1. How does disruptive mood dysregulation disorder differ from bipolar disorder in children?
2. What is the difference between Premenstrual Dysphoric Disorder and PMS?
3. What are the primary nonpharmaceutical and pharmaceutical treatments for enuresis?
4. What type of family system do children with encopresis typically have?
5. Case Study: Melissa
Melissa is a single, white, 14 y/o female, who is currently an 8th grade student. She was referred by the psychiatrist at St. Clare?s Hospital for medication management. She was recently released after a 10-day psychiatric inpatient stay where she was admitted for out-of-control behavior, severe temper outbursts, irritability, and severe conflict with friends and family.
Melissa began having problems about 5 years ago. She had a bullying incident the second week of school in third grade when a group of girls stole her jacket and threatened to beat her up. Although the girls were suspended, she was so distraught that she missed 7 days of school. She was unable to regain her equilibrium and catch up academically. By the end of December, she began experiencing symptoms of irritability, sadness, and mood swings. On Christmas Eve, 2012, she had a ?major meltdown? of explosive anger over not getting a new electronic device that she wanted. When her father refused to purchase it for her, she wouldn’t get into the car to return home and started screaming uncontrollably at him in the parking lot. Someone called the police and she was taken to St. Clare’s emergency room but was released after she calmed down.
After returning to school in January, she had difficulty concentrating and began having academic problems as well as relationship difficulties with her friends. She began having more conflict with her parents as well. After a family fight in March, 2011, following a limit setting attempt by her parents regarding time on the computer, she took an overdose of her sister’s medication (quetiapine and lamotrigine). She was admitted to St. Clare’s hospital for 11 days and then started their IOP program 3 times per week for 6 weeks. She had some improvement at home and at school. In May, however, she sent an inappropriate, seductive text picture to a boy she met on-line dressed in only her underwear. When her mother discovered this and confronted her, she broke glass and cut herself and took an overdose of 15 Advil. She was again admitted to St. Clares’ for 14 days. After discharge she started their PHP from 8:00 am to 3:30 pm, for the rest of the school year. There, she worked on developing better coping skills. The summer was uneventful and she started off her sophomore year on a positive note. After the first week, she started a relationship with a high school senior. After having her first sexual relationship with him, he soon broke up with her. She then, cut herself about 20 times on both forearms with a sharp knife and was readmitted to St. Clare?s for 5 days. She was released two days ago.
Currently, Melissa is still sad about the breakup with her boyfriend. She believes that she is unlovable and no one will ever want her. She is tearful and irritable and has difficulty concentrating. She admits to feelings of worthlessness, self-dislike, and pessimism. She states that sometimes her mood goes up and she feels on top of the world, but this happens infrequently. She has no difficulty sleeping and her appetite is good. She admits to having a terrible temper. There is no history of substance use. She also revealed that the sexual experience was very negative for her and her boyfriend wanted her to do ?lots of things? that he saw girls doing to men on internet porn and when she wouldn?t, he said he would find someone who would.
Melissa is currently on the following medication: Aripiprazole 5 mg; Intuniv 1 mg QAM; Doryx 150 mg HS (acne). In 4th grade her pediatrician thought she might have ADHD and was prescribed a low dose of Concerta but developed heart palpitations. She went for a cardiac evaluation and had increased PQ waves and a heart sequencing problem, so the Concerta was d/c and she was placed on Intuniv 1 mg, but she believes it doesn?t do anything for her and that she doesn?t have ADHD. Melissa is 5 ft, 7 inches; weight 124; BP 96/60. She has a mild case of acne.
Melissa was domestically adopted at 6 days from a single mother from Kentucky. She apparently had no psychiatric or medical history. Her father is a health care consultant and her mother a homemaker. There is no history of psychiatric problems. They appear to be good parents with appropriate parenting skills and without structural pathology in the family system. Melissa has a good relationship with them. Melissa has one sibling, Michelle, a 19 y/o sister who is also domestically adopted (no biological relationship). Michelle is diagnosed with Bipolar Disorder and is a freshman at Fairleigh Dickinson University, majoring in psychology. Michelle has had 3 psychiatric admissions and is currently stable and functioning well on Lithium 1200 mg/day.
Melissa is an accomplished ice skater and skates semiprofessionally. She has one good friend but their relationship is very conflictual. She is involved in community service for the homeless. She loves Face Book and other social media. Her family is miIDle to upper miIDle class and they own a farm in Tewksbury with a few horses.
Melissa is open and cooperative and looks her stated age. She is attractive with long blond hair, large green eyes, and mild acne. Her speech, communication, and behavior are normal. Her affect is appropriate and her mood is mildly labile moving from tearfulness to irritability during the evaluation. There is no indication of suicidal or homicidal ideation. Her thoughts are logical and goal directed. Her cognition is unimpaired. Her judgment and insight are fair.
Psychological Testing: A Young Mania Scale reveals a score of 7, indicating mild symptoms of bipolar disorder, but not enough to warrant a categorical diagnosis. A Beck Depression Inventory reveals a score of 10 indicating mild depression. A child study team evaluation report revealed two WISC scores different scores: scores at age 10 and 14 – went from FS IQ of 89 to 75, a VC from 91 to 87, PC from 91 to 87, WM from 97 to 71, and PS from 94 to 78.
How would you diagnose and treat this client?
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