INSTRUCTIONS
Answer the question presented in the below discussion (case presentation) supporting your rationale with at least two scholarly references from the literature.
CASE PRESENTATION
Discussion questions:
What are some treatments, for example, behavioral and psychopharmacological, used in treating DMDD?
1. Are there any controversies regarding diagnosing bipolar disorder in children and adolescents?
2. What are some contributing factors and protective factors for LM that you noticed in his case presentation?
Subjective:
Patient Initials: LM. Age 13 Y/O. Gender: male
CC (chief complaint): “We are looking to get a change in medication”
HPI: LM is a 13 Y/O Hispanic male who presents for an initial evaluation with his mother present for the interview. According to LM’s mother, he has had angry outbursts, seems extremely depressed, and is always sad and down, but has periods of being helpful. She states this has been going on for about 8 years. According to his mother, when LM was in the 5th grade, he verbalized suicidal thoughts stating, “I want to choke myself.” LM is home-schooled and states he has one friend and that “it is hard with my ADHD to keep up, so I have to ask my friend for help.” LM describes his mood as “all over the place” and states he got out of a relationship 2 days ago, and since then, he has been “a little down.” LM relays that his daily energy levels are “low” and that he gets 6-7 hours of sleep, but that it takes him “a while to get to sleep. The client describes his appetite as “ok” and reports 2 meals a day with snacks. LM also describes “jerks” and “muscle spasms” that he has had “his whole life” in his arm that is getting worse. LM states that his goal for treatment is that he would like his medications to make his “moods more stable, and easier for me to control myself, and figure out the reasons why I’m mad, so I can stop behaving like I do.”
Past Psychiatric History:
-General Statement: The patient has diagnoses of ADHD (combined type), disruptive mood dysregulation disorder, and irritability and anger.
-Caregivers: Mother
-Hospitalizations: None
-Medication trials: Strattera, Prozac, Zoloft, risperidone, clonidine (per mother, “helped with ADHD a bit”).
-Psychotherapy or Previous Psychiatric Diagnosis: History of Therapy (mother states “he never opened up enough, although it did help somewhat”). The client has not resumed therapy.
Substance Current Use: The client denies current or past use of illicit substances, including marijuana. He also denies alcohol use, and cigarette or vape use.
Family Psychiatric/Substance Use History: Mother-Bipolar (currently on Effexor and used starting in 2nd trimester while pregnant with LM). Father- depression, anxiety, substance use. Maternal uncle: Schizophrenia. Maternal grandmother: Bipolar.
Medical History:
· Current Medications: Cymbalta 20 mg(currently weaning by 20 mg weekly from 60 mg), Abilify 5 mg PO daily at HS, Doxycycline 100mg PO daily. Guanfacine 1 mg PO daily.
· Medical conditions: Acne
· Allergies: NKDA
· Reproductive Hx: No children
· Surgeries: None
Psychosocial History: LM is a 13 Y/O Hispanic male currently living in South Florida after moving from Jacksonville, where he grew up. He is currently in the 8th grade, is a “C student,” and is home-schooled. He lives with his mother and two brothers, who are 11 and 15 years old. LM states that the relationship with his mother is “not that good” and that his relationship with his brothers is distant. His father divorced his mother and left when he was 3 years old. LM used to see him twice a year, but not in the last 3 years as his father has been incarcerated. His mother relays that although the relationship with his father is stable, “they argue a lot because they are alike.” LM had to be pulled out of school due to disruptive behavior and outbursts. According to his mother, he would “flip tables, and when he got to school, “he would just put his head on the table and not do any work at all in school.” LM states he has a close relationship with his 14 Y/O male cousin and enjoys listening to music, playing video games, and coding.
ROS:
· GENERAL: 13 Y/O Hispanic male. Alert and cooperative, in no apparent distress.
· HEENT: Head normocephalic
· SKIN: no skin rashes
· CARDIOVASCULAR: Denies arrhythmias.
