brain Injury & Bipolar Disorder
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Q:  Brain Injury & Bipolar Disorder


Dear Dr. Phelps,

My 15 yo daughter, Amy, had a serious head injury at age 3.  She was in an altered state of consciouness and totally non-responsive for over 2 hours.  Just starring and absolutely no body movement.  The ER did a Cat Scan which revealed no abnormalities and she eventually started responding.  We were sent home with no follow-up care.  Since that accident she would have intermittent rage episodes which progressively increased in intensity as she got older.  This rage episodes would happen in the classroom, around adults and be totally out of proportion to the event that triggered the rage.  Around age 11 we had her in therapy and thought the anger was resolved.  She made it through Jr. High and is now a Sophomore in High School.  

I was called by the school in May because Amy showed another student where she was cutting herself with razor blades.  The school therapist stated she thought Amy had turned to cutting because it was no longer appropriate to has rage attacks in front of peers.  She has been seeing a therapist and psychiatrist since May with trials of Welbutrin (made her very angry), Paxil (I thought she seemed better, but she stated it made her angry) and lastly Effexor which made her suicidal.  

I was called to the school September 25 because Amy gave another student a note stating she intended to end her life.  Her psychiatrist advised we take her to the ER for assessment.  The intake worker stated that if anything Amy was downplaying how depressed she was and the fact that she was cutting herself on her hip greatly disturbed him.  She stated she had taken an overdose of homeopathic sleeping pills a month or so before and admitted to feeling suicidal.   She was admitted inpatient for 6 days and is currently on 1000 Depakote ER with 50mg of Seroquil evenings.  She just finished 8 days of Intensive Day Treatment and will return to school Monday.  

So here's my question:

The Depakote seems to be working which would imply some form of Bipolar.  Her therapist (before the hospitalization) stated she thought she had a personality disorder. Her therapist at day treatment stated Amy sees everything in Black or White (no gray). She has many ADD qualities, gifted but failing in school.  We just qualified for an IEP. Could the head injury she suffered at age 3 cause her to become bipolar?  There's no history of bipolar in our families, lots of depression thou.  I am so confused and depending on who you talk to I get a different answer.  The school is sending Amy to Marionjoy Brain Center to undergo neuropsychological testing.  If her problems are from the brain injury would she still benefit from the mood stabilizer (which she is).

Any feedback would be appreciated.

Sincerely

Dear Ms. D'
Bipolar disorder has been seen in association with traumatic brain injury when there was little hint of it prior to that time (and after strokes as well). So that's a yes.  You have already grasped another important principle:  after a while, when there are conflicting diagnostic impressions repeatedly, one simply has to proceed what we doc's would call (to make ourselves feel better) "empirically", meaning we don't really have a good explanation but heck we've got to treat the symptoms in any case because they're severe enough to justify the risks associated with medications, so we just start trying things based on the best logic we can muster at the time (which, as you point out, can improve as the results of medication trials are added to the data on which to proceed).  Thus "If her problems are from the brain injury would she still benefit from the mood stabilizer (which she is)" is a correct statement as well as a question the answer to which is based on this "empirical" logic you already figured out.  Ask her doctor about proceeding "empirically" and treating as though she had bipolar disorder, since the Depakote seemed to work (you could read more about that treatment approach on my website about a variation of bipolar disorder called BPII; see therein the essay about
bipolar and "borderline personality disorder" as well, in which you'll see the "empiric" theme return). 

Dr. Phelps

Published November, 2001

 

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