Case files psychiatry - part 5 ppsx

176 CASE FILES: PSYCHIATRY REFERENCES Emslic GJ. Hughes CW. Crismon ML, el al. A feasibility study of the childhood depression medication algorithm project (CMAP). J Am Acad Child Adolesc Psychiatry 2004:43(5):519-527. Hughes CW. Emslie GJ. Crismon ML. et al and the Texas Consensus Conference Panel on Medication Treatment of Childhood Major Depressive Disorder. The Texas children's medication algorithm project: report of the Texas consensus conference panel on medication treatment of childhood major depressive disor- der. J Am Acad Child Adolesc Psychiatry 1999:38(11): 1442-1454. Pataki CS. Mood Disorders and suicide in children and adolescents. In: Sadock BJ. Sadock VA, eds. Kaplan and Sadock's comprehensive textbook of psychia- try, 7th ed. Philadelphia: Lippincott Williams & Wilkins. 2000:2740-2757. •> CASE 19 A 15-year-old girl is brought to a psychiatrist by her parents because they are concerned that she might be depressed. The parents had no complaints until 2 or 3 years ago. The patient's grades have fallen because she cuts classes. She gets into fights, and her parents claim that she hangs out with the "wrong crowd"; some nights she does not come home until well past her curfew. The patient says that there is "nothing wrong" with her and that she wants her parents to "butt out of her life." She claims that she is sleeping and eating well. She says she skips school to hang out with her friends and admits that they frequently steal food from a convenience store and spend time watching movies at one of their homes. She claims that she fights only to prove that she is as tough as her friends but admits that she often picks on younger students. She is not concerned about her grades and just wants her parents to "lay off' and let her enjoy her youth. She denies the use of drugs or alcohol other than occasionally at parties. Her blood alcohol level is zero, and the results of a uri- nalysis are negative for drugs of abuse. • What is the most likely diagnosis? • What treatment should be started? 178 CASE FILES: PSYCHIATRY ANSWERS TO CASE 19: Conduct Disorder Summary: A 15-year-old girl gets into fights, intimidates others, steals, skips school (resulting in falling grades), and breaks her curfew regularly. She does not exhibit any remorse for her behavior. She denies having any depressive symptoms such as sleep or appetite disturbances and says she feels pretty good about herself. She does not report any suicidal or homicidal thoughts. • Most likely diagnosis: Conduct disorder (CD). • Best treatment: Multisystemic treatment (MST) approach with involvement of parents and teachers. The treatment of CD can be difficult. There are few studies that look at CD systematically and study various treatment techniques. Over the last few years, a number of new studies have begun to look at how to treat CD. In terms of behavioral interventions, multisystemic-based therapeutic approaches are quite helpful. These approaches combine a well-coordinated plan to help parents develop new skills at home, such as parent-child interaction training, to help the relationship between parents/caregivers and the child. In addition, it is helpful to teach classroom social skills, institute playground behavior programs, and facilitate and encourage communication between teachers and parents. Psychopharmacologic interventions also show some promise. Many children with CD have a comorbid diagnosis of attention-deficit/hyperactivity disorder (ADHD). This needs to be identified and treated. Even if a child does not meet full diagnostic criteria for ADHD, there is evidence that CD is amenable to treatment with stimulants—often leading to less aggression and impulsiveness. There are also a few studies showing that the use of newer antipsychotics, such as risperidone, may be useful with CD. Analysis Objectives 1. Understand the diagnostic criteria for CD. 2. Understand when medications should be used in CD. Considerations This patient presents with a pattern of aggression, truancy, deceitfulness, theft, and serious violations of the rules of expected behavior for her age that fits the criteria for CD (Table 19-1). This behavior has been ongoing for 2 or 3 years and appears to be at least in part peer-mediated. Although her parents are concerned that she might be depressed, she appears engaged and noncha- lant. It is important to collect information about substance use or abuse as well. This often requires gathering information from sources outside of the 179 CLINICAL CASES Table 19-1 DIAGNOSTIC CRITERIA FOR CONDUCT DISORDER A. Persistent, repetitive pattern of behavior that infringes on the basic rights of others or violates major age-appropriate societal norms: This pattern is manifested by the presence of at least three of the following symptoms in the last 12 months with at least one occurring in the last 6 months. The symptom categories are 1. Aggression toward people or animals 2. Destruction of property 3. Deceitfulness or theft 4. A serious rule violation The person can have more than one symptom in a category. B. The disturbance causes clinically significant impairment. C. If the patient is older than age 18. the criteria for antisocial personality disorder are not met. child, such as teachers, parents, siblings, and so on. It is important