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.
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).
Published November, 2001