Download F91 Conduct Disorders

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University of Santo Tomas
Faculty of Medicine and Surgery
Department of Psychiatry
School Year 2009-2010
First Shift
PSYCHIATRIC
CASE ANALYSIS
Submitted by
Ace Malvin Mindanao
Maria Carmela Miranda
Ramon Miguel Molina
Jerry West Monzon
Arriane Morales
Merwen Mitchel Musni
Anna Pauline Nallas
Ayne Rangel Naval
Jesus Ponciano Nepomuceno
Christian Ceasar Nerpiol
Clarel Camille Ng
Pauline Elyz Ng
Joanne Napoleon Niere
Terence Michael Nismal
Michiko Nofrada
Jayne May Nubla
Paula Nuqui
Windelyn Ocampo
Alex Gian Olfato II
Andrew Ong
Date of Submission
16 October 2009
I. HISTORY AND PHYSICAL EXAMINATION
General Data:

CPS, 14 year old, female, single, Filipino, Roman Catholic

Residing with her aunt and uncles (maternal side) in Sta. Cruz , Manila

Eldest child of a brood of two

Currently a third-year high school student in St. Jude College
Information Source:

Patient: fair reliability

Aunt: good reliability
Chief Complaint:

According to patient: “Nasaktan ko po kasi mga kasama ko sa bahay.”

According to aunt: “Nagiging violent na siya.”
Personality Profile:

Pre-morbid: Nice to other people, cheerful, obedient, cooperative and smart

Morbid: Self-destructive, irritable, aloof, impulsive, violent and manipulative
History of Present Illness:
July 26, 2009

CS stole around P5000 from her Ate Maricar’s wallet, the latter then confronted her and asked
her to return the money but CS denied stealing anything.

Her aunt threatened to confiscate her mobile phone if she would not return the money, but still CS
denied the allegations
July 27, 2009

Her Ate Maricar noticed that CS was sporting new clothes, shoes and a new watch which
aroused her suspicion that CS really stole her money.

She then browsed CS’s things and found P1500, she then took the money and confiscated CS’s
mobile phone

When CS discovered that her phone was missing, she confronted her Ate Maricar and demanded
that her cell phone be returned immediately

She went into a tantrum and her tantrum was described as “nagwawala”

She threw and banged things and transferred her anger to her cousins
One day prior to admission

CS packed her things and wanted to run away and stay in a dormitory

Ate Maricar stopped her because it was dangerous for CS and was worried that CS might not
come home anymore

CS got angry and fought with her aunt, saying “Pabayaan n’o na ‘ko, hindi naman ako mahal na
ibang taopati ng nanay ko” and “balik mo sa akin mga gamit ko dahil ito lang ang buhay ko”

Argument turned into a violent fight where CS attacked her aunt by slapping, biting and pulling
her hair

CS’s other aunts, uncles and grandfather tried to restrain her but they also got hurt in the process

CS only calmed down when her grandfather got pissed off and scolded her

She then went to the medicine cabinet and allegedly attempted to drink all the pills but CS denied
that she was going to overdose herself. She claimed that she was only going to get water and
accidentally knocked over the medicine bottles
Few hours prior to admission:

CS was seen on the terrace and threatened to jump off if she wasn’t allowed to go out of the
house. For this reason, her Ate Maricar called the USTH for help because she thought CS
needed medical attention
Review of systems:

Non-remarkable
Past medical history:

(+) hospitalization at Chinese General Hospital for a week due to high grade fever

(+) epistaxis since childhood

(+) PTB exposure

(-) DM, HPN, asthma, thyroid disease

(-) accidents, trauma
Family history:

(+) HPN

(+) DM father and grandfather

(+) asthma uncle

(+) PTB aunt (treated)
Personal and social history:

Smoker (3-10 sticks per day) since 2003

Alcoholic beverage drinker since 2008

Denies illicit drug use

Denies having sexual intercourse
Family profile:
RS (CS’s mother)

39 years old college undergraduate

Involved with RN, a Chinese restaurant manager and got pregnant with CD at 1994

In 1996, she had an arranged marriage with TF, a Japanese citizen, in order to reside legally in
Japan

When CS was 3, RS got involved with a L , a Chinese businessman, their relationship lasted for 6
years

In 2003, she got involved with W, a Spanish automobile dealer. She got pregnant and gave birth
to Lei

Currently resides in Japan where she works as an entertainer

CS describes her mom as good to her an Lei, although CS claims that RS loves Lei more than
her
RN (CS’s father)

Chinese restaurant manager in Tondo where RS used to work

Relatives claim that RN offered to marry RS and give support to CS, however RS refused
because RN already had a family

Died at 2007 due to complications of DM

A Japanese 20 years older than RS who had an arranged marriage with RS, he provided RS with
TF
a house and a bar to manage to provide income for them

He was a good person and accepted both RS and CS

Noted to support, love and “spoil” CS

Died at 2008 due to MI

Chinese businessman who was RS’s boyfriend for 6 years

Loved by CS and claims that he was like a father to her, CS describes her to be a good person
L
and that he would have wanted him to bi his father

Disappeared from CS’s life when RS refused to marry him

CS was hurt by what happened, she would at times dream of L married to her mother
W (Lei’s father)

CS claims him t be a bad person because he took RS’s love away from CS
Lei ( CS’s 6 year old half brother)

CS hated him before because her mother’s attention was divided between them but now she
claims that their relationship is improved
MS ( CS’s Aunt)

26 year old HRM graduate, youngest of CS’s mother’s siblings

Acts as the legal guardian of CS in the Philippines

Claims that CS treated her with respect and fear and CS follows her until the morbid state
CS Sr (CS’s grandfather)

CS considers him an ally

Provides CS escapes from MS rules
EDS (CS’s grandmother)

Used to take care of CS when she was young but is now in Japan
AR and A (CS’s Cousins)
CS describes her as her close friends and idols because of their achievements
Anamnesis:

Patients parents, RS and RN, Chinese Manager at a restaurant

RS met RN when she was 25 years old as an employee at the restaurant

RS and RN’s relationship lasted for 8-10 months but ended because they no longer loved each
other

RS was already 1 month into her unplanned but wanted pregnancy

RS kept her pregnancy a secret from RN and her Family and worked in Japan as an Entertainer

After 6 months she returned to the Philippines and went for her regular prenatal checkups with no
know complications during her pregnancy

On October 14,1994 RS gave birth to CS on via normal spontaneous delivery at Chinese General
Hospital

She was full term and healthy with no known complications from the delivery

RN came to know about his daughter and helped pay for the hospital bill

He was willing to marry RS and support CS but RS refused because RN already has a family

