Psychiatric Diagnosis and Management: Adult Essay

Psychiatric Diagnosis and Management: Adult Essay

The oppositional defiant disorder presents with a pattern of argumentative/defiant behavior, irritable/angry mood, or vindictiveness for a minimum of 6 months, according to the DSM-5 criteria. With an angry and irritable mood, the individual easily loses temper, gets annoyed and touchy, angry and resentful whereas, for argumentative/defiant behavior, the person argues with authority figures, adults, and children (Aggarwal & Marwaha, 2022). Vindictiveness entails the individual becoming spiteful/vindictive a minimum of two times within the last six months. For persons who are at least five years old, the behavior should happen at least one time per week for a minimum of six months (Burke & Romano-Verthelyi, 2018). In this case study, the patient is disrespectful towards her teacher, care provider, and mother. She yells, argues, curses the teacher and staff, and gets angry when changing course into something she is uninterested in. She has co-existing ADHD, which also explains the challenges with transitions/changing course in tasks at school. Oppositional defiant behavior and irritability are noted in reaction to stress, including a divorce or family move. The child lives with the mother as the father is in jail. She is currently under her neighbor’s care since the mother took another job. The disorder could be escalating to conduct disorder, as the patient threatened her teacher today, “I will get you, just you watch” when she was asked to climb down from the classroom windowsill. Nonetheless, the mother denies any threats against her and any history of stealing, fire setting, animal hurting, or property destruction, ruling out conduct disorder at present.

Management of oppositional defiant disorder involves the patient, family, school, and community. Parent management training and child problem-solving skills provide the most significant efficacy for children with ODD. Dulcan (2022) describes child problem-solving skills to correct dysfunctional social interactions while focusing on delaying impulsive response and increasing reflection on alternative solutions, anticipating consequences, and practicing self-assessment of behaviors. Parent management training imparts the skills to parents to develop and implement structural contingency management programs centered on diminishing disruptive behavior and improving child compliance (Booker et al., 2018).

 

References

Aggarwal A, Marwaha R. Oppositional Defiant Disorder. [Updated 2021 Sep 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557443/

Booker, J. A., Capriola-Hall, N. N., Greene, R. W., & Ollendick, T. H. (2020). The parent-child relationship and post-treatment child outcomes across two treatments for oppositional defiant disorder. Journal of Clinical Child and Adolescent Psychology, 49(3), 405–419. https://doi.org/10.1080/15374416.2018.1555761

Burke, J. D., & Romano-Verthelyi, A. M. (2018). Oppositional defiant disorder. In Developmental Pathways to Disruptive, Impulse-Control and Conduct Disorders (pp. 21-52). Academic Press. https://www.sciencedirect.com/science/article/pii/B978012811323300002X

Dulcan, M.K. (2022). Dulcan’s textbook of child and adolescent psychiatry. (3^rd ed.) American Psychiatric Association Publishing: Washington, DC.

25 days ago

Kimberly Bernacki 

9-yr-old girl with disruptive behavior

COLLAPSE

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Differential Diagnoses

 

1. Oppositional defiant disorder – DSM-5 states ODD is a pattern of angry/irritable mood, argumentative/defiant behavior, or vindictiveness lasting at least 6 months as evidenced by 4 symptoms from any of the following categories: Angry/Irritable Mood: loses temper, touchy and easily annoyed, angry and resentful, Argumentative/Defiant behavior: argues with authority figures, children, adults, Vindictiveness: spiteful or vindictive at least 2 times within the past 6 months (APA, 2013). For individuals 5 years or older, the behavior should occur at least 1x/week for at least 6 months (APA, 2013).
2. Conduct Disorder – Low probability because the patient is non-threatening and hasn’t violent toward animals or people. DSM-5 states diagnostic criteria for conduct disorder is a repetitive and persistent pattern of behavior in which the basic rights of others or major age appropriate societal norms or rules are violated as manifested by the presence of at least 3 of the following 15 criteria in the past 12 months from any of the categories listed, with a at least 1 criterion present in the past 6 months: Aggression to people/animals (bullies, threatens/intimidates others, initiates physical fights, has used a weapon to harm others, has been cruel to people or animals, has stolen something, forced someone into sexual activity (APA, 2013).

Destruction of property, Deceitfulness or theft, serious violation of rules (violating parental rules such as staying out at night or running away from home overnight at least 2 times while living in parent’s house (APA, 2013).

