Staying Up at Night: Overlapping Bipolar and Obsessive-Compulsive Disorder Symptoms in an Adolescent with Autism Spectrum Disorder.

[Author Affiliation]Philip Cawkwell. 1 Department of Psychiatry, New York University School of Medicine, New York, New York.Ashley Lawler. 2 Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts.Eleni Maneta. 2 Department of Psychiatry, Harvard Medical School, Boston Children's Hospital, Boston, Massachusetts.Barbara J. Coffey. 3 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemS. was a 16-year-old girl with a reported history of major depressive disorder (MDD), generalized anxiety disorder (GAD), obsessive-compulsive disorder (OCD), nonverbal learning disability (NVLD), and autism spectrum disorder (ASD). S. was admitted to an acute inpatient psychiatric unit because of worsening intrusive thoughts and active suicidal ideation (SI) with a plan.History of Present IllnessS. had a history of anxiety and depression beginning in childhood. She began to experience the onset of OCD symptoms, including preoccupation with contamination, at the age of 10, and began seeing a therapist at that time. S. then started to experience worsening depressive symptoms, including low mood, increased sleep, poor concentration, and fatigue, and was referred to a psychiatrist who started her on sertraline 75 mg at 12 years of age. There was minimal improvement, and S. was subsequently hospitalized for the first time after an incident of cutting and suicidal ideation. During this 2 week hospitalization, S.'s medication was switched to fluoxetine, which was titrated up to 30 mg. S. was discharged to an intensive short-term acute residential unit, but ultimately re-presented to the inpatient unit after 3 days, because of worsening intrusive thoughts and suicidal ideation while at the residential facility. This second hospitalization lasted 9 days, after which S. stabilized and was discharged back to the community on fluoxetine 40 mg.S. did well for ∼1 year, but after school ended the following year, she was referred to the emergency department (ED) after 2 weeks of worsening anxiety, depression, and suicidal ideation with a plan. It is of note that S. was no longer experiencing OCD symptoms, but had significant worsening of her anxiety. During this hospitalization, her fluoxetine was increased to 80 mg, and she was discharged in good condition. After this hospitalization, S. underwent psychoeducational testing; additional diagnoses of ASD and nonverbal learning disability were made.S. reportedly did very well in the 3 years between the last admission and her most recent hospitalization; OCD symptoms were well controlled and her depression and anxiety seemed to stabilize. Approximately 9 months prior to the current admission, S. started to report some worsening in her mood again, and her psychiatrist added bupropion extended-release to her fluoxetine. This did not provide adequate relief, and S. was tapered off fluoxetine and started on venlafaxine, which was titrated up to 112.5 mg. S. did well for a few months, but during the winter holiday from school she decompensated, with worsening depression and anxiety. She was subsequently switched from venlafaxine to lamotrigine, because of both family history of bipolar disorder, and increased irritability that had been noted. Cognitive rigidity was also noted at that time, and ziprasidone 40 mg was added as a stabilizing agent. Although these medication changes seemed to improve her depression, the outpatient psychiatrist noted that S.'s anxiety had worsened again.S. and her mother agreed that S. had begun to decompensate rapidly in the 4 weeks prior to this current admission following the end of the school year. …