RS also refused money from RN because she wanted to break all ties from RN and believed she
was capable for providing for CS

There was no more contact with RN

CS was breast fed for 12 weeks

After 2 months, RS returned to Japan and left CS under the care of her parents and her siblings

During this time CS was cared for by her maternal grandmother whom she called “mama”

CS was toilet trained at 1 ½ years old

Her development was at par with age

During the first few years RS would return to the Philippines when her 6 month contracts would
end

During her returns, CS was still open to her mother and the months of separation did not cause
her to feel aloof towards her mother

In 1996, CS was 2 years old when her mother had an arranged marriage with a Japanese named
TF in order to legalize her papers in Japan

In 1997, CS was 3 years old when RS met L a Chinese-Filipino during her stay in Manila. CS
called him Tito L and he acted like a Father figure to CS

CS was close to Tito L and he treated her like his own child

In 1998, at 4 years old ,CS started to go to preschool at a learning center near their home

She as an average student in school

She was described as “ Malakas and loob” and “suplada”

She had a few but close friends

At the age of 4 there was an incidence when a stranger commented “ang ganda ng bata” and she
responded with “ putang ina mo”

At 6-9 years CS studied at the Dominican school

She was an average student with a few close friends

There were 2 instances when she got involved in a fight

CS would sometimes throw tantrums when she didn’t get what she wanted

Her aunts and uncles gave into what she wanted to calm her down

When CS was 8 years old, L offered marriage to RS and planned to get settled in Hong Kong. RS
turned him down because she wanted to work and support her family.

CS was unaware or the situation and jus noticed that L no longer came to visit and wondered why
he never came back and felt hurt

In January 2003, at the age of 8, CS was petitioned to migrate to Japan.

In Japan they lived in Shikoku Island which was described as a provincial area. She lived wither
mother in the house of TF together with him and his 2 grandsons.

She claims that she got along well with her stepfather and her stepfathers grandsons which were
around the same again.

She attended special classes for 2 months and was able to learn Japanese

By June of 2003 she was able to attend regular classes as a grade 4 student

In 6 months she was able to speak Japanese and in 1 year she was able to read Japanese

She adapted very well to the environment but did not easily make friends

In school, her performance was average although she could do better.

She participated in extracurricular activities such as sports and dance.

When CS was 9 years old her mother met W, a Spanish automobile dealer in Japan. Her mother
got pregnant and gave birth to Lei.

CS did not favor having a half brother because she will not be the focus of her mother’s attention
anymore

When Lei was born, CS said she was also felt happy because she had another playmate and she
even took care of him or putting him to sleep

CS was said to have written “I hate you” on the photo album of Lei.

RS relation with W lasted 3 years during which CS was not able to get along with him

When CS was 10 years old, RS noticed her daughter to be more demanding with her attention
and she demands a lot of material thinks such as clothes and shoes

She goes into tantrums whenever her demands are not met and her mother usually gives into her
demands

During this time she started to feel unhappy in Japan and wanted to return to the Philippines.

When CS was 11 Years old, CS started to steal money from her mother because her mother
refused to buy the things she wanted. It was also at this age when her biological father tried to
contact her because h was close to death due complications in diabetes

RS urged CS to call her father but she was unwilling

CCS was described to be uninterested in what was happening. When convinced by her mother to
call her father she was unable to contact him

Her father died without having the chance to speak with him. When he died CS did not feel sad
since she did not know him; however , she felt frustrated she didn’t have a chance to meet and
speak with her father

When CS was 12 years old, her fights with her mother became worse and more frequent.

Sometimes their fight became physically violent.

The usual cause of their fights is when her mother would not buy her something she wants or
would not being her to a place she wants to go to.

In one instance, after he mom spanked her she allegedly said, “ang gusto kong mangyari ay
mamatay na ang babaeng iyon (mother)”

When angry at her mother she would sometimes hurt her half brother Lei

In school, CS was frequently involved in fights and violated school policies.

There was an incidence in which CS called her Ate Mariecar asking for help because her left wrist
was bleeding. It was interpreted as a suicide attempt though CS denies it.

When she came to the Philippines for her annual visit during summer vacation (July-August), her
relatives noticed she would go out more and would spend a lot of money.

When CS was 13 years old, she wanted to return to the Philippines because Japan had too
many rules and the malls were not accessible.

May 2008, RS could not control her daughter so Ater Mariecar advised RS that CS should be
sent back to the Philippines

While CS did not want to be separated from her mother, she was excited to return to the
Philippines

June 2008, CS went to school at St Jude College as a second year high school student

She adapted easily and made new friends but mostly with boys.

She met her first boyfriend during this time and their relationship lasted for only 2 months

She broke up with him because she thought he was immature

According to Ate Mariecar, she broke up with him because there was another girl involved

CS attempted her second suicide attempt by slashing her wrist due to this incident

CS denied the attempt as suicide and claimed it was just to get attention because she saw her
classmate do the same thing

After this incident, CS started drinking, smoking, cutting classes and coming home late. Her Ate
Mariecar scolded her often and limited her allowance.

She started t steal from her and the people in the house. They would lightly and jokingly tell her to
return the stolen money bus CS would deny having stolen the money

October 2008, her stepfather TF died due to a heart attack. When this occurred she realized how
it felt to lose someone she care about

December 2008, CS started escaping jus to go out and stated lying about her whereabouts.

She became worse and answers back whenever she was scolded about her activities

She got involved in fights and was failing school
Mental Status Exam (August 7, 2009)

Patient was well kempt

Normal gait and posture

Maintains good eye contact and follows command

Cooperative and eager to hold a conversation

Attentive and answers frankly but was somehow defensive in some personal questions

Spontaneous speech of normal rate and tone

No purposeless activity, abnormal gestures, or mannerisms noted

Claims to be unhappy and lonely

Has euthymic mood and appropriate affect

Denies having hallucinations or delusions

Comprehensible thought process

Did not exhibit circumstantiality, tangentiality, or blocking

Admitted and elaborated on when and how she attempted suicide

Felt guilty about the suicide attempt and admitted she was wrong

Alert, oriented to time, place, and person

Immediate, recent, and long-term memory are intact

Claims that she is not sick but is aware of a personality change
Physical Examination on Admission (August 7, 2009)

Essentially normal
Neurologic Examination on Admission (August 7, 2009)

