Complex psychiatric presentation in adolescent onset Wilson's disease

A previously healthy 15-year-old boy presented with a 2-week history of acute tremor in his hands, fasciculation of his tongue and a sensation that his mind was going blank. Physical examination and investigations confirmed a diagnosis of Wilson's disease and chelating treatment was started. As his neurological symptoms and liver function started to improve he developed tearfulness symptoms of depression and intense doubt about everything he thought and said. He was diagnosed with a moderate depressive episode and obsessive compulsive disorder as a result of Wilson's disease and started on citalopram. After an initial period of improvement with citalopram, his symptoms changed and he appeared irritable, restless, impulsive, disinhibited and was unable to sleep. Bipolar affective disorder was diagnosed and treatment changed to lithium carbonate and olanzepine, which led to a gradual mood stabilisation and successful recovery.