Case of treatment-resistant ADHD

[PistolPete]

I've been seeing an 8 year old boy for about the last year for treatment for ADHD, combined type. His history is pretty classic for hyperactivity as well as inattention, with Vanderbilt's completed by both mother and teacher, which are consistent and mostly 2's and 3's. He also has anxiety, which is now successfully controlled and asymptomatic after a course of play therapy with me. He has biliary atresia and is being followed by pediatric GI. I've discussed the case with them, and they want to minimize medications due to impact on his liver. His LFT's are slightly above normal, nothing to report home about, however per GI his liver ultrasound shows heterogeneity.

The main problem is the ADHD. He came to me from pediatrics on Concerta 27mg daily, which we titrated to 54mg daily over time due to poor control of his ADHD symptoms. Since there was little effect, we decided not to push to 72mg, and to switch to Adderall. He was eventually titrated to 20mg, regular release in the morning as well as at lunchtime, still with no effect.

GI states that they would prefer guanfacine, to minimize effect on his liver. So the Adderall was stopped and he was started on Tenex 1mg in the mornings, and now he's on 2mg (given in the morning since we wanted to see if that would actually decrease some of the hyperactivity).

Some questions in my mind:
1. So, let's say we titrate to max dose of 4mg, and still no effect. What do you do now?
2. Do we have the wrong diagnosis? From mother and teacher reports it sounds like classic ADHD combined type. I clarified with mother re: anxiety to make sure that he wasn't just nervous and mother was misconstruing that as hyperactivity, but she says no.
3. Is he a rapid metabolizer? He is a thin boy and since he's come off the Adderall he's gained some weight, which has been a problem since being on the stimulants previously.

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[smalltownpsych]

I'm thinking that it is still anxiety driving the hyperactivity. I would look at whether or not the mom tends toward anxiety or did the kids liver problems necessitate scary medical procedures or even the potential for them. When parents are scared for kid's life, the kid can pick up on it. Also, childhood anxiety doesn't just go away after effective treatment. Typically it just alleviates the more distressing and obvious symptoms. I think of one kid I work with who had trichotillomania. It resolved after a few weeks of treatment, but the kid still has anxiety that we have been working on for quite some time after. Also, might want to look at academic performance and cognitive testing.

 

[Ceke2002]

I'm thinking that it is still anxiety driving the hyperactivity. I would look at whether or not the mom tends toward anxiety or did the kids liver problems necessitate scary medical procedures or even the potential for them. When parents are scared for kid's life, the kid can pick up on it. Also, childhood anxiety doesn't just go away after effective treatment. Typically it just alleviates the more distressing and obvious symptoms. I think of one kid I work with who had trichotillomania. It resolved after a few weeks of treatment, but the kid still has anxiety that we have been working on for quite some time after. Also, might want to look at academic performance and cognitive testing.

I agree with this, and from a personal point of view would also add the following for consideration. Growing up as a child with ADHD there can be many different facets at play, both internally and externally, beyond just the core symptoms of the condition. There can be difficulties with developing age appropriate socialisation skills, leading to feelings of isolation and even sometimes a sense of 'otherness'. Feelings of guilt and a sense of desperation/frustration, whether conscious or not, surrounding a perceived inability to 'just be a good kid' can lead to an internalised sense of innate badness (I try hard to be good, no matter how hard I try I fail at being good, therefore I must be bad); these internalised messages and sensations can also come from externalised sources as well, constantly striving for correct behaviour in the face of a disorder like ADHD can sometimes make one hypervigilant to not only their own conduct, but with the responses and conduct of others as well (with the responses and conduct of those around them further compounding the sense of isolation, otherness and innate badness or 'wrongness'). Most of the time those who are feeding the externalised messages a child with ADHD is receiving from the world around them aren't even aware they are doing so, sometimes they are, the child's external world has to be attended to as much as their inner one. Add onto all of that a child who is also facing potentially serious medical issues, with all the stress that may engender, as well as the various effects on the dynamic of the caregiver/child relationship that can occur, and in my albeit non medical opinion I'd say it's probably not all that surprising that the child continues to struggle despite pharmacological treatment.

 

[smalltownpsych]

Also, if the pharmacological agents aren't helping, then the task is to figure out what will. In the past, I have come up with targeted interventional strategies that work with kids when nothing else does, but that requires more than what is typically expected or even available to either a psychiatrist or an outpatient psychologist.

