Introduction: Atomoxetine, a selective noradrenaline reuptake inhibitor, is the first non-stimulant drug approved by the Food and Drug Administration for the treatment of attention deficit hyperactivity disorder (ADHD). It has been reported that atomoxetine can be safely used in comorbid anxiety disorder and tic disorders. In this paper it was aimed to report hypomania-like symptoms triggered by atomoxetine in a case with ADHD and social anxiety disorder.
Case Report: A 10-year-old male patient was evaluated with complaints of attention deficit, forgetfulness, difficulty in memorizing, and low school success. It was determined that the patient could not express himself properly in social setting, avoided activities requiring performance such as attending classes due to fear of making mistakes, was usually quiet and shy, and therefore, his daily functions were unfavorably affected by his condition. According to clinical evaluation of the patient based on DSM IV diagnostic criteria, he was determined to fulfill the diagnostic criteria of ADHD-attention deficit subtype and social anxiety disorder-common type. He was begun on atomoxetine 10 mg/day with gradual dose increments. The patient was brought to our polyclinic with nervousness, defiance to parents, and over-activity on 7th day of atomoxetine treatment. A repeat evaluation revealed that his self-esteem increased; he also developed behavioral and emotional changes in the form of occasional anxiety and irritability, and sometimes excessive joy, restlessness, impatience, pugnaciousness, pressured speech, speech interruption behavior, tendency to commit violence to friends, very frequent and irritating kissing behavior toward his mother. His sleep time and appetite, on the other hand, did not change significantly. According to above mentioned findings, he was considered to have a hypomanic shift, and atomoxetine treatment was stopped. Upon cessation of treatment, his behavioral changes abated in psychiatric evaluation performed 5 days later. The case had no family history of any psychiatric diseases.
Discussion: Hypomania-like symptoms in this case were related to atomoxetine use since this case had previously no clinical symptoms or signs of mania or hypomania-like disorder, no similar history of a different drug use, and of hypomania-like symptoms started shortly after beginning of atomoxetine treatment and improved shortly after stopping the treatment. It has been concluded that the factor most closely related to “an increased risk of mania or hypomania induction or mood dysregulation” is the presence of personal or family history of a mood disorder. In our case, on the other hand, there was no personal or family history with a risk for bipolar disorder. Our patient also had social anxiety disorder accompanying ADHD diagnosis. It has been suggested that co-occurrence of anxiety disorders and bipolar disorder is quite common and the rate of anxiety disorder is higher in bipolar disorder compared to general population. Analysis of our patient under the light of literature data suggests that presence of comorbid social anxiety disorder in addition to ADHD and development of hypomania-like symptoms during atomoxetine treatment may be