to remem- ber that CD is a mental illness that is amenable to treatment. Without treat- ment. a large percentage of these children will go on to develop antisocial personality disorder and possible imprisonment. Treatment as children reduces the likelihood of this. APPROACH TO CONDUCT DISORDER Definitions Antisocial personality disorder: Pervasive disregard for and violation of rights of others starting by age 15 Wraparound: A framework for organizing services in high-needs, mentally ill children involving a number of core values including cultural sensitiv- ity, strengths focus, creativity, natural supports, and team approaches Clinical Approach Differential Diagnosis Oppositional defiant disorder also is characterized by a negative behavior pattern: however, the offenses do not typically cause significant harm to others or involve violations of major societal norms. The behavior cannot occur exclusively in the context of an episode of mania or as a reaction to some stressor (in which case, adjustment disorder with disturbance of conduct is diagnosed instead). Finally, antisocial personality disorder is diagnosed if the symptoms appear after the age of 18. 180 CASE FILES: PSYCHIATRY Working with Children and Their Families Conduct disorder is a very difficult disorder to treat, requiring participation from a number of systems involved with the child. The recommended inter- ventions require considerable effort and change on the part of the parents who are often frustrated and feel hopeless. By the time the family comes in for evaluation, many years of maladaptive behavior and parental responses to this behavior have already passed. The parents have lost control of their home and their child, and a great effort will be required to make an impact on the situation. The child has also learned that even if the parents change for a while, the change is not likely to last. He or she can simply outlast the latest parental efforts or "up the ante" on the problematic behavior. However, it is important to note that with appropriate community interventions and support, such as with wraparound pro- grams or MST, the outcome of this disorder can be hopeful. More than just about any other psychiatric illness in children, the prognosis is related to the degree in which one can organize a community-oriented intervention. Comprehension Questions [19.1] Which of the following is most appropriate in treating individuals with CD? A. Parents should be encouraged to give their child some slack and ease up on their demands. B. Store owners should be encouraged not to press legal charges against youthful offenders. C. Patients should be allowed to drop out of school if they choose. D. Patients should receive jail sentences in keeping with their behavior. E. Patients should be removed from their friends. 119.2] Which of the following treatment is best employed to treat the co-morbid depressive symptoms of an adolescent with CD? A. Multisystemic therapy B. Attendance in group therapy C. An antidepressant medication D. Treatment of the family to address the underlying reasons for the depression E. Helping the adolescent change schools [19.3] Which of the following epidemiologic statements about CD is correct? A. Patients are more likely to have parents with a history of schizophrenia. B. Patients are more likely to be female. C. Patients are more likely to have parents who have antisocial per- sonality disorder and alcohol dependence. D. The prevalence of CD is independent of socioeconomic class. 181 CLINICAL CASES Answers [19.1] D. Natural consequences (the legal consequences of criminal activity) is one of the most effective treatments for young people with CD. Avoiding consequences (as in answer B) is counterproductive and serves only to reinforce the negative behavior. Parents need to be encouraged to regain control of their homes by setting firm limits with their child. [19.2] C. If the criteria for a comorbid condition are met, this disorder should be the first target of psychopharmacologic intervention. [19.3] C. Conduct disorder is more common in children of parents with anti- social personality disorder and alcohol dependence than it is in the general population. CLINICAL PEARLS Conduct disorder can be a predecessor of antisocial personality disorder. Treatment of CD is very difficult and typically involves a community-oriented and highly organized treatment approach. When there are comorbid psychiatric conditions, they should be the target of psychopharmacologic interventions. Conduct disorder can be diagnosed prior to age 18, whereas antiso- cial disorder cannot be diagnosed until after age 18. REFERENCES Ebert M, Loosen P. Nurcombe B, eds. Current diagnosis and treatment in psychia- try. New York: McGraw-Hill. 2000:570-576. Kaplan H. Sadock B. Synopsis of psychiatry, 8th ed. Baltimore: Lippincott Williams & Wilkins. 