 

[PistolPete]

Good thoughts.

He definitely has had anxiety in response to the "medical" issues. I forgot to mention that there was some concern for absence seizures last year, and the pediatric neurologist voiced to mother a possibility of requiring an inpatient video EEG (prior EEG showed some sharps in the right temporal lobe, if I recall correctly). Mother did not want the admission, so they put him on Trileptal, only later to take him off of it after they learned it was all anxiety-induced.

The mother doesn't seem particularly anxious or concerned about the medical problems when in the office, other than repeatedly bringing up the issue of hyperactivity.

If the Tenex fails I'll have to talk with mother about trying an SSRI. He's about to re-start in-home therapy to address the hyperactivity as well as some newly emerging oppositionality.

 

[smalltownpsych]

Oppositionality developing is a bad sign. I get the feeling there is a piece missing here. Maybe the in-home therapist will be able to clue in on what is going on although they tend to be the least trained. I mean who really wants to go into peoples homes and work with them. Not this kid. Also, if the anxiety is so severe that it is causing "seizures" that is pretty significant. Final thought, sometimes the mother who appears least anxious is the one who is the most scared. Getting through that defensive structure could be what the kid needs in order to feel connected and secure. The way you described her continued focus on his hyperactivity makes me wonder. Might be telling that much of the anxiety goes away after a few sessions with yourself. I've got the feeling no medication will help this case much.

 

[Merovinge]

Good thoughts.

He definitely has had anxiety in response to the "medical" issues. I forgot to mention that there was some concern for absence seizures last year, and the pediatric neurologist voiced to mother a possibility of requiring an inpatient video EEG (prior EEG showed some sharps in the right temporal lobe, if I recall correctly). Mother did not want the admission, so they put him on Trileptal, only later to take him off of it after they learned it was all anxiety-induced.

The mother doesn't seem particularly anxious or concerned about the medical problems when in the office, other than repeatedly bringing up the issue of hyperactivity.

If the Tenex fails I'll have to talk with mother about trying an SSRI. He's about to re-start in-home therapy to address the hyperactivity as well as some newly emerging oppositionality.

His R temporal sharps were anxiety-induced? If this is a phenomenon, my pediatric neurologists never told me about it. If he has uncontrolled epilepsy that could easily be worsened by stimulants. If there is concern about rapid metabolism, there is send-out testing that can be done. One can also try multiple stimulants from the same class as different formulations can be metabolized differently. Also, alpha 2 agonists in a more severe case should be adjunct and not monotherapy. I would be relatively unimpressed about the GI concerns or the role stimulants play with his mildly elevated LFTs and much more concerned about his brain/eeg.

 

[masterofmonkeys]

Sensory Processing Disorder?

Whenever I hear about treatment refractory ADHD and comorbid anxiety I ALWAYS screen for this. Sensorytherapy through OT has been a consistently awesome adjunct formy kids with sensory issues.

 

[PistolPete]

His R temporal sharps were anxiety-induced? If this is a phenomenon, my pediatric neurologists never told me about it. If he has uncontrolled epilepsy that could easily be worsened by stimulants. If there is concern about rapid metabolism, there is send-out testing that can be done. One can also try multiple stimulants from the same class as different formulations can be metabolized differently. Also, alpha 2 agonists in a more severe case should be adjunct and not monotherapy. I would be relatively unimpressed about the GI concerns or the role stimulants play with his mildly elevated LFTs and much more concerned about his brain/eeg.

Well, the neurologists were concerned enough to start him on the Trileptal. I later learned that they changed their minds and believed it was all psychogenic and stopped the medication. How they came to that conclusion I'm not sure. No "seizure like episodes" happened again, so perhaps they thought the finding on the EEG was an anomaly? I'll leave treatment of that up to the neurology team.

 

[PistolPete]

Oppositionality developing is a bad sign. I get the feeling there is a piece missing here. Maybe the in-home therapist will be able to clue in on what is going on although they tend to be the least trained. I mean who really wants to go into peoples homes and work with them. Not this kid. Also, if the anxiety is so severe that it is causing "seizures" that is pretty significant. Final thought, sometimes the mother who appears least anxious is the one who is the most scared. Getting through that defensive structure could be what the kid needs in order to feel connected and secure. The way you described her continued focus on his hyperactivity makes me wonder. Might be telling that much of the anxiety goes away after a few sessions with yourself. I've got the feeling no medication will help this case much.

