Severe Temper Outbursts in a 10-Year-Old Girl

CASE VIGNETTE

Betty is a 10-year-old girl who initially presented to outpatient psychiatric care for severe temper outbursts—rages precipitated by minor issues. These lasted for 1 to 2 hours and included destruction of property, physical aggression, and suicidal threats. Bipolar disorder was diagnosed. She was initially treated with quetiapine(Drug information on quetiapine) and later with a combination of quetiapine and valproic acid. The medical record did not mention symptoms related to major depression, mania, ADHD, or anxiety.

Several months later, the Betty was hospitalized because of ongoing destructive psychiatric episodes. During the hospitalization, she was given a diagnosis of major depressive disorder and treatment with an antidepressant in conjunction with quetiapine was started. The hospital psychiatrist did not consider the outbursts as an indication of bipolar disorder; there was no record of manic symptoms.

Subsequent to the hospitalization, the patient was evaluated with the Mini International Neuropsychiatric Interview (MINI). During the evaluation, the presence of significant depressive symptoms, including low mood, reduced interest level in several activities, insomnia and fatigue, self-derogatory thinking, and poor concentration, were identified. Betty and her mother described a 5-day episode of clear hypomanic symptoms that had occurred 8 months earlier: euphoria, decreased need for sleep, grandiosity, very fast speech, and an increased activity level. A similar episode, of 2 days’ duration, occurred 4 months after the initial episode.

There were no symptoms of ADHD and no psychosis, trauma, PTSD, significant anxiety, or substance use. The family history was positive for bipolar disorder, although this could not be verified.