Seasonal Cyclothymia to Seasonal Bipolar Avective Disorder: a Double Switch After Stroke

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796 Journal of Neurology, Neurosurgery, and Psychiatry 1997;63:796–797 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.796 on 1 December 1997. Downloaded from

SHORT REPORT

Seasonal cyclothymia to seasonal bipolar aVective disorder: a double switch after stroke

Shailesh Kumar, Robin R Jacobson, K Sathananthan

Abstract some enlargement of the third and lateral ven- The appearance of bipolar aVective disor- tricles with widening of the cerebral sulci, der after stroke depends on the presence extensive patchy low density changes in the of two factors: a predisposing factor of white matter of both cerebral hemispheres, and either genetic loading or subcortical atro- in the right internal capsule extending into the phy, and a lesion of speciﬁc corticolimbic corona radiata, and focal lacunar type infarcts pathways involving the right hemisphere. in the right corona radiata extending to the left Whether cyclothymia and seasonal aVec- external capsule. Six months later he had tive disorder further predispose to post- another mild stroke, details of which were not stroke aVective disorder is not clear. A available. case is described which highlights these Three months after the ﬁrst stroke in issues. The aetiological factors, patho- November 1989 he experienced a manic physiology, and diagnosis are discussed. episode which remitted after three weeks of treatment with haloperidol. He had three (J Neurol Neurosurg Psychiatry 1997;63:796–797)

further manic episodes, in December 1990, copyright. October 1991, and October 1993, each lasting Keywords: poststroke bipolar aVective disorder; cyclothymia; seasonal aVective disorder for three to four weeks. Each was associated with memory impairment, and both deficits recovered after treatment with haloperidol or Secondary mania is thought to be a rare conse- thioridazine. quence of stroke and is only reported anecdo- He had experienced a depressive episode in tally in the literature.1 Although the incidence July 1989, when he was treated with dothiepin of bipolar aVective disorder decreases with (50 mg at night). This had to be withdrawn PRiSM, 9 Windsor 2 Walk, Institute of age, the mortality rate for late onset bipolar after 10 days when he began to exhibit Psychiatry, De aVective disorder exceeds the community base symptoms of hypomania. A second depressive Crespigny Park, rate for this age group3 and for geriatric episode occurred in March 1991 which re- http://jnnp.bmj.com/ London SE5 8AF, UK depressed patients.4 Poststroke mania is sponded to fluoxetine within four weeks (with- S Kumar thought to depend on the presence of two out a hypomanic switch). factors5:() a predisposing factor of either Department of a Premorbidly he was a moody person whose General Psychiatry, genetic loading or subcortical atrophy, and (b) “mood and personality varied regularly with the Jenner Wing, St a lesion of specific corticolimbic pathways seasons”. In the summers, he was flirtatious, George’s Medical involving the right hemisphere. The infre- cheerful, sociable, and spent money erratically. School, Cranmer quency of the combination of these factors may In the winters he became withdrawn, isolated, Terrace, London, UK explain the relative rarity of poststroke mania. R R Jacobson and spoke much less. His son and daughter in on September 25, 2021 by guest. Protected We report a case of poststroke bipolar aVec- law recalled witnessing, almost with predictable Maudsley and Bethlem tive disorder, in which symptoms “converted” regularity, these mood swings for 40 and 26 Trust, Department of to syndrome and their respective seasonal pat- years respectively. His family considered these Psychiatry, Mayday terns “switched”. This has not been described as vagaries in his personality, never serious University Hospital, previously. Mayday Road, enough to warrant medical attention. Thorntonheath, In the spring of 1978, immediately after his London, UK Case history wife’s death, he withdrew from his children and K Sathananthan An 88 year old retired man was referred from a friends, spoke little, neglected himself, and slept poorly for two to three weeks. He “pulled Correspondence to: home for elderly people with a one week Dr R Jacobsen, Department history of sudden onset of grandiose speech, himself through” without any treatment and of General Physiology, Jenner sexual advances towards female residents, soon remarried. There was no family history of Wing, St George’s Medical mental illness and he had no psychiatric School, Cranmer Terrace, undue cheerfulness, increased socialisation, London SW17 0RE, UK. pressure of speech, and decreased sleep. He history. had not received treatment for any physical or He recovered from the index episode after Received 26 September 1996 mental illness until 1989 when he experienced treatment with haloperidol and sodium val- and in revised form 26 March 1997 a left sided hemiplegia with ipsilateral supranu- proate. Investigations disclosed no new abnor- Accepted 8 April 1997 clear facial palsy. Brain CT at the time showed mality. He was discharged back to the old Seasonal cyclothymia to seasonal bipolar aVective disorder 797 J Neurol Neurosurg Psychiatry: first published as 10.1136/jnnp.63.6.796 on 1 December 1997. Downloaded from

