Dr. Phelps,
You may be our guardian angel. Our daughter 8, has had mean with extremely odd mood  swings since 2. She has generalized seizures (front lobes), but doctors don't think it could cause such weird moods. It is strange that  she wakes up every morning fine, then she slips into this very irritable difficult mood, with no focus. It happens everyday.   We have her eating fish and veggies, to see if its a food allergy, but its no help. She bumps into things, can't complete a task when the reaction starts.  Her eyes have a black look to them, and they seem to shift back and forth slightly. My husbands mother has epilepsy, and my brother has ocd. I don't know of any bi-polar in the family. We had her on trileptal, which improved her focus, but she had a bad rash from it. Going to bed at night is the worst! She starts hitting and going completely odd. We are totally lost. The slightest bit of sugar or starch seems to make her worse. You sound like your very compassionate and we are praying for some advice from you that may help. She does want to hurt herself and me (her mother) when she is feeling really out of control. She only gets really out of control after eating sugar. and some packaged foods. Does this sound like the seizures or bi-polar to you?
    

Dear Ms. C. --

Bipolar or epilepsy? Let's see, does it really matter at this point?

In the long run, it will matter: it may give you a sense of prognosis -- how this is likely to look over time. For example, in epilepsy, the goal would be to have no such symptoms, and you would not expect to have any mood symptom problems showing up either. By comparison, in bipolar disorder, you might get these major symptoms under control yet still see some mood symptoms showing up from time to time. 

Nevertheless, in each case, the goal would be to press forward, pursuing treatment options, until symptoms or behaviors that seemed to be associated with some sort of sudden shift in focus and energy were no longer occurring. The reason for this goal is that when both bipolar disorder and epilepsy, the current working supposition is that when some symptoms remain, the condition is more likely to continue to default, potentially becoming more difficult to treat, over time. This does not happen in everyone, but it happens often enough to keep making us want to pursue that goal of "zero symptoms".

Therefore, in your daughter's case, right now I'm not sure that it makes very much difference whether you think of this as epilepsy or as bipolar disorder. The goal is the same: her symptoms sound sufficiently severe to warrant a fairly aggressive effort to get them under control. One anticonvulsant, Trileptal, has so far shown some benefit. There are numerous others which have also been used in the treatment of bipolar disorder. So the least to consider those options, differentiating between these two diagnostic ways of thinking is not crucial. 

These anticonvulsants include lamotrigine -- which also can cause a rash, quite often in children, and so must be started with great caution, beginning with as little as one quarter of the usual standard recommended doses for starting an adult. (The typical starting dose in an adult is 25 mg, and when I am trying to be ultra-cautious, even in an adult, I will use the 5 mg pediatric dose, increasing by that increment per week. You could discuss that with your daughter's current physician -- whether that is a neurologist, or a psychiatrist, both should be familiar with this strategy. 

Since lamotrigine is not associated with weight gain, as is the other main alternative, Depakote, it may be preferable even though the rash risk is definitely of concern. By comparison, Depakote (although it too can cause a rash, though more rarely) can cause a problem called polycystic ovarian syndrome (PCOS) which is associated with both weight gain and some hormone changes that are not good, especially in a young girl.

After anticonvulsants, then the issue about diagnosis becomes more prominent, because then there are numerous other medication approach is for these kinds of symptoms, but they are not routinely used in epilepsy, and some of them can actually make an epileptic condition somewhat worse (particularly a family of medications which technically are "antipsychotics"; see that link to understand why such a medication could be of value even though her symptoms do not currently include psychosis).

But for now, the fact that she "bumps into things" when their reaction starts, still -- in my view, based on what you have written here -- makes the "seizure" way of thinking about all this more appropriate. That is, bipolar disorder does not cause such problems with muscle control, or balance, or whatever might be the basis of this symptom your daughter experiences. If in the long run this is indeed more like an epilepsy condition, continuing to pursue help from neurologists, including second or third opinions, would end up being more productive than seeing a psychiatrist. 

There is a test called a "video EEG", where the patient has brain recordings obtained while his or her behavior is filmed, so that correlation between the two can be drawn if possible. If your daughter has not had this, that might be worth asking about. Unfortunately, however, if it is "negative"; meaning that the test is not demonstrate a connection between brain activity and behaviors; this does not necessarily mean that the basis of the behavior is "psychological". It could still be a seizure condition that the test cannot detect, for example because the starting point for the seizure is too deep in the temporal lobe, where the test is not very sensitive. When this test is negative, there is a tendency for the neurologists to use the term "pseudo-seizures", which in my experience means "we cannot be held responsible for treating this, it is not our problem, you need to see a psychiatrist". I mention this just to warn you that even if that is what you are told ("pseudoseizures"), this does not necessarily mean you should give up on the neurologic angle, i.e. the possibility that this is a seizure-like condition more than a mood-based condition. This is the point at which a second or third neurologic opinion could be useful. All of this may require going to multiple specialists, or even significant travel to a regional specialty center.

I hope some of that might be of use. Good luck with the process --

Dr. Phelps



Published January, 2008