Normal Neurological Examination
Course in the Ward

Vital signs monitoring on q4

Medications given: Depakote 500mg/tab ½ BID and Clonazepam 20mg/tab ¼ qid

Laboratory work ups:
o
CBC with platelets = normal
o
Urinalysis=

Yellow, slightly turbid urine

RBC 0-2/hpf, pus cell 10-20/hpf, bacteria +++, mucus threads ++++, and
squamous cell ++
o
Creatinine was normal
o
Sodium and potassium were normal

Repeat Urinalysis was done due to pyuria on previous exam

RBC 1-4/hpf, pus cells 8-12/hpf, bacteria ++, mucus threads ++++, squamous cell ++

Increased oral fluid intake advised

Baseline Young Mania Rating Scale was done with an initial score of 7 (repeated every 7 days)

Psychotherapy on 12th hospital day

Rest of the hospital stary were unremarkable
Mental Status Examination (August 24, 2009)

Generally identical with MSE on admission

Admits that she has been a burden to her family

Aware of a personality change that she became “pasaway” and that she became impulsive and
lost control over her actions

Admitted to do those things to get the attention of everyone around her

Patient has good judgement
Physical Examination on Discharge (August 24, 2009)

Essentially normal
Neurologic Examination on Discharge (August 24, 2009)

Normal
II. SALIENT FEATURES
General Data

14 year old, female

Resides with her uncles and aunts

Eldest child

3rd year High school student
Aggression/ Violent Behavior

At age 4:
o
Described as “malikot”, “suplada”, and “malakas ang loob”
o
When praised for being beautiful by a stranger, CS replied “Putang-ina mo”

At age 6-9, Got involved in fights in 2 instances in school

At age 12, her fights with her mother got worse, frequent, and violent

In one instance, when she got spanked, she said “Ang gusto kong mangyari ay mamatay na ang
babaeng iyon” (referring to her mother)

Hurts her half-brother when angry with her mother

She got worse and answered back when scolded

She got involved in fights and was failing school

Confrontational towards her aunt when her cell-phone was confiscated

and directed her anger to cousins by ordering them around – indicative of displacement as
defense mechanism



Got angry and fought with aunt; Said things like:
o
“Pabayaan niyo na ako”
o
“Hindi naman ako mahal ng ibang tao, pati ng nanay ko”
o
“Balik mo sa kin mga gamit ko dahil ito lang ang buhay ko”
She fought with her aunt and got violent and attacked her –
o
Biting
o
Slapping
o
Hair pulling
CS also hurt her grandfather, uncles, and other aunts
Self Destructive Behavior

1st suicide attempt by slashing her wrist -- asked for help from her Auntie Maricar bec. Her left
hand was bleeding. Denied committing suicide

2nd suicide attempt by slashing her wrist because her boyfriend left her

Attempted to overdose with pills in the medicine cabinet, but claimed that she was just getting
water and accidentally knocked over the bottles

Threatened to jump off the terrace because she was not allowed to go out of the house
Manipulative behavior

At age 8, when she first threw tantrums when she couldn’t get what she wanted and was
accommodated

At age 10, goes into tantrums when demands are not met and her mother usually gives in

Went into a tantrum, described as “nagwawala” (threw and banged things)
Stealing / Deceit

At age 11, she started to steal money from her mother when she refused to buy her things

Allowance was limited, which prompted her to steal from the people in her home

Denies stealing the money, when confronted

Stole 5,000 from her aunt and vehemently denied it
Impulsiveness

Spends a lot of money and went out more when on vacation in the Philippines

Packed all her clothes because she wanted to run away and stay in a dormitory
Rule Breaking

At age 12, violated school policies

She then started drinking, cutting classes, smoking and coming home late

December 2008, started to escape just to go out and lying about her whereabouts
Rejection / Loss

No permanent father figure
o
Father died in 2007
o
T.F. , her step-father died in 2008 , thus, she first experienced losing someone she cared
about
o
Was hurt when she never saw L again -- dreamed about her mother marrying him

Broke up with her boyfriend due to her immaturity and possible third party

She was unwilling to call her father and was uninterested although her biological father was near
his death

When her father died, she didn’t feel sad, but was frustrated that she didn’t get to meet and talk to
him

