Letters to the Editor
Problems With Crystallizing Phenomenology and Nosology in Adolescent Psychiatry
Dear Editor:
Debate over the DSM-IV criteria for child and adolescent disorders continues, focusing on developmental modifications to symptom clusters such as bipolar disorder and posttraumatic stress disorder (PTSD) and their expression in children and adolescents (1,2). Findings from a recent study on PTSD showed that absence of the triad does not indicate a lack of posttraumatic stress problems; rather, such absence may be owing to developmental differences in symptom expression. As such, current diagnostic criteria may not be appropriate for children (2). Similarly, a study of major depression and dysthymia included pathological behaviour such as disobedience, which was found to be quite frequent in adolescents with dysthymia (3). Even though child or adolescent symptomatology may not fit the criteria for a diagnosis, there can be significant impairment, which is important for nosology and prognosis (4). We report on 3 cases wherein symptom description and expression were ambiguous as a function of verbal expression, intelligence, and age-related psychosocial stresses.
Case Report 1: Depression— Growing Pain or True Morbidity?
A 16-year-old boy was admitted for acute suicidal risk after his third appointment with a psychiatrist. He first presented with symptoms of depression and met the criteria for major depressive disorder (MDD). He was given a selective serotonin reuptake inhibitor (SSRI) and weekly appointments. After a night on the ward, the patient showed dramatic improvement in mood, sleep, appetite, and energy. Medication was discontinued and he remained euthymic. He had significant learned helplessness attributable to an underlying learning disorder. Further inquiry revealed an amorous crisis as the main precipitator. The patient was discharged with a diagnosis of situational reaction.
Case Report 2: Psychosis or Hypomania?
A 17-year-old boy of limited intellectual and cognitive functioning was escorted by police and admitted involuntarily for insomnia and acute onset of nonstop activity lasting 72 hours. His maternal family history was positive for schizo- affective disorder. He was very suspicious on the ward, refusing ward food and isolating himself from others. He had no insight regarding his mental state and was noncompliant with medication. A drug screen was negative, and he had no neurological abnormalities. He was granted appeal against his admission and left 4 days later with a discharge diagnosis of queried bipolar affective disorder. He was readmitted 7 days later for psychiatric assessment and observation over 14 days. He had periods of immobility, agitation, and extreme negativism that were consistent with catatonia. He also had frank paranoid delusions and ideas of reference. Administration of zuclopenthixol acetate (50 mg) led to amelioration of symptoms, but not to their previous discharge level. The patient’s discharge diagnosis was changed to schizophrenia, catatonic type. He was readmitted again 2 weeks later with a similar presentation. This time, he was transferred to a longer- stay ward and put on depot neuroleptic owing to ongoing noncompliance.
Case Report 3: PTSD or Schizophrenia?
A 16-year-old girl with a history of sexual and physical abuse presented with periods of bizarre behaviour, auditory hallucinations, and persecutory delusions. At age 14 years, she had been diagnosed with PTSD attributable to chronic abuse; she did not respond to SSRI treatment. Previously, at age 12 years, she had been diagnosed with Asperger’s disorder. Observation and assessment over a 3-week period showed bizarre delusions with incongruent affect, third-person hallucinations, thought disorder, and severely impaired functioning. Neuroleptic medication provided mild symptom relief, but her psychotic symptoms remained for 8 months. Her diagnosis was changed to schizophrenia, disorganized type.
These cases demonstrate that a disorder tends to evolve over time as the brain develops, before crystallizating into an operational diagnostic entity. Patients who are behaviourally and emotionally immature may not fully meet existing diagnostic criteria, because these often fail to take developmental stage into account (5). In Case Report 1, the patient met criteria for MDD at his first consultation. However an adolescent’s first breakup can have a highly significant impact on symptom presentation. Further, the time period required by the DSM-IV may be inadequate for an adolescent. In Case Report 2, the patient’s extreme hyperactivity, disrespectful demeanour, and refusal to comply led to his behaviour being described as hypomanic, despite the absence of elevated mood and affect. Structured observation and assessment over time uncovered the underlying psycho- pathology and phenomenology. Note that catatonic symptoms are uncommon among adolescents. In Case Report 3, the patient’s diagnosis of Asperger’s disorder may have been a description of premorbidity to her later schizophrenic illness. The confusion arose from her known history of abuse; her presenting symptoms were attributed to dis- sociative phenomena rather than to positive symptoms of psychosis. The full presentation of schizophrenia can require the passage of 2 years to crystallize.
Note
These cases were previously presented as a poster at the World Psychiatric Association Symposium; June 2003; Vienna.
References
1. Biederman J, Klein RG, Pine DS, Klein DF.
Resolved: mania is mistaken for ADHD in prepubertal children. J Am Acad Child Adolesc Psychiatry 1998;37:1091–6. Discussion 1096–9.
2. Carrion VG, Weems CF, Ray R, Reiss AL. Toward an empirical definition of pediatric PTSD: the phenomenology of PTSD symptoms in youth. J Am Acad Child Adolesc Psychiatry 2002;41:166–73.
3. Flament MF, Cohen D, Choquet M, Jeammet P, Ledoux S. Phenomenology, psychosocial correlates, and treatment seeking in major depression and dysthymia of adolescence. J Am Acad Child Adolesc Psychiatry 2001;40:1070–8.
4. Pickles A, Rowe R, Simonoff E, Foley D, Rutter M, Silberg J. Child psychiatric symptoms and psychosocial impairment: relationship and prognostic significance. Br J Psychiatry 2001;179:230–5.
5. Weller EB, Weller RA. Depression in adolescents growing pains or true morbidity? J Affect Disord 2001;61(Suppl 1):9–13.
Nasreen Roberts, MD
John CC Chan, MD
Kingston, Ontario
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