Good points. Appreciate the feedback.

 

[PistolPete]

Sensory Processing Disorder?

Whenever I hear about treatment refractory ADHD and comorbid anxiety I ALWAYS screen for this. Sensorytherapy through OT has been a consistently awesome adjunct formy kids with sensory issues.

Interesting. I don't know much about this, will have to read up on it more.

 

[Merovinge]

Well, the neurologists were concerned enough to start him on the Trileptal. I later learned that they changed their minds and believed it was all psychogenic and stopped the medication. How they came to that conclusion I'm not sure. No "seizure like episodes" happened again, so perhaps they thought the finding on the EEG was an anomaly? I'll leave treatment of that up to the neurology team.

Basing that all off of one spot EEG is not ideal. EEGs are a good test but spot ones miss a lot and being "unwilling" to get a more definitive 24 hour EEG that sounds completely indicated is a problem into itself. You are boarded through ABPN and really should have more than a generalists understanding of ictyl phenomonology, particularly as it relates to psychiatric phenomenon, not a "I'll leave that to neurology" stance.

 

[Information Underload]

Sensory Processing Disorder?

Whenever I hear about treatment refractory ADHD and comorbid anxiety I ALWAYS screen for this. Sensorytherapy through OT has been a consistently awesome adjunct formy kids with sensory issues.

Agreed. I received essentially zero training on this, but the more I screen, I'd say half of my ADHD kids or so have sensory processing difficulties. I could really keep the OTs busy if I wanted, but I only send the more severe cases. It can certainly make a difference.

 

[vistaril]

I've been seeing an 8 year old boy for about the last year for treatment for ADHD, combined type. His history is pretty classic for hyperactivity as well as inattention, with Vanderbilt's completed by both mother and teacher, which are consistent and mostly 2's and 3's. He also has anxiety, which is now successfully controlled and asymptomatic after a course of play therapy with me. He has biliary atresia and is being followed by pediatric GI. I've discussed the case with them, and they want to minimize medications due to impact on his liver. His LFT's are slightly above normal, nothing to report home about, however per GI his liver ultrasound shows heterogeneity.

The main problem is the ADHD. He came to me from pediatrics on Concerta 27mg daily, which we titrated to 54mg daily over time due to poor control of his ADHD symptoms. Since there was little effect, we decided not to push to 72mg, and to switch to Adderall. He was eventually titrated to 20mg, regular release in the morning as well as at lunchtime, still with no effect.

GI states that they would prefer guanfacine, to minimize effect on his liver. So the Adderall was stopped and he was started on Tenex 1mg in the mornings, and now he's on 2mg (given in the morning since we wanted to see if that would actually decrease some of the hyperactivity).

Some questions in my mind:
1. So, let's say we titrate to max dose of 4mg, and still no effect. What do you do now?
2. Do we have the wrong diagnosis? From mother and teacher reports it sounds like classic ADHD combined type. I clarified with mother re: anxiety to make sure that he wasn't just nervous and mother was misconstruing that as hyperactivity, but she says no.
3. Is he a rapid metabolizer? He is a thin boy and since he's come off the Adderall he's gained some weight, which has been a problem since being on the stimulants previously.

guanfacine mono therapy isn't going to do ****. If the 'main problem' is the adhd, then thats an inadequate treatment. I don't know what to do here, but you've been seeing him for a year and things don't seem to be better. I would just sit the mother down and say "look, I've tried some different things and nothing has worked. At this point I recommend we either stop psych treatment(again assuming there really is no improvement) or you are welcome to take another route with a different provider".

For my patients that are 'stuck' and I've given them some seemingly appropriate treatments, I just lay it out for them that they are a non responder(at least a non responder to what I am doing for them) and since they are a non responder they should try another approach....meaning either discontinuing treatment period or trying treatment with a different provider and different perspective.

 

[whopper]

Wow a great brainstorm of good ideas.

I'm not child psychiatrist but I love engaging myself into difficult cases so long as I don't have too many at once.
Agree with guanfacine being avoided as a monotherapy unless you tried it and it is working as such.
Get some testing to see if the kid is a rapid-metabolizer. If you don't know how to do it there is no shame in asking especially since many doctors don't know how to do it. I'm sure any of us would be willing to help you with this.
IF the kid is a rapid-metabolizer the solution may be to give the kid a mega-dose of a med but of course if there are other meds that he won't rapidly metabolize try those.
As mentioned-is the kid's diagnosis right? Kids can be so difficult in diagnosing.