Thought she lost her mother’s love and attention
o
Claims she hated her brother because her mother’s attention would be divided between them
o
Wrote “I hate you” in brother’s photo album
o
W, her mother’s boyfriend, was described as a bad person – took her mother’s love away
III. DIFFERENTIAL DIAGNOSES
A. Oppositional Defiant Disorder (ODD)
Oppositional, negativistic behavior, in moderation, is developmentally normal in early childhood
and adolescence. The ability of the child to communicate his or her own will opposing others’ will is
crucial to normal development as a route toward establishing autonomy, forming an identity, and setting
inner standards and controls. The most dramatic example of normal oppositional behavior peaks between
18 and 24 months, the “terrible twos”, when toddlers behave negativistically as an expression of growing
autonomy. Pathology begins when this developmental phase persists abnormally, authority figures over
react, or oppositional behavior recurs considerably more frequently than in most children of the same
mental age.
ODD is characterized by enduring pattern of negativistic, disobedient, and hostile behavior toward
authority figures, as well as inability to take responsibility for mistakes, leading to place blame on others.
Children with oppositional defiant disorder frequently argue with adults and become easily annoyed with
others, leading to a state of anger and resentment. They may have difficulty in the classroom and with
peer relationships, but generally do not result to physical aggression or significant destructive behaviors.
ODD can begin as early as 3 years of age but is generally noted at 8 years old and usually not later than
adolescence. This disorder seems more prevalent in boys than in girls before puberty, but the sex ratio
equalizes after puberty.
Table 1. DSM-IV-TR Criteria for Oppositional Defiant Disorder
A. A pattern of negativistic, hostile and defiant behavior lasting at least 6 months, during which
four or more are present:
(1) Often loses temper
(2) Often argues with adults
(3) Often actively defies or refuses to comply with adult’s requests or rules
(4) Often deliberately annoys people
(5) Often blames others for his or her mistakes or misbehavior
(6) Is often touchy or easily annoyed with others
(7) Is often angry and resentful
(8) Is often spiteful and vindictive
Note: consider a criterion met only if behavior occurs more frequently than is typically observed
in individuals with comparable age and development level
B. The disturbance in behavior causes clinically significant impairment in social, academic or
occupational functioning
C. The behaviors do not occur exclusively during the course of a psychotic or mood disorder
D. Criteria are not met for conduct disorder, and if the individual is age 18 or older, criteria are not
met for antisocial personality disorder
Patient, CS, has more than a 6-month history of negativistic, hostile and defiant behavior. She
exhibited 5 out of the 8 behaviors enumerated in the first criterion in Table 1. The patient’s behavior also
caused significant impairment in social functioning. In addition, the episodes did not happen during any
psychotic or mood disorder, making ODD a probable diagnosis. Concrete examples of the patient’s
behavior that could signify ODD are her tantrums and incidences wherein she argued with her mom, aunt,
uncle and even her grandfather. She is defiant of rules and would insist on going out as reported in her
history of present illness. Unfortunately, despite the previously raised points, it is possible to rule out ODD
since CS manifested with serious violation of social norms and rights of others. This was seen when she
started stealing money after her mother refused to buy her the things she wanted. She was confronted by
her aunt about it, but CS denied doing such. Also, she has been physically harmful to other people, a
characteristic not prominent in ODD. In the advent of the violation of these societal norms, such are not
present in ODD but rather more of feasible for the diagnosis of Conduct Disorder.
Part of conduct disorder is truancy from school, running away from home. In Dec. 2008 she
started escaping just to go out and started lying about her whereabouts. She even became worst and
answers back whenever she got scolded. She got involved in fights and was failing in school.
CPS started stealing money when she was 11 years old after her mother refused to buy things
that she wanted. On July 26 of 2009 CPS stole 5000php from her Ate Maricar’s wallet. Her aunt
confronted CS and asked her about it. CS denied stealing anything. The next day her aunt saw that CS
bought new clothes and shoes. She confiscated CS’s cellphone and took the money which she saw on
CS things. CS attempted to move out but they stopped her. She attacked her aunt by slapping, biting and
pulling on her aunt’s hair. This prompted them to call the hospital for medical attention.
B. Depressive Disorder
Major depressive disorder (a.k.a. clinical depression, major depression, unipolar depression, or
unipolar disorder) is a mental disorder characterized by an all-encompassing low mood accompanied by
low self-esteem, and loss of interest or pleasure in normally enjoyable activities. The key symptoms of
depressive episodes are depressed mood, loss of interest or pleasure, and anxiety.
Patients often
describe the symptoms of depression as one of agonizing emotional pain that has a distinct quality that
differentiates it from the normal emotion of sadness and grief. About two thirds of all depressed patients
contemplate suicide, and 10 to 15 percent commit suicide. Even though patients exhibit withdrawal from
family, friends, and activities that previously interested them, some depressed patients are still unaware
of their disorder and do not complain of their mood disturbance.
Almost all patients (97%) with
depression complain about reduced energy; have difficulty finishing tasks; and have less motivation to
undertake new projects. About 80% of depressed patients complain of trouble sleeping, especially early
morning awakening and multiple awakenings at night, during which they ruminate about their problems.
In addition, many patients have decreased appetite and weight loss, but others experience increased
appetite and weight gain and sleep longer than usual and are classified in DSM-IV-TR as having atypical
features. Anxiety, alcohol abuse, and somatic complaints often complicate the treatment of depression.
Cognitive symptoms may also present which includes subjective reports of an inability to concentrate and
impairments of thinking.
Symptoms of depression vary in children and adolescents. School phobia and excessive clinging
to parents may be symptoms of depression in children. In adolescents, symptoms include poor academic
performance, substance abuse, antisocial behavior, sexual promiscuity, truancy, and running away.
Depressive disorders occur in children of all ages, but are much more prevalent with increasing age.
These symptoms may lead to devastating social isolation.
The core features of depression have
similarities in children, adolescents, and adults, although developmental factors influence its clinical
presentation.
Table 2. DSM-IV-TR Criteria for Major Depressive Episode
A. Five (or more) of the following symptoms have been present during the same 2-week period
and represent a change from previous functioning; at least one of the symptoms is either
(1) depressed mood or
(2) loss of interest or pleasure.
Note: Do not include symptoms that are clearly due to a general medical condition, or moodincongruent delusions or hallucinations.
(1) Depressed mood most of the day, nearly every day, as indicated by either
subjective report (e.g., feels sad or empty) or observation made by others (e.g.,
appears tearful). Note: In children and adolescents, can be irritable mood.
(2) Markedly diminished interest or pleasure in all, or almost all, activities most of
the day, nearly every day (as indicated by either subjective account or
observation made by others)
(3) Significant weight loss when not dieting or weight gain (e.g., a change of more
than 5% of body weight in a month), or decrease or increase in appetite nearly
every day. Note: In children, consider failure to make expected weight gains.
(4) Insomnia or Hypersomnia nearly every day
(5) Psychomotor agitation or retardation nearly every day (observable by others,
not merely subjective feelings of restlessness or being slowed down)
(6) Fatigue or loss of energy nearly every day
(7) Feelings of worthlessness or excessive or inappropriate guilt (which may be
delusional) nearly every day (not merely self-reproach or guilt about being sick)
(8) Diminished ability to think or concentrate, or indecisiveness, nearly every day
(either by subjective account or as observed by others)
(9) Recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation
without a specific plan, or a suicide attempt or a specific plan for committing
suicide
B. The symptoms do not meet criteria for a Mixed Episode
C. The symptoms cause clinically significant distress or impairment in social, occupational, or
other important areas of functioning.
D. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication) or a general medical condition (e.g., hypothyroidism).
E. The symptoms are not better accounted for by Bereavement, i.e., after the loss of a loved one,
the symptoms persist for longer than 2 months or are characterized by marked functional
impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms,
