Severe Temper Outbursts in a 10-Year-Old Girl
Severe Temper Outbursts in a 10-Year-Old Girl
We invite you to answer the following question after reading the Case Vignette. Discussion follows on the next page.
On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why?
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 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.
QUESTION:
On the basis of the patient's depression symptoms in the past year and the hypomanic episodes, what is the diagnosis and why?
In this article, two different doctors state that rages are not highly related to bipolar disorders. That is important information for current mental health professionals to understand. But very few of these mental health professionals have much of an idea what rages do relate to. The answer that I have found to be the most consistent is that rages occur when the level of control over reflex emotions is over-powered by the emergency adrenaline system. Medicines which modulate adrenaline levels like clonidine are sometimes therapeutic to stop rage behavior, but most people with rage reactions require stronger adrenaline-blocking medications, such as the alpha-blocking mediation, Cardura and various beta-blocking medications like Bystolic or metoprolol. In over 25 years of treating individuals with rage behavior, I have found that adrenaline-modulating medications, when properly used, can eliminate rage behavior in up to 80% of patients. These patients no longer demonstrate the rage which was the basis of the bipolar disorder diagnosis. In a few patients, even manic symptoms were eliminated.
Ralph Ankenman MD
www.HopefortheViolentlyAggressiveChild.com
Seems as though one question would have given the correct diagnosis if it were that clear. This scenario makes me think of all the times when reviewing a patient's history with them, I get completely different answers to questions answered and documented years before. Sometimes we are asking questions too early, i.e. the mood changes are not present yet, and sometimes we open the door to those possibilities by asking the questions- which years later bring an "oh, yeh!!" You think?
What about Axis II?
Whatever happened to the bio psychosocial evaluation of a patient?There is no psycho social information, therefore it is hard to construct a differential. I agree with another poster, why isn't axis 2 part if the differential?
The following is on behalf of the author, Leo Bastiaens, MD:
The comment by Lucianne Cronin is well taken: the report of symptoms changes with time, circumstance, interviewer, and presence of co-lateral informants. However, in this case, neither the outpatient nor the inpatient records indicated whether or not (hypo)manic symptoms were explored at all.
Structured interviews do not reduce all variance of history taking, but they have certain advantages: they "force"the interviewer to explore and document core symptoms, and they "force" the interviewer to explore other, possible co-morbid, conditions. There are several interviews available that are clinician friendly and leave plenty of time to perform the other tasks of an evaluation.
i have just read a new publication from the max- planck institute for experimental medicine in göttingen, germany: author: prof. dr. dr.ehrenreich, head of the dpt. of clinical neuroscience. subject: the success acieved with the systematic treatment of schizophrenic patients through infusion of recombinant erythropoetin (EPO) over several months. prof.e. will be back from her tour in the usa by the beginning of june. -- a big pilot study has verified the success mentioned above. kind regards, dr. ruth kleinknecht, germany
Very good concise useful case with timely and wise, even handed historical commentary. I especially like the pithy differentiations re right dd for wrong reasons and the obverse. Use of the MINI instrument and others like it are truly much needed to drastically clean up years of our profession vastly overdiagnosing "bipolar disorder" in youth. But this also reflects the totally inadequate spectrum of clinical categories in the current DSM.
Frank Miller MD, North Carolina