1998:1205-1209. Siennick, SE. Findling RL. Guelzow. BT. Conduct disorder/aggression. Emotional and Behavioral Disorders in Youth 2005;5(2):35. •> CASE 20 A 36-year-old man is referred to his employment assistance agency because he has trouble making timely decisions and is often late with important work. The patient has angrily complied with this request although he does not believe that anything is wrong with him. He describes himself as "so devoted to my work that I make others look bad," believing that this is why he has been singled out for attention. The patient says that he has worked at the company for 4 years and during that time has put in anywhere from 10 to 12 hours of work per day. He admits that he often misses deadlines but claims that "they are unreason- able deadlines for the quality of work that 1 provide." He states, "If more peo- ple in the country were like me, we would get a lot more done—there are too many lazy slobs and people who don't follow the rules." He points out that his office is always perfectly neat, and he says, "I know where every dollar I ever spent went." On a mental status examination, the patient does not reveal any abnormali- ties in mood, thought processes, or thought content. His manner is notable for its rigidity and stubbornness. • What is the most likely diagnosis? • What other psychiatric disorder is this condition often confused with, and how does one tell them apart? 184 CASE FILES: PSYCHIATRY ANSWERS TO CASE 20: Obsessive-Compulsive Personality Disorder Summary: A 36-year-old man has a lifetime preoccupation with rules, work, order, and stinginess. Even so. he is in trouble at work because he keeps miss- ing deadlines and has difficulty making decisions. The patient does not realize that he is the cause of his problems—rather, he blames them on others. He comes across as rigid and stubborn in manner. • Most likely diagnosis: Obsessive-compulsive personality disorder. • Differential diagnosis: Obsessive-compulsive disorder (OCD). When recurrent obsessions or compulsions (checking rituals, washing hands repeatedly, etc.) are present, OCD should be diagnosed on axis I. Analysis Objectives 1. Recognize obsessive-compulsive personality disorder. 2. Understand the difference between obsessive-compulsive personality disorder and OCD itself. Considerations This patient's difficulties fit a personality disorder in that he is inflexible in his thinking or behavior, which causes problems in social or work settings. This man came into the employee assistance program because of problems he was having at work: rigidity, stubbornness, and difficulty in making decisions and keeping to deadlines. Typically (as in this case) the patient's disorder is ego- syntonic; that is, he does not recognize his problems as originating from within himself but rather blames them on others in the outside world. Also, he is stingy with his money, although he works many hours a week. He seems somewhat moralistic about others and about their work habits, especially when they are compared to his own. No obsessions (intrusive, repetitive thoughts) or compulsions (ritualistic behaviors) are noted that are typical of OCD; the results of his mental status examination are otherwise normal. APPROACH TO OBSESSIVE-COMPULSIVE PERSONALITY DISORDER Definitions Compulsion: The pathologic need to act on an impulse. If the action is not performed, anxiety results. Usually, the compulsion has no true end in itself other than to prevent some imagined disaster from occurring. For 185 CLINICAL CASES example, a patient has an obsession about being dirty, and the compul- sion associated with it is ritualistic washing. Defense mechanisms: A psychodynamic term that defines various means that an individual might use to psychologically cope with a difficult sit- uation. These defense mechanisms range from relatively mature ones such as humor to quite immature ones such as often seen with border- line personality disorder. These might include mechanisms such as devaluation, idealization, projection, projective identification, and split- ting. Commonly used defense mechanisms with obsessive personality disorder are intellectualization. rationalization, undoing, and isolation of affect. Intellectualization: A defense mechanism by which an individual deals with emotional conflict or stressors by the excessive use of abstract thinking to control or minimize disturbing feelings. For example, a man is involved in a car accident that causes him to be paralyzed. He spends hours in the hospital brooding over the details of the accident and the treatment he has received in the hospital but does so in an emotionally barren manner. Isolation of affect: A defense mechanism by which an individual deals with emotional conflict or stressors by separating ideas from the feel- ings originally associated with them. The individual loses touch with the feelings associated with the given idea (e.g., the traumatic event) although remaining aware of the cognitive elements of it (e.g descrip- tive details). For example, a man comes home to find his wife in bed with another man. Later, describing the scene to a friend, the man can relate specific details of the scene but appears emotionally unmoved by the whole event. Obsession: An intrusive, repetitive thought that comes unbidden and can- not be eliminated from consciousness by effort or logic. It is usually anxiety-producing. Personality disorder: An enduring pattern of inner experience and behav- ior that deviates markedly from the expectations of the individual's culture, is pervasive and inflexible, has an onset in adolescent or early adulthood, is stable over time, and leads to distress or impairment. Rationalization: A defense mechanism by which an individual deals with emotional conflict or stressors by concealing the true motivations for thoughts, actions, or feelings through the elaboration of reassuring or self-serving but incorrect explanations. For example, a woman steals a coat from a local department store although she can afford to pay for it. She tells herself, "It's okay—that department store has plenty of money, and they won't miss one coat!" Undoing: A defense mechanism by which an individual deals with emo- tional conflict or stressors with words or behavior designed to negate or to symbolically make amends for unacceptable thoughts, feelings, or actions. Undoing can be realistically or magically associated with the [...]