or psychomotor retardation.
Based on the medical history and mental status examination of the patient (CS), she presented
with depressed or irritable mood, one of the necessary symptoms of major depressive disorders.
Hopelessness/worthlessness and negativistic or frankly anti-social behavior are other symptoms of the
patients that may justify additional diagnoses of oppositional defiant disorder and conduct disorder seen
in our patient. School difficulties were likely in the case. According to the DSM-IV-TR diagnostic criteria
for major depressive episode, at least five symptoms must be present for a period of 2 weeks that
includes changes in appetite and weight, changes in sleep and activity, lack of energy, feelings of guilt,
problems thinking and making decisions, and recurring thoughts of death or suicide (Table 2). These said
distinct features weren’t presented in our patient and were lacking to meet the criteria for depressive
disorder, thus ruling out depression in the patient.
In addition, anhedonia, feelings of restlessness,
reluctance to cooperate in family ventures, withdrawal from social activities, psychomotor retardation, and
delusions are other more common depressive episodes in adolescents that were not seen in our patient.
C. Manic Disorder
Patients with an elevated mood demonstrate expansiveness, flight of ideas, decreased sleep,
heightened self-esteem, and grandiose ideas. A manic episode is a distinct period of an abnormally and
persistently elevated, expansive, or irritable mood lasting for at least 1 week. This is associated with
inflated self-esteem, decreased need for sleep, distractibility, great mental and physical activity and over
involvement in pleasurable behavior. According to DSM-IV-TR, bipolar I disorder is defined as having a
clinical course of one or more manic episodes, and sometimes, major depressive episodes. Usually, a
major depressive episode precedes a manic episode in an adolescent who develops bipolar I disorder.
When a classic manic episode occurs in adolescent, it emerges as a definitive change from a preexisting
state and often appears with grandiose and paranoid delusions and hallucinatory phenomena. The
diagnostic criteria for a manic episode are the same for children and adolescents as for adults. The
diagnostic criteria include a distinct period of an abnormally elevated, expansive, or irritable mood that
lasts for at least 1 week or for any duration if hospitalization is necessary. During the periods of mood
disturbance, at least three of the following symptoms must be present: inflated self-esteem, decreased
need for sleep, pressure to talk, flight of ideas, distractibility, an increase in goal-directed activity, and
excessive involvement in pleasurable activities that results in painful consequences. The mood
disturbance suffices to cause marked impairment, and is not due to the direct effect of a substance or a
general medical condition.
There is a higher incidence of psychotic features than in adults, and hospitalization is often
necessary. Delusions may involve grandiose notions about their power, worth, knowledge, family or
relationships.
Table 3. DSM-IV-TR Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting
at least 1 week (or any duration if hospitalization is necessary)
B. During the period of mood disturbance, three (or more) of the following symptoms have
persisted (four if the mood is only irritable) and have been present to a significant degree:
(1) Inflated self-esteem or grandiosity
(2) Decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
(3) More talkative than usual or pressure to keep talking
(4) Flight of ideas or subjective experience that thoughts are racing
(5) Distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
(6) Increase in goal-directed activity (either socially, at work or school, or sexually) or
psychomotor agitation
(7) Excessive involvement in pleasurable activities that have a high potential for painful
consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or
foolish business investments)
C. The symptoms do not meet criteria for mixed episode
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational
functioning or in usual social activities or relationships with others, or to necessitate
hospitalization to prevent harm to self or others, or there are psychotic features
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of
abuse, a medication, or other treatment) or general medical condition (e.g., hyperthyroidism)
NOTE: Manic-like episodes that are clearly caused by somatic antidepressant treatments should
not count toward a diagnosis of bipolar I disorder
The patient, CS, has been showing irritable moods lasting more than one week. She has been
distracted, has had increased goal-directed activity, and excessive involvement in pleasurable activities
that usually has potential consequences, as seen in patients diagnosed with manic disorder. She was
fond of going out and was usually being secretive about her whereabouts. She was always determined to
“get what she wants” even if she ends up hurting people around her. Nevertheless, CS did not meet the
criteria for a manic episode, having manifested only 2 out of the 7 symptoms usually present during the
period of mood disturbance (Table 3). The patient also exhibited more deviant than manic behaviors,
often breaking rules and resorting to manipulation in order to get what she wants.
D. Antisocial Personality Disorder
Antisocial personality disorder is the ability to conform to the social norms that ordinarily govern
many aspects of a person’s adolescent and adult behavior. Although it is characterized by criminal acts,
it is not synonymous to criminality. It is more prevalent in men than in women and is most common in
poor urban areas. The onset of this disorder is before the age of 15. Girls usually have symptoms before
puberty, and boys even earlier. A familial pattern is present and the disorder is five times more common
among first degree relatives of men with the disorder than among controls.
In the diagnosis of antisocial personality disorder, the patients may appear normal but may have
hidden tension, hostility and rage. A diagnostic workup should include a thorough neurological exam.
Patients often show abnormal EEG results and soft neurological signs suggesting minimal brain damage
during childhood. These findings may be used to confirm the clinical impression. The DSM-IV-TR criteria
for antisocial personality disorder are presented below (Table 4).
Table 4. DSM-IV-TR Criteria for Antisocial Personality Disorder
A. There is a pervasive pattern of disregard for and violation of the rights of others occurring
since the age of 15 years, as indicated by 3 or more of the following:
(1) Failure to conform to social norms with respect to lawful behaviors as indicated by
repeatedly performing acts that are grounds for arrest
(2) Deceitfulness, as indicated by repeated lying, use of aliases, or conning others for
personal profit or pleasure
(3) Impulsivity or failure to plan ahead
(4) Irritability and aggressiveness, as indicated by repeated physical fights or assaults
(5) Reckless disregard for safety of self or others
(6) Consistent irresponsibility, as indicated by repeated failure to sustain consistent work
behavior or honor financial obligations
(7) Lack of remorse, as indicated by being indifferent to or rationalizing having hurt,
mistreated, or stolen from another
B. The individual is at least age 18 years.
C. There is evidence of conduct disorder with onset before age 15 years.
D. The occurrence of antisocial behavior is not exclusively during the course of schizophrenia or
manic episode
In our case, the patient fulfilled criteria (a, d and e) by exhibiting violent episodes during her
disagreements with her aunt.
She repeatedly went into tantrums described as “nagwawala” with
subsequent violent outbursts which result in harming the aunt and other family members.
She was
always irritable and aggressive whenever she is confronted. She has a history of always fighting with her
mother that would result to violent actions towards herself or to her younger brother. She was also often
involved in fights at school. She also doesn’t want to conform to the rules at home, so she frequently
fought with her mother and eventually her aunt when she moved back to the Philippines. She started
drinking and smoking and cutting classes in 2008 and she often lies in order to get out of the house and
would escape when she is not allowed to go out.
On July 2009, she lied to her aunt about the money
that she stole in order to buy new clothes and shoes. This was not the first incident that she stole money
from people in her home. She has a history of stealing from her mother and from her other family
members as well, but every time she was confronted and asked about the stolen money, she would lie
and deny it. She also has a number of attempts at suicide which she denied when confronted.
Despite her fulfillment of a number of criteria described above, the patient could not be diagnosed
as having antisocial behavior since the onset of her symptoms started before 15 years of age.
E. Borderline Personality Disorder
Patients with borderline personality disorder stand on the border between neurosis and
psychosis. They are characterized by extraordinarily unstable affect, mood, behavior, object relations,
and self-image. The prevalence of borderline personality disorder is estimated to be about 2% of the
general population, about 10% among individuals seen in outpatient mental health clinics, and about 20%
