Forty-Eighth Annual Teaching Conference Pediatrics for the Practitioner -UT Health Science Center San Antonio School of Medicine June 10-12, 2011

Transcription

1 Child Psychiatry Case Studies Adelaide Robb, MD Associate Professor Psychiatry and Pediatrics Source Advisory Board Disclosure Speaker s Bureau Bristol Myers Squibb Epocrates Research Contract Royalties Stock Janssen Forest Glaxo Smith Kline McNeil Merck/Scherring Lilly Lundbeck Pfizer Otsuka Shinogi Supernus NICHD CHADD Overview Cases are illustrative of the three main topics I will be presenting OCD and other anxiety disorders Treatment of major depression in the era of the black box Diagnosing and treating bipolar disorder Details on cases have been changed and stories blended to obscure identities

2 No Peeking at the Answers Case 1 Nick Presenting Symptoms 16 yo high school junior at a private school treated since elementary school for ADHD Grades dropping, noncompliant with ADHD medication New girlfriend, active participation in sports and clubs Arguments over curfew and driving privileges Therapist concerned Case 1 Nick Additional Data

3 Case 1 Nick Additional Data HPI: deterioration over course of summer when off stimulants FH: ADHD and substance use no suicides or mood disorder PSH: flunking most of classes not doing work, taking car and driving w/o permission, going to gf house for liaisons MSE shaved off eyebrow, verbose, thinks teachers find him charismatic tox screen negative thyroid function normal Case 1 Nick Diagnosis Bipolar Disorder most probably manic ADHD by history Plan Trial of atypical antipsychotic and remain off stimulants Brief stint in PHP when behaviors escalated with sleep deprivation Struggles with need to control impulses Case 2 Tiffany Presenting Symptoms 12 yo girl entering middle school Always a worrier now having panic attacks on a regular basis Poor sleep at night Since starting on sertraline feels like she cannot go on with living Also on clonazepam 0. 5 mg bid Admitted for safety

4 Case 2 Tiffany Additional Data Case 2 Tiffany Additional Data HPI: 10 pound weight loss, tremors, sweating, racing heart, stopped going to the mall for shopping, quit cheerleading due to discomfort FH cousin with MVP, uncle with epilepsy, mom worrier, pgm perfectionist PSH no drugs or smoking MSE anxious affect, tremors evident, easily startled LT EEG nl, ECG sinus tachycardia, tox screen negative, TSH<0. 2, ft4 14.0ng/dl Case 2 Tiffany Diagnosis Panic Disorder and Hyperthyroidism Consulted endocrinology treated with beta blocker and PTU Tapered off clonazepam Remained on sertraline 50 mg Suicidality resolved with treatment of thyroid dysfunction

5 Case 3 Will Presenting Symptoms 9 yo third grader with long history of ADHD and tics both motor and verbal Stable on long acting alpha-2 adrenergic agonist Now getting stuck on homework and not meeting deadlines for projects, gets frustrated when working in groups Case 3 Will Additional Data Case 3 Will Additional Data HPI Homework taking 4 hours, recent strep infection, lots of hand washing, gel and wipes everywhere, closet and bureau immaculate FH Dad, brother ADHD cousin Tourettes, both grandmothers rigid and cleaners PSH plays sports, has dog, picks at sores on skin MSE sores on skin, taps on corners of all objects, mumbling to self in room, tics include blinking LT ASO titer > 8X ULN, strep culture negative

6 Case 3 Will Diagnosis OCD and possible PANDAS Tourette s and ADHD by history Trial of SSRI for OCD symptoms Monitor titers for PANDAS and consider treatment with antibiotic Have dog checked by vet as they are frequent strep carriers Case 4 Jessica Presenting Symptoms 14 year old 9 th grader mom brings in for ADHD evaluation and treatment Issues mom notes include dropping grades, lack of friends in high school and poor sleep with trouble getting up to meet the bus Teen is somewhat reluctant to speak initially and hates her current therapist Case 4 Jessica Additional Data

7 Case 4 Jessica Additional Data HPI: struggle since middle school with friends and being social, transition to high school has been a struggle, spending hours looking at work but not finishing, room a mess, forgets to shower FH father dropped out of college, lost job, great uncle was eccentric recluse PSH quit travel soccer team, no friends, embracing the grunge look MSE when asked why did your mom bring you I have been depressed for the last two years and thinking about killing myself for the last two months, poor sleep energy appetite, anhedonia, LT all normal Case 4 Jessica Diagnosis Major Depression Brought mom in had long discussion about signs and symptoms of depression and suicidality Spoke with therapist and brought on board seeing 2x/week Started FDA approved SSRI Back in two weeks still depressed Back in six weeks-my kid is returning Case 5 Juan Presenting Symptoms 8 yo Hispanic second grader who presents with 15 pound weight loss and food refusal Lives with parents and two older brothers Has friends at school but recently stopped playing tball because too tired Grades all S or O

8 Case 5 Juan Additional Data Case 5 Juan Additional Data HPI several siblings had called him fat and 3 classmates had food poisoning on trip to museum vomiting on bus FH diabetes and hypertension no psychiatric disorders PSH large caring family both parents working two jobs, little supervision of meals MSE anxious, terrified of germs and vomiting, going in and out of doorways, lots of fear about god and the devil, LT bradycardia low WBC and low TFTs with normal TSH Case 5 Juan Diagnosis Met criteria for OCD and EDNOS Worked on refeeding with calorie supplements in beginning, family mealtime On SSRI for OCD and CBT Now normal weight and OCD symptoms resolved Dad has his son back

9 Questions?