J. Indian Assoc. Child Adolesc. Ment. Health 2018; 14(4): Case report

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1 125 J. Indian Assoc. Child Adolesc. Ment. Health 2018; 14(4): Case report Methylphenidate induced acute psychosis in a case with mild intellectual disability and ADHD Brajesh Mahawer, Jitender Aneja, Naresh Nebhinani Address for correspondence: Department of Psychiatry, All India Institute of Medical Science, Jodhpur, Rajasthan, , India. drnaresh_pgi@yahoo.com Abstract Methylphenidate (MPH) is used as the first line drug for treating the attention deficit hyperactive disorder (ADHD). Therapeutic dose of MPH is known to causes psychotic symptoms in a small number of cases and these symptoms usually disappear on discontinuing MPH. Here we describe a case of 11 years old boy with diagnosis of ADHD and mild intellectual disability, who was treated with methylphenidate and later developed acute psychosis. Keywords: Methylphenidate, Attention deficit hyperactive disorder, psychotic symptoms Introduction Methylphenidate (MPH) is a central nervous system (CNS) stimulant drug, commonly prescribed for treating attention deficit hyperactive disorder [1]. It acts by blocking the dopamine and norepinephrine transporter and D1 receptor activation in postsynaptic neurons which leads to increased concentration of dopamine within the brain. It improves attention and concentration, maintains alertness, controls activity and behavioral problems [2]. MPH also has off label prescription for treatment resistant depression and narcolepsy [3]. Therapeutic dose of methylphenidate rarely causes psychotic symptoms and FDA reported stimulant induced psychosis in 0.25% children receiving therapeutic dose of stimulant. Here we present a case of

2 year-old boy with diagnosis of ADHD and mild intellectual disability, who was treated with methylphenidate and later developed acute psychosis. Case report An 11-year-old boy, born by full term normal vaginal delivery, but had significant global delay in developmental milestones. At home, he would not sit at one place, had very high energy levels, could not sustain attention even in tasks of his interest like watching cartoon on TV, often ran when expected to walk and jumped in bed or even from height without knowing the consequences of his action. He would interrupt the elders, could not follow the commands of parents, often shouted at them if his demands were not met, since age of 7 years. In view of these problems, he was brought to us for evaluation. There was no past history of head injury, epilepsy, fever and psychosis or family history of psychosis or other psychological disorders. His intelligence quotient (measured on Stanford Binet scale, Developmental screening test and Vineland social maturity scale) score was 65. In view of this he was diagnosed with mild intellectual disability and attention deficit hyperkinetic disorder, combined type by using DSM-5 criteria. He was rated on Vanderbilt ADHD diagnostic parent rating scale and scored 64. His body weight was 28 kg, height was centimeters and no physical abnormality was detected during general physical examination. His complete blood count, liver function test, kidney function test, thyroid function test, blood sugar, and serum electrolytes were within normal limits and no abnormality was detected on MRI brain. He was prescribed methylphenidate 10 mg/day and in view of no response, after 15 days dose was hiked to 20 mg/day. On 10 th days of 20 mg MPH dose (and 25 th day of MPH prescription), he started remaining fearful with reporting that his toys would kill him, and also started talking to himself, smiling inappropriately, and gesturing into the air. His sleep, appetite and self care were also reduced. He was brought to us

3 127 within a day of onset of these symptoms. On brief psychiatric rating scale (BPRS) he was scored 40. Methylphenidate was stopped and only gave clonazepam 0.5 mg twice in a day. In view of previous literature, that showed MPH induced psychotic symptoms tend to remit once the offending drug is taken off, we did not add any antipsychotic agent. The child remitted within a week and after a gap of 2 weeks, we introduced Atomoxetine 10 mg/day which was gradually hiked up to 25 mg/day. The child responded well to Atomoxetine with more than 50% improvement in his ADHD symptoms, scored 24 on Vanderbilt ADHD diagnostic parent rating scale. The various non-pharmacological interventions done in the index patient included parental psycho-education and training (based on behavioral principles), play therapy and social skills training for the child. Discussion Stimulant medications at higher doses can induce symptoms of mania and psychosis that are highly similar to those of bipolar disorder or schizophrenia like illnesses [4]. MPH induced psychosis is an uncommon event, without any clear association with age, gender, past and family history of psychiatric illness but drug should be used with caution in person with family history of affective disorder [5]. Methylphenidate has a high abuse potential in oral, intranasal and intravenous ways of application, abuse of this medication associated with psychosis [6]. The onset of psychosis with MPH does not seem to be related to the doses administered as previous case reports have mentioned occurrence in very low to high doses [4, 5, 7, 8, 9]. Similarly, the relation of occurrence of psychosis and duration of MPH therapy is also not consistent with its onset within a few days of start to months of therapy [4, 5, 7, 10].Immediate cessation of stimulant medication is the management of choice in a case of stimulant induced psychosis and symptoms were

4 128 resolved within few days to a week [12]. But in some case reports antipsychotic drugs were added to manage psychotic symptoms after discontinuation of MPH [5, 7]. Till date, there is no strong evidence that MPH induced acute psychosis increases future risk of psychotic illness. Thus, there is no need for prophylactic use of antipsychotic medicine. But some literature mentioned that individuals with psychotic disorders previously exposed to prescription stimulants will have an earlier onset of psychosis which associated with poor long term function and worst prognosis [13]. The mechanism by which psychotic symptoms occur during MPH treatment in small proportion of patient is unclear. The possibility may include genetic predisposition, catecholaminergic hypersensitivity and idiosyncratic drug reaction [11]. In future a systemic research is recommended to clarify the mechanism of MPH induced psychosis, and stimulant should or should not be reintroduced in same patient for symptoms of ADHD. Therapeutic doses of MPH can induce psychosis in a small proportion of patients which is characterized by hallucinations, delusions, bizarre behaviour, aggressive and agitated behavior, euphoria, flight of ideas, and impaired cognitive functions. These symptoms were found to disappear within few days after discontinuation of treatment. Clinician should be aware for such presentation and risk of adverse reactions with MPH, therefore a careful history, thorough evaluation and regular follow-ups are essential in all patients receiving MPH. Conflict of interest: None declared References 1. McCarthy S, Wilton L, Murray ML, Hodgkins P, Asherson P, Wong IC. The epidemiology of pharmacologically treated attention deficit hyperactivity disorder (ADHD) in children, adolescents and adults in U primary care. BMC Pediatric 2012, 12:78.

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6 Brajesh Mahawer, Senior Resident; Jitender Aneja, Assistant Professor; Naresh Nebhinani, Associate Professor, Department of Psychiatry, All India Institute of Medical Science, Jodhpur, Rajasthan, , India 130