 

[whopper]

d since they are a non responder they should try another approach....meaning either discontinuing treatment period or trying treatment with a different provider and different perspective.

Not a bad idea in general, and I'm not accusing you of it but I have seen other doctors give up before putting any real brain power into it. If you do defer to someone else do so because you know the other person is better than you or else you're going to just prolong the agony.

 

[vistaril]

Not a bad idea in general, and I'm not accusing you of it but I have seen other doctors give up before putting any real brain power into it. If you do defer to someone else do so because you know the other person is better than you or else you're going to just prolong the agony.

generally I am not referring to any one specific person.

 

[lymphocyte]

The biliary atresia got my attention. I attended a Grand Rounds on neonatal hyperbilirubinemia and long-term neurobehavioural outcomes. (This topic might make for an interesting C&A literature review if anybody's interested.) I'll see if I can dig up my notes, but some of the more memorable references are below.

There's strong evidence that neonatal hyperbilirubinemia is associated with ADHD symptoms that resolve in adulthood (possibly due to greater cortical myelination). Also, strongly agree with @masterofmonkeys and sensory processing disorder, as this has been shown to be associated with neonatal hyperbilirubinemia as well. Finally, biliary atresia doesn't often cause kernicterus, but is there any concern for structural lesions that may explain the abnormal EEG and ADHD symptoms?

(I'm really intrigued about the psychosocial dimensions of being a sick kid with "Worried Parent Syndrome" as @smalltownpsych pointed out. I don't know the literature on this topic, but it seems like it could be a strong exacerbating factor.)

Please keep us posted! What a discussion!! Thank you.

Hokkanen L, Launes J, Michelsson K. Adult neurobehavioral outcome of hyperbilirubinemia in full term neonates-a 30 year prospective follow-up study. PeerJ. 2014;2:e294.

Compared to controls, the odds for a child with HB having neurobehavioral symptoms at 9 years was elevated (OR = 4.68). Forty-five per cent of the HB group were affected by cognitive abnormalities in childhood and continued to experience problems in adulthood. This was apparent in academic achievement (p < 0.0001) and the ability to complete secondary (p < 0.0001) and tertiary (p < 0.004) education. Also, the subgroup of affected HB reported persisting cognitive complaints e.g., problems with reading, writing and mathematics. Childhood symptoms of hyperactivity/impulsivity (p < 0.0001) and inattention (p < 0.02) were more common in HB groups, but in adulthood the symptoms were equal.
​

Johnson L, Bhutani VK. The clinical syndrome of bilirubin-induced neurologic dysfunction. Semin Perinatol. 2011;35(3):101-13.

Bilirubin-induced neurologic dysfunction [BIND] represents a spectrum of neurologic manifestations among vulnerable infants who have experienced an exposure to bilirubin of lesser degree than generally described in previous publications. Clinical neuro-motor manifestations extend to a range of subtle processing disorders with objective disturbances of visual-motor, auditory, speech, cognition, and language among children with a previous history of moderate-to-severe hyperbilirubinemia of varied duration.​

 

[Shikima]

I hate to add this as I don't do C&A, but with the biliary complications and seizure history, have you gotten a good sleep history and diagnostic PSG? Majority of seizures are occurring during sleep. But not all could be related to this alone. Have you gotten genetic testing? With the biliary tract involved, how is his liver metabolizing medications?

 

[PistolPete]

We know that about 80-90% of patients that have ADHD will respond to either a methylphenidate derivative, or mixed amphetamine salt. Given that he's failed both classes, the question is whether he's a rapid metabolizer and we just never pushed the dose high enough, or we have the wrong diagnosis and he doesn't have ADHD, perhaps a sensory processing disorder or untreated seizure disorder, in addition to his anxiety.

He hasn't gotten a sleep study. We haven't gotten genetic testing. No focal neurological signs per neurology. He's had a brain MRI done 1 year ago when he had his EEG, and the MRI was negative.

How would I go about obtaining genetic testing to see if he's a rapid metabolizer? I'm assuming this would be a send out. He's a Medicaid patient, would that be covered?

I'll talk about this with my attending and see what her thoughts are.