1. Intermittent Explosive Disorder – DSM-5 states IED as recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following: verbal aggression (verbal arguments/fights, temper tantrums, physical aggression that does not result in damage or destruction of property, animals, or individuals for a period of 3 months, twice weekly on average or 3 behavioral outbursts involving damage or destruction of property and/or physical assault involving injury against animals or individuals within a 12 month period (APA, 2013). 6 years of age or older. 3-month requirement of active symptoms. Severe temper outbursts. Does not require persistent disruption of mood like disruptive mood dysregulation disorder. Rapid onset of the outbursts typically lasting for less than 30 min and commonly occur in response to a minor provocation by a close intimate individual or associate (APA, 2013).
2. Disruptive Mood Dysregulation Disorder – DSM-5 states disruptive mood dysregulation disorder as severe recurrent temper outbursts manifested verbally and/or behavior outbursts grossly out of proportion to the situation (APA, 2013). Temper outbursts occur on average 3 or more times/week, mood between temper outbursts are persistently irritable or angry most of the day, nearly every day, and is observable by others, and has been present 12 months or more, diagnosis should not be made before age 6, and cannot co-exist with ODD, IED, or bipolar disorder, though it can co-exist with MDD, ADHD, Conduct and Substance-Use Disorder (APA, 2013). 12-month requirement of active symptoms. Persistent irritability.
3. Autism Spectrum Disorder – Low probability. This patient does not display deficits in social communication and there appears to be no evidence of repetitive patterns of behavior, isolation, or indifference to facial and tonal communication cues. DSM-5 criteria for autism spectrum disorder is persistent deficits in social communication and social interaction across multiple contexts (APA, 2013).

Restrictive/repetitive patterns of behavior, interests, or activities as manifested by at least 2 of the following (repetitive motor movements (lining up toys), inflexible adherence to routines and ritualized patterns of verbal/nonverbal behavior (extreme distress with changing up routines, difficulty with transitions, rigid thinking, and rituals such as taking same route every day or eating same food everyday), highly restricted fixated interest in unusual objects, adverse response to specific sounds or textures, excessive smelling/touching of objects and fascination of lights/movement (APA, 2013).

Symptoms must be present in early developmental period, cause clinically significant impairment in social, occupational, or other important areas of current functioning, and are not better explained by intellectual disability or global development delay (APA, 2013). Children with autism may display tantrums because of inability to tolerate a change from their expected course of events (APA, 2013). There is social dysfunction and peer rejection seen in ADHD but the social disengagement, isolation, and indifference to facial and tonal communication cues are missing in ADHD but present in autism spectrum disorder (APA, 2013).

1. Attention Deficit Hyperactivity Disorder (ADHD) – Moderate probability that this disorder co-exist with the patient’s oppositional defiant disorder. This patient has difficulty with changing course and transitioning in school and doesn’t want to focus on activities that don’t interest her. APA (2013) states patients with ADHD may misbehave or have a tantrum during a major transition because of impulsivity or poor self-control.  DSM-5 states ADHD diagnostic criteria as a persistent pattern of inattention and/or hyperactivity-impulsivity that interferes with functioning characterized by inattention and/or hyperactivity and impulsivity (APA, 2013).

The inattentive type has six or more of the following symptoms for at least 6 months that interferes with social and academic/occupational activities: overlooks or misses details, difficulty sustaining attention in tasks, mind seems to wonder and doesn’t listen when spoken to directly, doesn’t follow through on instructions and fails to finish chores or duties, difficulty managing and organizing task and fails to meet deadlines, reluctant to engage in task that take sustained mental effort, loses things, distracted by external stimuli, forgetful in daily activities (APA, 2013).

The hyperactivity/impulsivity type has six or more of the following symptoms and have persisted for 6 months: fidgets and can’t stay in seat, leaves seat when remaining seating is expected such as in classroom, runs or climbs when not appropriate, unable to play or engage in leisure activities quietly, restless and unable to stay still for a period of time when appropriate, talks excessively, blurts out answers in class, difficulty waiting in line or his/her turn, interrupts or intrudes on others (APA, 2013).

 

Final Diagnosis

 

Oppositional Defiant Disorder (Transient due to high stress environment) – High Index of probability. Dulcan (2022) states transient oppositional defiant behaviors and irritability can be seen in reaction to stress, such as a family move or divorce. This 9-yr-old child lives with a single mother who has a father in jail and has been put into the care of the neighbor since the mother recently took another job. Patient is disrespectful toward teacher, staff, and mother. Patient yells, argues, and curses at teacher and staff and is triggered by changing course to do something she does not have any interest in. The patient’s co-existing ADHD can cause the patient to have difficulty with transitions and changing course with tasks in school. The patient consistently doesn’t follow rules, argues constantly, and tries to be annoying. Patient is not threatening and hasn’t been violent toward animals or people which would rule out conduct disorder, a more severe anti-social behavior. Patient is defiant and doesn’t want to follow bedtime routines. The MSE reveals a bright young lady who is easily frustrated and irritated and is disrespectful during the interview. The patient has a normal IQ and routine lab screening tests are normal which rules out any learning disabilities. Per DSM-5 criteria, individuals with oppositional defiant disorder may resist work or school tasks that require self-application because they resist conforming to others’ demands and behavior is characterized by negativity, hostility, and defiance (APA, 2013).  Oppositional defiant disorder can co-exist with ADHD.

 

Co-existing with Attention Deficit Hyperreactivity Disorder.  APA (2013) states patients with ADHD may misbehave or have a tantrum during a major transition because of impulsivity or poor self-control. This patient has difficulty with changing course and transitioning in school and doesn’t want to focus on activities that don’t interest her.