· RESPIRATORY: Denies SOB or history of asthma
· GASTROINTESTINAL: patient denies changes in appetite
· GENITOURINARY: patient denies urinary issues
· NEUROLOGICAL: denies hx of seizures or head trauma
· MUSCULOSKELETAL: Denies trauma or fractures
· HEMATOLOGIC: denies hx of bleeding disorders
· LYMPHATICS: denies hx of enlarged lymph nodes
· ENDOCRINOLOGIC: denies heat or cold intolerance. Denies polyphagia or polydipsia
Objective:
Diagnostic results: Height 65 in. Weight 135 lbs. BMI=22.5
Assessment:
Mental Status Examination: LM is a 13 Y/O Hispanic male alert oriented to person, place, time, and situation. The patient appears his stated age, appears overweight and maintains good eye contact during the interview. LM is dressed appropriately for the weather and situation. His speech is a regular rhythm and tone. His affect was anxious during the interview, and his mood was calm. His remote memory is unimpaired, and his recent memory is intact. His thought processes are unimpaired, judgment and insight are also unimpaired. LM denies current suicidal, homicidal ideation and denies psychotic symptoms such as auditory or visual hallucinations or paranoid delusions.
Diagnostic Impression: ADHD (combined type), Irritability and anger, Disruptive Mood Dysregulation Disorder. The diagnosis of DMDD, a mood disorder, reflects the irritable mood element of DMDD. The highest rate of DMDD was found in preschoolers, and after the preschool, period ends the levels of irritability tend to be comparably stable over time. Treatment for this patient includes a stimulant, an SSRI, and an atypical antipsychotic. (Brotman et al., 2017). The patient was previously on Cymbalta 120 mg daily but wanted to be weaned off it as his mother stated it was not working, and at the next appointment reported that he felt tired in the daytime and had trouble sleeping at night. LM also reported that the Guanfacine helped significantly with the frequency and intensity of his tics. In a review regarding medications for children with ADHD with tics, it was found that dose increases of dextroamphetamine and methylphenidate can be limited because it may exacerbate tics. It was also found that, for most children, tics can actually improve with stimulant medication use (Osland et al., 2018) I agree with the use of guanfacine, and the patient has reported some reduction in his tics.
Studies show that in a 6-week trial, aripiprazole in combination with methylphenidate among 51 children and adolescents resulted in significant decreases in patient-reported irritability; this occurred in patients with both ADHD and DMDD (Breaux et al., 2022). Alternate medication options were explored with the client and family as to other medication alternatives in future.
Differential Diagnoses:
(1) Bipolar Disorders: In differentiating DMDD from bipolar disorder in children involve a linear course of the central symptoms. Children manifest bipolar I and II the same way as adults do as an episodic illness with distinct episodes of agitation in mood, which are different from the child’s usual presentation. Also, during the manic episode, worsening of cognitive, behavioral, and physical symptoms must accompany the changes in mood. The contrast between DMDD and bipolar disorder is that with DMDD, the irritability is persistent over many months, while bipolar is episodic (APA 2022). According to Demeter et al., there is growing evidence that an elevated mood may be a crucial symptom of Bipolar spectrum disorders in the pediatric population which distinguishes this disorder from other psychiatric conditions. Axelson et al. found that 82% of children and adolescents with BP-NOS (bipolar disorder not otherwise specified) and 92% of those with BP-I also reported elevated mood. Yet another finding, Findling et al., showed that elevated mood was the best predictor of cyclothymic disorder or BP NOS in the children of a parent with bipolar disorder. (Demeter et al., 2022). For bipolar I, the criteria include a distinct period of abnormally and persistently elevated and irritable mood and persisting increased activity lasting at least one week; during this disturbance, there are three or more of the following; inflated self-esteem, grandiosity, flight of ideas, distractibility, and increase in goal-directed activity. The episode is not severe enough to impair functioning socially or occupationally. For Bipolar II the individual must meet the criteria for past or current major depressive episode and a past or current hypomanic episode (APA, 2022). During his interview, LM stated that he was a “liitle more irritable, and I’m up and down.” And due to his family history of bipolar disorder, it is beneficial to continue to explore his moods since he is currently being seen every 2-4 weeks for medication management.
(2) Oppositional Defiant Disorder: Individuals with this disorder tend to defy school work or tasks requiring them to apply themselves due to resistance in conforming to the demands of others. Characteristic behavior for this disorder is hostility, negativity, and defiance. This disorder must be differentiated from an aversion to school because of impulsivity, or difficulty in maintaining efforts mentally or forgetting instructions, such as in ADHD. Incidentally, some individuals with ADHD may also develop oppositional attitudes. According to the DSM-5-TR, symptoms of DMDD are relatively rare in children diagnosed with ODD (APA, 2022).