 

[PistolPete]

The biliary atresia got my attention. I attended a Grand Rounds on neonatal hyperbilirubinemia and long-term neurobehavioural outcomes. (This topic might make for an interesting C&A literature review if anybody's interested.) I'll see if I can dig up my notes, but some of the more memorable references are below.

There's strong evidence that neonatal hyperbilirubinemia is associated with ADHD symptoms that resolve in adulthood (possibly due to greater cortical myelination). Also, strongly agree with @masterofmonkeys and sensory processing disorder, as this has been shown to be associated with neonatal hyperbilirubinemia as well. Finally, biliary atresia doesn't often cause kernicterus, but is there any concern for structural lesions that may explain the abnormal EEG and ADHD symptoms?

(I'm really intrigued about the psychosocial dimensions of being a sick kid with "Worried Parent Syndrome" as @smalltownpsych pointed out. I don't know the literature on this topic, but it seems like it could be a strong exacerbating factor.)

Please keep us posted! What a discussion!! Thank you.

Hokkanen L, Launes J, Michelsson K. Adult neurobehavioral outcome of hyperbilirubinemia in full term neonates-a 30 year prospective follow-up study. PeerJ. 2014;2:e294.

Compared to controls, the odds for a child with HB having neurobehavioral symptoms at 9 years was elevated (OR = 4.68). Forty-five per cent of the HB group were affected by cognitive abnormalities in childhood and continued to experience problems in adulthood. This was apparent in academic achievement (p < 0.0001) and the ability to complete secondary (p < 0.0001) and tertiary (p < 0.004) education. Also, the subgroup of affected HB reported persisting cognitive complaints e.g., problems with reading, writing and mathematics. Childhood symptoms of hyperactivity/impulsivity (p < 0.0001) and inattention (p < 0.02) were more common in HB groups, but in adulthood the symptoms were equal.
​

Johnson L, Bhutani VK. The clinical syndrome of bilirubin-induced neurologic dysfunction. Semin Perinatol. 2011;35(3):101-13.

Bilirubin-induced neurologic dysfunction [BIND] represents a spectrum of neurologic manifestations among vulnerable infants who have experienced an exposure to bilirubin of lesser degree than generally described in previous publications. Clinical neuro-motor manifestations extend to a range of subtle processing disorders with objective disturbances of visual-motor, auditory, speech, cognition, and language among children with a previous history of moderate-to-severe hyperbilirubinemia of varied duration.​

Very interesting. Thanks for this.

 

[PistolPete]

.

 

[thoffen]

This is not my field of expertise, and it does seem worth reconsidering diagnosis and relation to other medical comorbidities. However, I don't expect stimulant treatment to be effective for 100% of patients with ADHD. Perhaps it means they have a different biological illness with behavioral overlap, but we just don't have enough information to separate these things.

I am more curious, though, about non-pharmacologic interventions.

 

[smalltownpsych]

Like the thinking about possible neurological issues caused by the biliary disease. It is important to understand that much of what we deal with won't show up on neurological exams, eeg, CAT, or MRI because if it is bad enough to be seen that way, the problems are grossly apparent to us. The neurological dysfunction that we tend to see is much more subtle. Sometimes neuropsychological testing can pick up some of the deficits and would definitely look into that as well as the OT stuff. Keep in mind that subtle neurological deficits can impact the interpersonal and if that is not addressed well, then the outcome will be poor. I have seen cases where mom and others are using normal range of responding to assist in self-regulation of affect and kid does not respond.

One great example I have is a kid I worked with who after about 6 months of treatment with another psychologist and a psychiatrist, mom came to me in desperation because of friends referral. After about three months of thinking that the other psychologist was right to recommend long-term inpatient treatment, I finally figured out that the kid exhibited a minimal fear response and would often laugh when other kids would be afraid. Took me awhile to figure it out because I usually don't try to scare kids. Fortunately, this kid has a high need for social affiliation and so we have shifted interventional strategies to maximize social reinforcers and have seen remarkable turnaround. We take for granted the inhibitory effect of fear in helping to regulate kids behavior. Other times we have kids who won't respond well to social reinforcers for a variety of reasons.

 

[PikminOC]

I had a kid get the round the clock eeg monitoring in hospital. It was extremely expensive and insurance wouldn't cover it.