people’s home where he died of an unrelated ported, poststroke bipolar aVective disorder is chest infection three weeks later. more often associated with right hemispheric lesions especially involving right orbitofrontal Discussion and basotemporal cortices, the thalamus, and Before his stroke, the patient manifested the head of the caudate nucleus.5 Brain CT had persistent mood instability, involving periods of shown lesions in the right corona radiata and in mild depression and mild elation, thereby the left external capsule. A single lesion may attracting an International Classification of have extended from the right hemisphere to the Diseases version 10 (ICD 10) diagnosis of left, or he may have had two separate infarcts. cyclothymia.6 The consistent seasonal pattern In either case, he had sustained at least one of his subaVective episodes was remarkable, right sided stroke. and has not been reported previously to our The first appearance of mania in elderly knowledge. These subaVective episodes people is not thought to reflect the presence of changed after his strokes in two ways: firstly, a unique bipolar aVective disorder, but rather a into full-blown bipolar aVective disorder (ICD conversion factor, especially an organic disor- 10)6: and secondly, the seasonal pattern of the der aVecting CNS function, acting in concert now aVective episodes switched from the with a predisposition to aVective illness.12 Such polarity of his previously subaVective episodes. a model fits with this case, but does not explain Cyclothymic temperaments along with dys- the switching of the seasonal pattern of the thymic and hyperthymic temperaments are mood swings. thought to represent putative developmental In conclusion, we present a case of late onset pathways to bipolar aVective disorder; whereas bipolar aVective disorder in which a right inhibited or anxious-phobic temperaments hemispheric stroke extending to the subcorti- 7 seem related to non-bipolar outcomes. Tricy- cal areas precipitated a seasonal bipolar 8 clic antidepressant drugs are recognised trig- aVective disorder in a person predisposed to gers which can convert cyclothymia to bipolar cyclothymia and cerebral atrophy, and also aVective disorder. Little is known about other reversed the previous seasonal pattern of the converting factors . premorbid mood swings. Seasonal aVective disorder has been reported after right sided lesions involving the temporal and frontal lobes.9 Two types (A and 1 Krauthammer C, Klerman HL. Secondary mania: manic syndromes associated with antecedent physical illness or B) of seasonal aVective disorder have been drugs. Arch Gen Psychiatry 1978;35:1333–9. described.10 Type A is seasonal aVective disor- 2 Broadhead J, Jacoby R. Mania in old age: a first prospective study. International Journal of Geriatric Psychiatry 1990;5: copyright. der with fall-winter depression with or without 215–22. spring-summer mania or hypomania, and type 3 Dhingra V, Rabins PV. Mania in the elderly: A five to seven year follow-up. J Am Geriatr Soc 1991;39:581–3. B is seasonal aVective disorder with spring- 4 Shulman KI, Tohen M, Satlin A, Mallya G, Kalunian D. summer depression with or without fall-winter Mania compared with unipolar depression in old age. Am J Psychiatry 1992;149:431–5. mania or hypomania. Both types are thought to 5 Starkstein SE, Robinson RG. A ective disorders and 10 V show consistent times of onset and remission. cerebrovascular disease. Br J Psychiatry 1989;154:170–82. Our patient manifested a type A pattern of 6 World Health Organisation. International Classification of Diseases, 10th ed. Geneva: WHO, 1992. cyclothymia before the stroke, which changed 7 Akiskal HS. Developmental pathways to bipolarity: are to a type B pattern afterwards (manic episodes: juvenile-onset depressions pre-bipolar? J Am Acad Child Adolesc Psychiatry 1995;36:754–63. two in the fall, one in winter and depressive 8 Akiskal HS. The temperamental borders of aVective episodes: one in spring and one in summer). disorder. Acta Psychiatr Scand Suppl 1994;89:32–7. 9 Hunt N, Silverstone T. Seasonal aVective disorder following http://jnnp.bmj.com/ He developed bipolar aVective disorder after brain injury. Br J Psychiatry 1990;156:884–6. a right hemispheric lesion. Brain CT showed 10 Fiedda GL, TondoL, Teicher MH, Baldessarini RJ, Gelbard HA, Gianfranco FF. Seasonal mood disorders: patterns of widespread bilateral atrophy of the white mat- recurrence in mania and depression. Arch Gen Psychiatry ter . The existence of cerebral atrophy has been 1993;50:17–23. 11 Starkstein SE, Robinson RG, Price TR. Comparison of cor- identified as a factor increasing the vulnerabil- tical and subcortical lesions in the production of post- ity to mania after stroke.211 By contrast with stroke mood disorders. Brain 1987;110:1045–59. poststroke depression, in which anterior left 12 Shulman K I, Tohen M, Satlin A. Mania revisited. In: Arie T, ed. Recent advances in psychogeriatrics. Edinburgh: hemispheric lesions are more commonly re- Curchill Livingstone, 1992;2:71–9. on September 25, 2021 by guest. Protected