Is This From a Head Injury or Bipolar Disorder?
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Q:  Is This From a Head Injury or Bipolar Disorder?

My son Matthew 23yrs old OU graduate in Industrial engineering Honor student, says he fell and hit his head last July 15,2008,on the left side.

He says he was running across yard and feet went out from under him and and came down with great force on raise cement knocking him out. Know one saw this but he told some people shortly afterwards this accord.

He started slurring and lost his vision and after a 4 day period began to hallucinate .

He seemed to get better and saw Neurologist was told to go home and symptoms would go away in 3 to 6 months.

3 Days later he was sent home from work completely disoriented and having delusions , seeing things that were not there ,extremely hyper spent a week in local hospital , MRI EEG showed nothing, Had to take him to Houston to Methodist Hospital, Again MRI, EEG, showed nothing a PET scan may have shown something in Mid Brain.

His eyes would not respond to light, very small fixed pupils . Neurologist said he had not ever seen anything like this but prescribed Aricept about 3 times the normal dosage for a alzhimer patient . His vision came back in about a week.

Mood up and down ,anger, feeling of grandiose , his is only opinion , prescribed 800 MG a day of Seroguel, seems to of leveled of after 7 months seeing psychiatrist who thinks he is Bipolar.  As you can imagine lots of other things also happened. I believe he had head trauma. But not sure of Bipolar .

I know this is especially hard thing to ask since 2 Neurologist have said they did not know what it was or is.

What do you think?


Dear DJ’ –
Just one thought to offer here, as you already understand that: a) this is complicated, hard to figure out; and b) I have only what you’ve written to go by.

That thought: just make sure you don’t get stuck thinking “this isn’t bipolar disorder, this is a head injury”. That’s a false split.  He didn’t have bipolar disorder before the injury but he has manic symptoms now. So first you have to see that the symptoms are controlled (obviously he can’t do well unless that’s done). Then later will come the question – when he’s done well with symptoms fully controlled for at least several months, preferably over a year; I hope – as to whether he needs to stay on whatever treatments got him well, or whether he might dare taper them, one at a time, very slowly (e.g. 6 months per each treatment).

Related thought: since the early symptoms included visual hallucinations, that might be a really tiny clue (and might also be a red herring, but I’d factor it in were I running the show). Visual hallucinations are unusual in bipolar mania (auditory hallucinations are not; they’re common, though that’s poorly understood by a lot of people, including even some psychiatrists). Visual hallucinations might signal a more “neurologic” kind of problem here (the neurologists might agree; they were trying to treat this instead of saying “take your son to a psychiatrist, this is not our territory”, which they would probably say if someone showed up with auditory hallucinations and grandiosity).

By “neurologic” I mean that the brain disturbance might be more like epilepsy (abnormal firing of neurons) or a stroke (some damaged neurons); versus bipolar disorder, which is thought to be more like a mismatch between growth and atrophy control systems, not cell damage as such, or out-of-control neuron firing.

And if that’s true, it’s more “neurologic” in this sense, that might mean a slight shift is warranted in choosing among treatments (this will only be necessary if he’s not getting better; if that’s already happening, ignore this). Or at least I’d be thinking about a slight shift in how I rated the options, as follows: usually the options for psychotic mania include “antipsychotics”. Often these are relied upon heavily, in fact. Seroquel is one, and your son’s dose is in the antipsychotic range (it can be used at lower doses to target bipolar depression). That’s fine, if it works. If it doesn’t, and here’s the shift, I’d lean toward the anti-seizure medications also used in bipolar disorder. The two main candidates to consider are valproate (Depakote; divalproex generic) and carbamazepine (and perhaps it’s close cousin oxcarbazepine, which has fewer risks but may have less clout also). Although another anticonvulsant, lamotrigine, is also often used, it does not have anti-manic effects, at least not directly, we think, so in your son’s case it would not be as obvious a choice.

The point of all that is that sometimes people get focused on the psychotic symptoms (delusions, hallucinations) and think they need an “antipsychotic”. Even the name rather suggests this is an obvious medication to use, right? But antipsychotics might be the best for your son; or might not be such an obvious choice, in his case, because: a) some people hate the way they feel on these medications if they don’t really need the antipsychotic effect, they just need an antimanic effect (which the antipsychotics do provide, but they also have a direct effect on thought processes, usually making people feel like it’s harder to think properly compared to their usual normal); and b) for a more “neurologic” kind of mania, they may be actually a bit off target, whereas the anticonvulsants – because their target is abnormal neuron activity – is closer to the mark.

For example, or to carry this logic just a little further, an EEG that’s normal doesn’t necessarily mean there is no epileptic activity taking place.  The EEG is not a perfect test. It can miss some. Deep in the temporal lobe – the side of the brain one might injure by falling on the side of one’s head – is known to be particularly poorly scanned by scalp electrodes used in the standard EEG.  So if an anticonvulsant can be used just on the basis of it’s known anti-manic effects, there’s a potential here for getting two for one: the manic symptoms and any possible underlying seizure-like activity that didn’t happen to turn up on the EEG. 

Tricky logic. I hope you can see why I thought it was worth writing this all out. Sometimes psychiatrists are a little slow to come around to this way of thinking. They see psychosis and they want to use an antipsychotic, end of story.  Well, that’s my point of view anyway. Now, whether this applies to your son or not is a different question, one which I can’t really know. But now you know it; just in case you need it (that is, just in case you need to wonder out loud, if things aren’t going well, “you know, I heard that the EEG sometimes misses deep epileptic activity; in other words, it gives a false negative test result?  And if that was the case here, maybe using an anticonvulsant that could treat manic symptoms would be worth considering just in case it could hit both targets?”)

I hope things proceed more simply than that.  Good luck with the process –

Dr. Phelps

Published May, 2009


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