 

[Information Underload]

guanfacine mono therapy isn't going to do ****. If the 'main problem' is the adhd, then thats an inadequate treatment..

Maybe. Maybe not. I'm still not sure how I feel about genetics testing for COMPT for ADHD, but I have run across a kid who did horribly on stimulants (and not with the expected agitation you would expect but rather seemed to become more inattive) but had obvious ADHD. He did much better on guanfacine and later on Strattera, as well.

Genetics testing for this kid ultimately came back as having the COMPT Val158Met variant, meaning he exhibited slow dopamine metabolism and that he was basically in a hyperdopinergic state. There is a study that show that if you give someone with ADHD a large dose of an amphetamine with this COMPT Val158Met that they actually do worse on testing that they did prior to having been given a dose of a stimulant, which speaks to the U-shaped curve in the treatment of ADHD in terms of dopamine levels.

I'm still waiting for the test that shows that those with COMPT Val158Met variant do better on a more noradrenergic medication like guanfacine or Strattera, though I'm not holding my breath. You might think that would be the case given that COMPT seems to prioritize the degradation of dopamine over NE. Interesting in theory, I guess.

 

[vistaril]

Maybe. Maybe not. I'm still not sure how I feel about genetics testing for COMPT for ADHD, but I have run across a kid who did horribly on stimulants (and not with the expected agitation you would expect but rather seemed to become more inattive) but had obvious ADHD. He did much better on guanfacine and later on Strattera, as well.

Genetics testing for this kid ultimately came back as having the COMPT Val158Met variant, meaning he exhibited slow dopamine metabolism and that he was basically in a hyperdopinergic state.

every week I read this forum I think I can't find anything more absurd and hilarious than the next....every week I'm surprised.

 

[lymphocyte]

.

 

[birchswing]

hyperdopinergic

Only Greek and German could come together to make such an ugly word.

It's actually hyperdopaminergic. But still so ugly. Like a rock on the coastline covered by a tarp, never polished by the breaking waves.

 

[Crayola227]

Only Greek and German could come together to make such an ugly word.

It's actually hyperdopaminergic. But still so ugly. Like a rock on the coastline covered by a tarp, never polished by the breaking waves.

I like the word

 

[birchswing]

I like the word

Yeah, I guess when I think about it more it's a nice word in that each part is self-explanatory. One of those building block words where you have a general idea of what the prefix and suffix mean. It's functional in that Greek gives us these common meanings. Dopa is German, which is a fine sound. Not sure about the origin of amine, but I would guess Latin. I guess it just sounds contrived to me, like it was put together with great intentionality rather than having some flow. I'm not sure how old of a word it is, but it's the type that won't change much over time. I like words where you can look back and see the sound changes and how they become more efficient and pleasing sounding over time. When you draw from dead languages, they just sort of sit there, somewhat inorganic sounding. It's an English word, but it hasn't been put through the English tumbling machine.

 

[Shikima]

I like the word

You'll like this one better.

rindfleischetikettierungsüberwachungsaufgabenübertragungsgesetz
It's the law for the delegation of monitoring beef labeling.

 

[Crayola227]

You'll like this one better.

rindfleischetikettierungsüberwachungsaufgabenübertragungsgesetz
It's the law for the delegation of monitoring beef labeling.

I'm cool with Greek or Latin. Spanish. Don't like German.

 

[Shikima]

I'm cool with Greek or Latin. Spanish. Don't like German.

But it's so fun putting the verb at the end of the sentence! hehe

 

[smalltownpsych]

Sort of apropos how far afield this topic has become.

 

[birchswing]

Sort of apropos how far afield this topic has become.

That was on me.

I am horrible at reading. Much better at copy-editing. I can literally get through a page of text faster while looking for mistakes than trying to just read it (I glaze over and read the same thing over and over). I seek out anything novel or in error. And as such, I came across "hyperdopinergic."

 

[smalltownpsych]

That was on me.

I am horrible at reading. Much better at copy-editing. I can literally get through a page of text faster while looking for mistakes than trying to just read it (I glaze over and read the same thing over and over). I seek out anything novel or in error. And as such, I came across "hyperdopinergic."

I kind of enjoy following tangents anyway. If everyone stayed on topic, how dull would that be?

 

[Igor4sugry]

I second the sleep study idea as next step.

 

[Shikima]

I second the sleep study idea as next step.

Be sure it's done as a diagnostic with a seizure montage.