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A patient with a history of autism spectrum disorder and epilepsy was hospitalized for management of acute onset psychosis and agitation. The acuity of his behaviors warranted abrupt shifts in treatment and multiple pharmacologic interventions were ineffective. The atypical nature of his presentation and intense pressure from ancillary staff to consider organic etiologies drove frequent transitions of care within the hospital setting. Multiple diagnoses were considered including a primary psychosis, excited catatonia and antiepileptic drug-induced psychotic disorder. Ultimately the patient was diagnosed with bipolar disorder and effectively treated with quetiapine and valproic acid. The authors suggest that rapid consideration of comorbid bipolar disorder in autism spectrum disorder patients presenting with affective dysregulation may expedite trial of an anticonvulsant with mood stabilizing properties, which would have simplified this patient’s clinical course and limited potential for iatrogenic harm. This course of treatment should especially be considered when a history of epilepsy is present.

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