... low-dose, high-potency antipsychotic or a low-dose, short-acting benzodiazepine can be helpful in decreasing the agitation seen in patients with dementia REFERENCES Cummings JL Frank JC Cherry D et al Guidelines for managing Alzheimer's disease: part II Treatment Am Fam Physician 2002: 65( 12): 252 5- 2 53 4 Ebert M, Loosen P Nurcombe B, eds Current diagnosis and treatment in psychiatry New York: McGraw-Hill... Should this patient be given any medication? 198 CASE FILES: PSYCHIATRY ANSWERS TO CASE 22: Dysthymic Disorder Summary: A 34-year-old man suffered from major depression in the past and, according to his history, a 10-year-period of depressed mood with insomnia, a fluctuating appetite, and a decreased ability to concentrate He also notes that his self-esteem is low He is experiencing no suicidal ideation,... mental disorders, 4th ed Washington, DC: American Psychiatric Publishing, 1994:11 3-1 15 Ebert M Loosen P Nurcombe B eds Current diagnosis and treatment in psychia­ try New York: McGraw-Hill 2000:48 2-4 84 Kaplan H Sadock B Synopsis of psychiatry 9th ed Baltimore: Lippincott Williams & Wilkins, 2003:11 1-1 14 •> CASE 21 A 34-year-old woman comes to a psychiatrist with a chief complaint of a depressed mood She... physician for more than 12 years for treatment of mild hyper­ tension (well-controlled) Some mild aphasia is noted, and the patient can recall only two out of three objects at 5 minutes • What is most likely diagnosis for this patient? • What is the next step? 204 CASE FILES: PSYCHIATRY ANSWERS TO CASE 23: Dementia Summary: A 69-year-old man has been having problems with memory and disorganized behavior... is also a medical student Which of the following disorders does this student most likely have? A B C D E OCD Obsessive-compulsive personality disorder Obsessive-compulsive traits Schizoid personality disorder Paranoid personality disorder 188 CASE FILES: PSYCHIATRY [20.3] A 26-year-old woman comes to see a psychiatrist because she has been taking showers for 6 to 7 hours every day She explains, "It... be used to self-monitor whatever condition is being observed (For example, patients with obsessive-compulsive personality disorder and insulin-dependent diabetes can be asked to self-monitor their blood glucose level at exact times during the day and physicians can be sure this will be done.) The definitive treatment for obsessive-compulsive personality disorder is long-term, insight-oriented psychodynamic... posttraumatic stress disorder J Clin Psychiatry 1999;60(suppl I6):3—76 Foa EB Keane TM Friedman MJ, eds Effective treatments for PTSD New York: Guilford Press, 2000:13 5- 1 64 Ursano RJ el al Practice guidelines for the trealmeni of patients wilh acute stress disorder and posttraumatic stress disorder Am J Psychiatry 2004:161 (Nov suppl):l 1 V •> CASE 22 A 34-year-old man visits a psychiatrist with a... although she says that she wishes her attacker would "die a horrible death." • What is the most likely diagnosis? • Should this patient be hospitalized? 192 CASE FILES: PSYCHIATRY ANSWERS TO CASE 21: Posttraumatic Stress Disorder Summary: A 34-year-old woman suffered a traumatic event 1 year ago Since that time, she has been depressed, irritable, angry, and disconnected emotion­ ally She has trouble... more agitated and aggressive Which class of medication would be the most appropriate management for his behavior? A B C D Acetylcholinesterase inhibitor High-potency antipsychotic Long-acting benzodiazepine Low-dose antidepressant 210 CASE FILES: PSYCHIATRY Answers [23.1] A For a diagnosis of dementia, one or more additional cognitive deficits must be present in addition to memory impairment They can... Nurcombe B, eds Current diagnosis and treatment in psychiatry New York: McGraw-Hill 2000:30 7-3 11 Kaplan H, Sadoek B Synopsis of psychiatry 9th ed Baltimore: Lippincott Williams & Wilkins 2003 :57 2 -5 76 •> CASE 23 A 69-year-old man is brought to his primary care physician by his wife, who complains that his memory has been failing for the past several months The patient states that he forgets the names of . confused with, and how does one tell them apart? 184 CASE FILES: PSYCHIATRY ANSWERS TO CASE 20: Obsessive-Compulsive Personality Disorder Summary: A 36-year-old man has a lifetime preoccupation. Sadock's comprehensive textbook of psychia- try, 7th ed. Philadelphia: Lippincott Williams & Wilkins. 2000:274 0-2 757 . •> CASE 19 A 1 5- year-old girl is brought to a psychiatrist by her. Obsessive-compulsive personality disorder C. Obsessive-compulsive traits D. Schizoid personality disorder E. Paranoid personality disorder 188 CASE FILES: PSYCHIATRY [20.3] A 26-year-old woman