among psychiatric inpatients. It ranges from 30% to 60% among clinical populations with personality
disorders and is twice as common in women as in men. An increased prevalence of major depressive
disorder, alcoholic use disorders, and substance abuse is found in first-degree relatives of persons with
borderline personality disorder. Numerous studies have pointed to early traumatic experiences as a
cause of this personality disorder. A tripartite etiological model, including childhood trauma, vulnerable
temperament, and a series of triggering events were formulated.
According to DSM-IV-TR, the diagnosis of borderline personality disorder can be made by early
adulthood when the patient shows at least five of the criteria in the list (Table 5).
Table 5. DSM-IV-TR Criteria for Borderline Personality Disorder
A pervasive pattern of instability of interpersonal relationships, self-image, and affects, and
marked impulsivity beginning by early adulthood and present in a variety of contexts, as indicated
by five (or more) of the following:
(1) Frantic efforts to avoid real or imagined abandonment. Note: Do not include suicidal or
self-mutilating behavior covered in Criterion 5.
(2) A pattern of unstable and intense interpersonal relationships characterized by alternating
between extremes of idealization and devaluation.
(3) Identity disturbance: markedly and persistently unstable self-image or sense of self.
(4) Impulsivity in at least two areas that are potentially self-damaging (e.g., spending, sex,
substance abuse, reckless driving, binge eating). Note: Do not include suicidal or selfmutilating behavior covered in Criterion 5.
(5) Recurrent suicidal behavior, gestures, or threats, or self-mutilating behavior
(6) Affective instability due to a marked reactivity of mood (e.g., intense episodic dysphoria,
irritability, or anxiety usually lasting a few hours and only rarely more than a few days).
(7) Chronic feelings of emptiness
(8) Inappropriate, intense anger or difficulty controlling anger (e.g., frequent displays of
temper, constant anger, recurrent physical fights)
(9) Transient, stress-related paranoid ideation or severe dissociative symptoms
Persons with borderline personality disorder almost always appear to be in a state of crisis. Mood
swings are common. Patients can be argumentative at one moment, depressed the next, and later
complain of having no feelings. Patients may have short-lived psychotic episodes, so-called
micropsychotic episodes, rather than full-blown psychotic breaks, and the psychotic symptoms of these
patients are almost always circumscribed, fleeting, or doubtful.
Because they feel both dependent and hostile, persons with this disorder have tumultuous
interpersonal relationships. They can be dependent on those to whom they are close and when frustrated
can express enormous anger toward their intimate friends. They consider each person to be either good
or all bad. They cannot tolerate being alone, and they prefer a frantic search for companionship, no
matter how unsatisfactory, to their own company. They often complain about chronic feelings of
emptiness and boredom and lack of consistent sense of identity. The painful nature of their lives is
reflected in repetitive self-destructive acts. Such patients may slash their wrists and perform other selfmutilations to elicit help from others, to express anger, or to numb themselves to overwhelming affect.
A diagnosis of borderline personality disorder was considered due to the presence of unstable
interpersonal relationships and marked impulsivity. An example of such was when she was given a
chance to speak with her biological father, CS appeared uninterested and refused to do so. She,
however, felt frustrated upon learning about her father's death for she did not have the chance to meet
and speak with her father. In terms of marked impulsivity, the patient manifested this when she came to
the Philippines for her annual visit during her summer vacation when her relatives noticed that she woul
go our more and would spend a lot of money. Moreover, after a year, she really wanted to return to the
Philippines. She expressed that she no longer wanted to stay in Japan because there were too many
rules. In addition to this, CS also exhibited recurrent suicidal behavior, as reported by her multiple
attempts. Establishing further her potentially self-damaging behavior, she started drinking, smoking,
cutting classes and coming home late after the alleged suicidal attempt in June 2008.
Although the patient exhibited some patterns of instability of behavior, she failed to meet the
DSM-IV-TR diagnostic criteria for borderline personality disorder as she only exhibited 3 out of the 9
criterion as a minimum of 5 was warranted to complete the diagnosis. Moreover, the patient is also too
young to be diagnosed with a personality disorder ergo, ruling it out as the diagnosis.
IV. DIAGNOSIS
CONDUCT DISORDER
The patient, CS, a 14-year old female, with a chief complaint of episodes of violent behavior, that
the patient states that it drives her to hurt her relatives (“nasasaktan ko po kasi mga kasama ko sa
bahay”) and described by the patient’s aunt as episodes of becoming violent (”nagiging violent siya”). The
patient had manifested characteristics suggestive of conduct disorder early in life that can be classified
according to four behaviors usually present in patients with conduct disorder, particularly physical
aggression or threats of harm to people, destruction of their own property or that of others, thefts or acts
of deceit, and frequent violation of age-appropriate rules.
RS has a complex family structure, with her mother having 2 children from different fathers. RS,
the patient’s mother, is residing in Japan with Lei, CS’ step brother, and is currently working as an
entertainer in order to provide for her 2 kids. CS is left in the care of her aunt MS. She also lives with her
2 cousins, AR and A. There have been instances where CS displayed aggression and violation of the
rights of others, both of which describe Conduct Disorder.
Conduct disorder was also said to arise from “chaotic home conditions”. In our patient, this is
seen in different events in CS’ life. First, her mother had various relations with different men, RN, L, TF,
W, early in CS’ life. CS, at those times, most likely did not understand why these men would be present in
their lives and then be gone after a while. She also had to deal with having a step-brother because she
did not want to share her mother’s attention and her expected inheritance with anyone. She also had to
adjust to moving to Japan and adapting to a different lifestyle while in grade school. CS was sent back to
the Philippines when she was 13 years old and was separated from her mother in the Philippines she had
to learn again to live with her new guardians.
The DSM-IV-TR criteria for Conduct Disorder require 3 specific behaviors of the 15 listed in order
to diagnose Conduct Disorder.
Table 6. DSM-IV-TR Criteria for Conduct Disorder
A. A repetitive and persistent pattern of behavior in which the basic rights of others or major ageappropriate societal norms or rules are violated, as manifested by the presence of three (or
more) of the following criteria in the past 12 months, with at least one criterion present in the
past 6 months:
Aggression to people and animals
(1) often bullies, threatens, or intimidates others
(2) often initiates physical fights
(3) has used a weapon that can cause serious physical harm to others (e.g., a bat, brick,
broken bottle, knife, gun)
(4) has been physically cruel to people
(5) has been physically cruel to animals
(6) has stolen while confronting a victim (e.g., mugging, purse snatching, extortion, armed
robbery)
(7) has forced someone into sexual activity
Destruction of property
(8) has deliberately engaged in fire setting with the intention of causing serious damage
(9) has deliberately destroyed others' property (other than by fire setting)
Deceitfulness or theft
(10) has broken into someone else's house, building, or car
(11) often lies to obtain goods or favors or to avoid obligations (i.e., "cons" others)
(12) has stolen items of nontrivial value without confronting a victim (e.g., shoplifting, but
without breaking and entering; forgery)
Serious violations of rules
(13) often stays out at night despite parental prohibitions, beginning before age 13 years
(14) has run away from home overnight at least twice while living in parental or parental
surrogate home (or once without returning for a lengthy period)
(15) is often truant from school, beginning before age 13 years
B. The disturbance in behavior causes clinically significant impairment in social, academic, or
occupational functioning.
C. If the individual is age 18 years or older, criteria are not met for Antisocial Personality
Disorder.
Specify type based on age at onset:
Childhood-Onset Type: onset of at least one criterion characteristic of Conduct Disorder prior to
age 10 years
Adolescent-Onset Type: absence of any criteria characteristic of Conduct Disorder prior to age 10
years
Specify severity:
Mild: few if any conduct problems in excess of those required to make the diagnosis and conduct
problems cause only minor harm to others
Moderate: number of conduct problems and effect on others intermediate between "mild" and
"severe"
Severe: many conduct problems in excess of those required to make the diagnosis or conduct
problems cause considerable harm to others
The following manifestations were present in our patient:

Has been stealing from relatives and denies doing so. Recently, she stole P5000 from her aunt
and did not admit to have done the act even though her aunt confronted her about it

Has started fights in school and has been physically and verbally cruel to people

Exhibited truancy from school by age 13

Escapes from the house just to go out (age 13) and started lying regarding her whereabouts

Has become violent especially during tantrums and when arguing with her mother, aunt, and
relatives

Expressed desire to run away from home

Has exhibited suicidal behavior in the past and recently threatened to jump off the terrace when
she was not allowed to go out of the house
All of these occurred in the last 12 months and some occurred in the last 6 months.
ICD-10 ( F90-F89 )
Behavioural and emotional disorders with onset usually occurring in childhood and adolescence
F91 Conduct disorders
F91.0 Conduct disorder confined to the family context
F91.1 Unsocialized conduct disorder
F91.2 Socialized conduct disorder
F91.3 Oppositional defiant disorder
F91.8 Other conduct disorders
F91.9 Conduct disorder, unspecified
F91 Conduct Disorders
Conduct disorders are characterized by a repetitive and persistent pattern of dissocial, aggressive, or
defiant conduct. Such behaviour, when at its most extreme for the individual, should amount to major
violations of age-appropriate social expectations, and is therefore more severe than ordinary childish
mischief or adolescent rebelliousness. Isolated dissocial or criminal acts are not in themselves grounds
for the diagnosis, which implies an enduring pattern of behavior.
Features of conduct disorder can also be symptomatic of other psychiatric conditions, in which case the
underlying diagnosis should be coded.
Disorders of conduct may in some cases proceed to dissocial personality disorder (F60.2). Conduct
disorder is frequently associated with adverse psychosocial environments, including unsatisfactory family
relationships and failure at school, and is more commonly noted in boys. Its distinction from emotional
disorder is well validated; its separation from hyperactivity is less clear and there is often overlap.
Diagnostic Guidelines
Judgments concerning the presence of conduct disorder should take into account the child's
developmental level. Temper tantrums, for example, are a normal part of a 3-year-old's development and
their mere presence would not be grounds for diagnosis. Equally, the violation of other people's civic
rights (as by violent crime) is not within the capacity of most 7-year-olds and so is not a necessary
diagnostic criterion for that age group.
Examples of the behaviors on which the diagnosis is based include the following: excessive levels of
fighting or bullying; cruelty to animals or other people; severe destructiveness to property; firesetting;
stealing; repeated lying; truancy from school and running away from home; unusually frequent and severe
temper tantrums; defiant provocative behavior; and persistent severe disobedience. Any one of these
categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.
Exclusion criteria include uncommon but serious underlying conditions such as schizophrenia, mania,
pervasive developmental disorder, hyperkinetic disorder, and depression.
This diagnosis is not recommended unless the duration of the behavior described above has been 6
months or longer.
CPS had an unsatisfactory relationship with her family. Her mother had multiple partners (RS, TF,
L., W.) CPS was hurt when L suddenly disappeared from their life because their mother refused to marry
him. She had one sibling, Lei which she hated before because her mother’s attention would be divided
between them. When angry at her mother, she would sometimes hurt her brother.
She fights with her mother, which became worst, more frequent and physically violent. The usual
cause of these fights is when her mother would not buy something she wants. The first suicidal attempt
happened when she was 12 years old. The second attempt was when she went back to the Philippines
for a vacation with her aunt and went to school in June 2008. She had her first relationship with her
boyfriend who broke up with him because she was immature. Although CPS denied that she did not do
that just to get attention and that she only saw her classmate do the same thing. Part of conduct disorder
is truancy from school, running away from home. In Dec. 2008 she started escaping just to go out and
started lying about her whereabouts. She even became worst and answers back whenever she got
scolded. She got involved in fights and was failing in school.
CPS started stealing money when she was 11 years old after her mother refused to buy things
that she wanted. On July 26 of 2009 CPS stole 5000php from her Ate Maricar’s wallet. Her aunt
confronted CS and asked her about it. CS denied stealing anything. The next day her aunt saw that CS
bought new clothes and shoes. She confiscated CS’s cellphone and took the money which she saw on
CS things. CS attempted to move out but they stopped her. She attacked her aunt by slapping, biting and
pulling on her aunt’s hair. This prompted them to call the hospital for medical attention.
Examples of the behaviors on which the diagnosis is based include the following: excessive
levels of fighting or bullying; cruelty to animals or other people; severe destructiveness to property;
firesetting; stealing; repeated lying; truancy from school and running away from home; unusually frequent
and severe temper tantrums; defiant provocative behavior; and persistent severe disobedience. Any one
of these categories, if marked, is sufficient for the diagnosis, but isolated dissocial acts are not.
In conduct disorder, as seen in our patient, many symptoms develop over time until a consistent
pattern develops which involves violating the rights of others. The average age of onset for girls is 14-16
years old, usually later than the onset in boys.
Children who meet the criteria for conduct disorder express their overt aggressive behavior in
various forms. It may take the form of bullying, physical aggression and cruel behavior toward peers. In
our patient’s case, she has started several physical fights, has been overbearing towards her cousins and
at times has hurt her younger brother Lei as retaliation to her mother. Children with conduct disorder may
be hostile, verbally abusive, impudent, defiant and negativistic toward adults, as manifested in our patient.
CS lies persistently, frequently goes out without asking for permission from her guardians,
demonstrates stealing and physical violence, has started smoking and drinking liquor, and has attempted
suicide. CS had attempted suicide twice in the past; the first incident occurring when she was 12 years
old and the second incident which was triggered by her break-up with her first boyfriend (13 years old).
Many children with conduct disorder have poor self-esteem although they may project an image
of toughness. Many of these patients suffer from the deprivation of having few of their dependency needs
met and may have had either overly harsh parenting or lack of appropriate supervision, which may have