 

** Please note: I believe the patient currently has a diagnosis of ODD, however, due to today’s presentation, the disorder could be escalating to conduct disorder. Today the patient threatened to harm her teacher, stating, “I will get you, just you watch”, after she was asked to climb down from the classroom windowsill. The patient is vindictive, disrespectful, and extremely argumentative, however, the mother denies that the patient has threatened or become violent toward her and there is no previous history of stealing, fire setting, hurting animals or destruction of property which would rule out conduct disorder at this time.

 

 

Management Plan

 

1. Problem solving skills training
2. Parent management training (PMT)
3. Collaborative and proactive solutions (CPS)
4. School based interventions – education and specific tools for the teacher to improve classroom behavior, techniques to prevent oppositional behavior and decrease the escalation of the behavior, and other methods that facilitate adherence to classroom rules and acceptable social norms (Aggarwal, 2022).
5. No pharmacological treatments at this time. Will reevaluate once problem solving skills training, PMT, and CPS have been used for several weeks. At that time, I would consider treating the co-existing ADHD and determine if this medication is also helping with the patient’s ODD. If after careful review and evaluation of the patient’s current symptoms are severe enough, I might consider a mood stabilizing agent or antipsychotic.

 

Rationale

 

Treatment of oppositional defiant disorder is multimodal and should involve the patient, family, school, and community (Aggarwal, 2022). Dulcan (2022) states parent management training and child problem-solving skills training have demonstrated greatest efficacy for children with ODD. Child problem-solving skills training derives from cognitive behavioral therapy techniques for correcting dysfunctional social interactions and focuses on delaying impulsive responses increasing reflection on alternative solutions, anticipating consequences, and practicing self-assessment of behaviors (Dulcan, 2022). Cognitive-behavioral therapy (CBT) based anger management training is useful in treating anger problems (Aggarwal, 2022). Parent management training affects child behavior by improving parent skills in dealing with negative acts and promoting desired behaviors (Dulcan, 2022). Children diagnosed with ODD are often lacking skills such as emotion regulation and social interaction making it difficult to relate to others further propagating problematic behaviors (Booker et al., 2018). Negative parent-child relationship factors including forms of rejection or dismissal of the child’s emotional distress can increase oppositional symptoms (Booker et al., 2018). Parent management training (PMT) teaches parents how to develop and implement structural contingency management programs to focus on decreasing the disruptive behavior and increase child compliance (Booker et al., 2018). The treatment focus with parent management training includes the use of direct and clear commands, one-on-one time to increase positive reinforcement for prosocial child behaviors, and time-out from reinforcement for negative child behaviors (Booker et al., 2018). PMT results in declines in parenting stress and parent dysfunction which are important factors that contribute to healthier parent-child relations (Booker et al., 2018). PMT is the gold standard for treating youth with ODD (Booker et al., 2018). Another treatment collaborative and proactive solutions (CPS) focuses on helping parents and children collaboratively and proactively solve problems that are contributing to behavior problems (Booker et al. 2018). CPS improves flexibility, problem solving, and adaptability that contribute to the development and symptoms of ODD (Booker et al., 2018). CPS has demonstrated comparable efficacy to PMT, however CPS appeared to be better suited for families where hostile interactions were common in the home and both parents and children were struggling to be able to display positive warmth with one another (Booker et al., 2018). CPS appeared to identify underlying issues that contribute to hostile interactions between parents and children and address the causes and consequences of hostile interactions so that parents could redirect these interactions and promote constructive behaviors in their children (Booker et al., 2018). No evidence exists to support an indication for specific medication use in the treatment of ODD (Dulcan, 2022). Psychosocial interventions are the first-line treatment for children with ODD and pharmacologic agents are typically reserved for cases in which aggressive and disruptive behaviors cannot be managed by the above treatment modalities alone (Aggarwal, 2022). Dulcan (2022) reports that children with severe physical aggression or those who are not improving with other management strategies such as PMT, CPS, or problem-solving skills training may benefit with an antipsychotic or mood stabilizing agent. Bower (2019) states valproic acid or divalproex sodium may be considered for the treatment of children and adolescents for children with disruptive behavior disorders.

 

References

 

Aggarwal A, Marwaha R. Oppositional Defiant Disorder. [Updated 2021 Sep 22]. In: StatPearls [Internet]. Treasure Island

(FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557443/

 

Booker, J. A., Capriola-Hall, N. N., Greene, R. W., & Ollendick, T. H. (2020). The parent–child relationship and

posttreatment child outcomes across two treatments for oppositional defiant disorder. Journal of Clinical Child and             Adolescent Psychology, 49(3), 405–419. https://doi.org/10.1080/15374416.2018.1555761

 

Bowers, R.T., Weston, C.D., Mast, R.C., Nelson, S.C., Jackson, J.C. (2019). Green’s Child &

Adolescent Clinical Psychopharmacology. (6^th ed). Wolters Kluwer.

 

Dulcan, M.K. (2022). Dulcan’s textbook of child and adolescent psychiatry. (3^rd ed.) American Psychiatric

Association Publishing: Washington, DC.

 

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