Interesting case study: bipolar vs depression

Discussion in 'General Parenting' started by TerryJ2, May 10, 2012.

  1. TerryJ2

    TerryJ2 Well-Known Member

  2. InsaneCdn

    InsaneCdn Well-Known Member

    Just wish you didn't have to sign up, to see it...
    (I do NOT sign up... this board is a RARE exception)
     
  3. DammitJanet

    DammitJanet Well-Known Member Staff Member

    Terry, this is exactly why Cory's diagnosis has been changed now as an adult. Now that they have included the TDD in the DSM-V, it is obvious that he has/had TDD instead of Bipolar 1 because he really never had true manic episodes. He did have periodic depressive episodes that resulted in rages and very poor impulse control which we know now they should have never removed his ADHD label. I failed miserably with him. I listened to therapists who really knew nothing. They gave horrible advice and it is effecting his life badly.

    Now me? I am a living example of early onset bipolar. I have no doubt that I have had bipolar since I was a toddler. I started running away from home at like 4 years old. I wanted to "kill" someone when I was six and tried by pouring pool water into their cup. I thought that would hurt them. Then I ran away again. Most pictures of me as a kid dont have a smile in them.
     
  4. TerryJ2

    TerryJ2 Well-Known Member

    That's such a sad childhood, Janet. But I'm glad Cory is on the right track now.

    Insane, could you not read it at all? I may be able to cut and paste it here.
     
  5. TerryJ2

    TerryJ2 Well-Known Member

    CHALLENGING CASES Case Vignette: Severe Temper Outbursts in a 10-Year-Old Girl


    By Leo Bastiaens, MD |March 5, 2012

    Dr Bastiaens is Clinical Associate Professor of Psychiatry at the University of Pittsburgh. He reports no conflicts on interest concerning the subject matter of this article.

    QUESTION:

    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(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.


        Answer: Bipolar II disorder
        DISCUSSION
        In a previous commentary—Poor Practice, Managed Care, and Magic Pills: Have We Created a Mental Health Monster?—I attributed the overdiagnosis of pediatric bipolar disorder to poor diagnostic practices and contemporary insurance and societal pressures.[SUP]1[/SUP] The responsibility for improvement was placed on psychiatrists: diagnostic skills had to be improved and patients and their families and caregivers as well as the general public needed to be better educated about the disorder and treatment options. Here, I will discuss how diagnostic accuracy can be significantly enhanced through the use of structured psychiatric interview tools, such as the MINI.[SUP]2[/SUP]
        This case clearly demonstrates that with clinical interviewing only, the correct diagnosis was made, but for the wrong reason (bipolar disorder diagnosis made because of rages), while the wrong diagnosis was made because of the right reason (major depressive disorder; rages not considered as symptom for bipolar disorder). However, a structured approach with a validated clinical tool identified major depressive symptoms and at least 1 hypomanic episode, which indicated a bipolar spectrum condition, regardless of severe angry outbursts.
        Severe temper dysregulation, angry outbursts, and rages are not part of the diagnostic criteria for bipolar disorder, which requires a cyclical condition that includes core manic symptoms.[SUP]3[/SUP] Although outbursts can be part of bipolar disorder, they also occur in depressive disorders, ADHD, conduct disorder, and anxiety disorders and thus are not diagnostic in their own right. Structured interviews force the clinician to evaluate core symptoms of different disorders. In this case, neither the outpatient nor the inpatient psychiatrist identified core manic symptoms with unstructured clinical interviewing. In addition, benefits of using a structured interview include systematic evaluation of comorbidity and homogeneity of diagnostic assessments.
        It is becoming increasingly important to differentiate pediatric bipolar disorder from other mood dysregulation syndromes. Ongoing research shows that in children who have mood disorders without core manic symptoms, bipolar disorder does not develop in later years, despite the severe impairment related to their temper dysregulation episodes.[SUP]4[/SUP]
        There is ongoing research to evaluate whether different treatment approaches, other than mood stabilizers, are more effective in children with nonbipolar mood disorders. Thus, correctly diagnosing severe mood-related symptoms in youths is not an academic exercise; it is needed to help make correct treatment decisions—behavioral and pharmacological.​
     
  6. InsaneCdn

    InsaneCdn Well-Known Member

    Boy, they got THAT right!
    Wrong labels are as bad as or worse than no labels, just like wrong medications are worse than no medications.
    The more we can take the "subjective" out of all these "behavioral" evaluations, the better.
     
  7. TerryJ2

    TerryJ2 Well-Known Member

    Yes, it's so obvious, it's painful to think they felt obligated to type it in ...
     
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