been a factor in the development of conduct disorder in our patient. Severe punishments for behavior in
children with conduct disorder increases their maladaptive expression of rage and frustration rather than
ameliorating the problem, as seen in our patient’s violent episodes whenever she was scolded by her
mom and her aunt.
As evident in our patient, children with conduct disorder are more likely to be unplanned or
unwanted babies and are part of severe marital disharmony. CS was born out of wedlock and her family
life was far from conventional. A child with conduct disorder usually have aggressive behavior that rarely
seem directed toward any definable goal and offers little pleasure, success or even sustained advantages
with peers or authority figures. Early problems pertaining to conduct disorder were also present in the
patient, such as marginal performance in school which has now progressed, CS has recently started
failing in school and has demonstrated repeated truancy, she has also shown progressive physical and
verbal aggression towards the people in their home.
CS, upon interview in the hospital, was compliant until she was asked to talk about her recent
behavior. When asked regarding her behavior she readily admitted to her fault and was quite uncertain
regarding her admission, she believes that her admission was not actually necessary and that she could
have managed her personality on her own, this may be the expression of her denial of her condition.
Similar to most children with conduct disorder, CS obviously feels guilt and remorse regarding some of
her behaviors which has led to the present admission.
The patient, CS, had a Young Mania Rating Scale (YMRS) initial score of 7. The YMRS is an 11item clinician rated scale that is traditionally used to assess the degree or severity of manic
symptomatology. A score of less than or equal to 12 indicates a period of remission of symptoms (Lam,
Michalak, & Swinson, 2006). This is suggestive that CS is not presently going through a manic episode
but to have a better observation, a battery of assessment tests is recommended.
Multiaxial Evaluation
AXIS I
Diagnostic Code
3 1 2.8 1
DSM-IV name
Conduct Disorder, Childhood-onset type, Severe
.
AXIS II
Diagnostic Code
_ _ _._ _
DSM-IV name
____No Diagnosis________
_____________________
AXIS III
ICD-10 Code
N39.0
ICD-10 name
Urinary tract infection, site not specified
.
.
AXIS IV
Problems with primary support group Specify: Recent death of step-father
Inadequate discipline
Educational problems Specify: Discord with classmates, Academic problems
AXIS V: GAF
Score: 60
Time Frame: Current
V. TREATMENT
Conduct disorder is best managed with multimodality treatment programs that use all available
family and community resources. The use of behavioral interventions in which rewards may be earned for
prosocial and non-aggressive behaviors, social skills training, family education and therapy and
pharmacologic interventions may all be used in an effort to obtain the best results for our patient. In our
patient’s case, a good environmental structure that constantly encourages and supports the patient may
help in addressing the problem. Her mother or her guardians may also consider setting some rules and
regulations in which the patient will face some kind of penalty for improper conduct will help control the
patient’s aggressive behavior. Reduction of violence and aggression in school is also an important setting
of intervention. A functioning security hierarchy, peer-participant programs, threat assessment and crisis
response initiatives are some approaches that could be made in order to manage threats of violence.
The mother and guardians may also be counseled on the therapies that may be used in our
patient’s case so they may also apply it at home. They may also be made aware of the possible stressors
that could hay lead to the patient’s condition. The patient may also benefit from behavioral based
individual psychotherapy in which targeted problem-solving skills with appropriate rewards may be useful.
This will greatly help our patient because patients with conduct disorder may have long standing pattern
of maladaptive responses to daily situations. It is also helpful and important that the psychotherapy be
recommended and be initiated as early as possible because the longer the maladaptive behavior
continue the more establish they become and may become more difficult to address.
Pharmacologic treatment can also be used as adjuncts to the treatment being given. It has been
employed to further have an effective improvement in the behavior with fewer long-term adverse effects
among patients with conduct disorder. One has to challenge in delivering optimal pharmacologic
treatment for decreasing maladaptive behaviors and promote productive academic functioning, taking in
consideration the medical side effects of each drug given. Atypical anti-psychotics such as resperidone,
olanzapine, quetiapine, ziprasidone, and aripriprazole can be of benefit to the patient. These drugs can
decrease the aggressive and assaultive behaviors of the patient. Other drugs that can be used like SSRIs
(fluoxetine, sertraline, paroxetine, and citaloprm) can be employed to decrease the impulsivity, irritability,
and the lability of the mood of the patient. Lithium and clozapine are currently under investigation for their
use in cases that present similar to our patient.
The patient has been prescribed to take Depakote (500 mg/tab; ½ tablet bid) and Clonazepam (2
mg/tab; ¼ tablet qd before bedtime). These drugs may help in controlling the patient’s aggressive
behavior as well as her depressive mood changes like suicidal tendencies. Depakote, also known as
semisodium valproate or divalproex sodium (valproic acid) is an anticonvulsant and mood stabilizer
indicated for manic episodes of bipolar disorder. It is also used as a treatment for major depressive
disorder and increasingly taken long-term for prevention of both manic and depressive phases of bipolar
disorder. Side effects may include vomiting, loss of appetite, fever, or dark urine. Clonazepam is a
benzodiazepine which stimulates GABA-A receptors and acts on the limbic, thalamic, and hypothalamic
levels of the CNS. It is considered the drug of choice for anxiety, reduction in daytime activity, tempering
excitement, quieting patients, producing drowsiness, facilitating the initiation and maintenance of sleep.
The last reason explains why clonazepam has been increased to ½ tablet when the patient had
experience difficulty in sleeping. The drug is also indicated to patients with generalized anxiety disorder
and severe situational anxiety, sleep disorders requiring short term therapy, alcohol withdrawal, panic
disorder or anxiety with depression, epilepsy, muscular disorders, and premedication or sedation for
procedures.
REFERENCES
Lam, R.W., Michalak, E., & Swinson, R.P. Assessment Scales in Depression, Mania and Anxiety.
London: Taylor & Francis Ltd, 2006.
Sadock, B.J. & Sadock, V.A.. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Scicences/Clinical
Psychiatry, 9th ed.. New York: Lippincott Williams & Wilkins, 2003.