(3) Intermittent explosive Disorder: Children with this disorder present with temper outbursts that are severe, much like DMDD. However, intermittent explosive disorder does not need the individual’s mood to be consistently irritable between outbursts like DMDD would. Intermittent explosive disorder that involves verbal or physical aggression not resulting in property damage or physical injury to individuals or animals that occurs at least 2 times/week; the diagnosis can be made after 3 months of symptoms vs. a 12 month requirement for DMDD. Therefore both these diagnoses should not be made for the same child (APA, 2022)
Reflections:
What I would do differently, in this case, is to get a better timeline of how long his mood episodes last and how often his outbursts happen, especially during homeschool sessions. I would also inquire if his grades had gotten any better since being homeschooled and if he had any inclination as to what he wanted to do for a profession when he gets to be an adult. Special considerations for this population would be to make sure that the child or adolescent diagnosed with DMDD is able to find resources in seeking psychotherapy(CBT, DBT-C) and early treatment. This is due to them having difficulty maintaining healthy relationships with members of their family and their peers. They also may experience trouble in school, and have a hard time participating in team sports, or other social settings. Other disorders, such as ADHD, and anxiety disorders, may also exist at the same time (NIMH, nd).
Case Formulation and Treatment Plan:
Plan: Continue to wean off Cymbalta by 20 mg weekly. Start Guanfacine 1 mg PO daily. Follow up in clinic in 2 weeks. Continue to explore moods also due to a family history of bipolar disorder. Continue to clarify mood disorder vs. DMDD vs. BPD. Explore the use of Guanfacine also to be beneficial for tics. The provider also recommends that the client restart therapy sessions.
-The patient and family were educated during this appointment on the importance of sleep hygiene, such as discontinuing the use of cell phones at bedtime, reducing or eliminating caffeine intake, and going to bed at a reasonable time since teenagers, on average, need more sleep per night than adults, lowering the temperature of the bedroom at night, and minimizing naps during the daytime.
-Patient educated on illnesses, symptoms, and diagnoses. Treatment options were reviewed with the patient, and the patient and family verbalized understanding and is in agreement with the treatment plan.
-Advised patient to routinely follow up with pediatrician for lab testing and monitoring of blood pressure
-Discussed medication side effects, benefits, and risks with the patient and family; the patient verbalizes willingness to take medications as prescribed.
-The patient was advised against using illicit substances or alcohol while on psychotropic medications due to the risk of negative interactions.
-The Client was advised to call 9-1-1 or go to the nearest emergency room if the patient experiences a medical or mental health emergency, including but not limited to suicidal/homicidal/ideation or plan.
References
American Psychiatric Association. (2022a). DSM-5-TR (5th ed.). APA Publishing. https://doi.org/10.1176/appi.books.9780890425787.x01_Neurodevelopmental_DisordersLinks to an external site.
American Psychiatric Association & . (2022). DSM-5-TR. Bipolar and related Disorders (5th ed.). APA Publishing. https://doi.org/10.1176/appi.books.9780890425787.x03_Bipolar_and_Related_DisordersLinks to an external site.
American Psychiatric Association. (2022b). DSM-5-TR. Depressive Disorders (5th ed.). APA Press. https://doi.org/ht10.1176/appi.books.9780890425787.x04_Depressive_DisordersLinks to an external site.
Breaux, R., Dunn, N. C., Swanson, C. S., Larkin, E., Waxmonsky, J., & Baweja, R. (2022). A Mini-Review of Pharmacological and Psychosocial Interventions for Reducing Irritability Among Youth With ADHD. Frontiers in Psychiatry, 14. https://doi.org/10.3389/fpsyt.2022.794044Links to an external site.
Brotman, M. A., Kircanski, K., & Leibenluft, E. (2017). Irritability in Children and Adolescents∗. Annual Reviews in Clinical Psychology, 13, 317–41. https://doi.org/10.1146/annurev-clinpsy-032816-044941Links to an external site.
Demeter, C. A., Townsend, L. D., Wilson, M., & Findling, R. L. (2022). Current research in child and adolescent bipolar disorder. Dialogues in Clinical Neuroscience, 10(2), 215–228. https://doi.org/https:/10.31887/DCNS.2008.10.2/cademeterLinks to an external site.
Disruptive Mood Dysregulation Disorder: The Basics [Press release]. (n.d.). National Institute of Mental Health. https://www.nimh.nih.gov/health/publications/disruptive-mood-dysregulation-disorderLinks to an external site.
Osland, S., Steeves, T., & Pringsheim, T. (2018). Medications for attention deficit hyperactivity disorder (ADHD) in children with tics. Cochrane Database of Systematic Reviews, (6). https://doi.org/https10.1002/14651858.CD007990.pub3Links to an external site.
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