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Home » Bipolar Disorder

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CHALLENGING CASE 

Would a Diagnostic Label Improve Your Rx For These Children?

By David Axelson, MD | February 14, 2012
Dr Axelson is associate professor of psychiatry and director of Child and Adolescent Bipolar Services Outpatient Program at the Western Psychiatric Institute and Clinic of the University of Pittsburgh Medical Center.

In addition, Albert’s mother reports that he has been chronically hyperactive, impulsive, and distractible for as long she can remember. He has had low frustration tolerance since his toddler years and never grew out of his “terrible twos.” He responds to limit setting by doing the opposite of what the authority figure demands. Albert is bossy with peers and will quit playing with them if they do not do what he wants to do and will get back at other children if they do anything to bother him.

Henry’s mother states that he was very shy with strangers, starting at an early age. He was also very anxious in anticipation of situations of separation from his parents and some of his “meltdowns” occurred during these times, often prompting his parents to curtail planned activities. Marital relations between his parents have been strained. Henry has frequent nightmares about his parents being harmed and often demands to sleep with them at night. Transition to first grade was very problematic, and Henry’s “explosions” often occur before school. However, they can also occur at other times, especially when his parents set limits, refuse to give him something he wants, or are arguing with each other

Bill’s mother has noticed that since the onset of the rages, he has times when he becomes very silly and inappropriately giddy, to the point where it annoys other children. During these episodes, Bill is hyperactive; is talkative to the point at which others cannot understand what he is saying; and engages in reckless, risk-taking behaviors with his bike and skateboard. However, if he is thwarted in his desires during these moods, it provokes a major outburst. Sometimes during these moods, Bill stays up much of the night “bouncing off the walls” and can get up for school without a problem. However, his mother says that these episodes only last a day at most and happen 2 or 3 times a month, and she cannot recall them ever occurring for days in a row. Bill’s mother is worried because the child’s father has bipolar disorder and his paternal grandmother says that Bill is “just like his dad was when he was a kid.”

CHALLENGING QUESTIONS

Each of the boys in this Case Vignette could meet the DSM-5-proposed criteria for Disruptive Mood Dysregulation Disorder (DMDD), but . . .

•Do you think that these presentations are all the same syndrome that share a similar neurobiological basis, family history, and response to treatment?

•Do you think the availability of a diagnostic label of DMDD improves the diagnostic formulation and treatment plan for these children?

Weigh in with your comments below.

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by George Isaac | April 19, 2012 1:41 PM EDT

The diagnostic label DMDD will not change the treatment and prognosis much, but it may help to a degree in convincing everone involved that these children's problems cannot be explained away by a label of ADHD and prescription of stimulants (as many psychiatrists and others do now) and that these children's problems are more related to a mood disorder ( Mood disorder NOs / Bipolar Disorder in today's terminology). It will help prescription of Meds more attuned to treatment of Mood disorders, specifically bipolar disorder. Parents may accept a diagnosis of DMDD more readily as they may think it is not as bad as bipolar disorder.

it will not change the prognosis much as most such chldren end up as menatlly ill adults with the problems continuing and they more likely than not will end up being identified/ treated as adults with bipolar / schizoaffective/ borderline personality disorder problems. In the worst case they will be identified and dealt with / neglected as just bad personalities and abused in the criminal justice system and denied SSD benefits. Suicide risk, violent behavior, and substance abuse are frequent risks.
I believe all three siblings suffere from the same or very closely related clinical syndrome and as no two scizophrenic or bipolar siblings have excatly same symptoms and same treatment response, these siblings will also differ in some details and intensity of problems and response to treatment.
I believe their illnesses are more related to bipolar disorder than anything else. We can change names, but remeber: "A rose by any other name is still a rose."
George Isaac, MD

by lucianne cronin | April 12, 2012 10:52 AM EDT

i agree with Salvatore.

by Leia Gill | March 14, 2012 3:22 PM EDT

Yes, the most likely diagnoses here are ADHD/ODD, Separation anxiety, and Bipolar d/o. I don't think adding a new definition to temper tantrums is beneficial. It only gives a clinician a label and buys time to tease out what may be the actual underlying source of the rage. They are unlikely to respond to the exact same treatments (ie, stimulant for the first child would worsen the second child).

by Salvatore Argiro | February 17, 2012 12:08 AM EST

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