A 15-year-old girl is brought to the office by her mother for evaluation of moodiness and behavioral concerns over the past year. Her mother says, "She always stays out past curfew. I've already tried grounding her, but she doesn't seem to care. When I ask her to do household chores, she gets extremely annoyed and slams her bedroom door in my face." The patient is failing multiple classes at school and blames her grades on "boring teachers" and being unfairly penalized for handing in assignments late. A few months ago, the patient was sent to the principal's office after refusing to put away her cell phone during a test. When the principal said her phone would be confiscated, she started arguing and impulsively cursed at him, resulting in suspension from school. Family history is significant for bipolar disorder in the patient's maternal aunt and depression in her sister. Physical examination shows no abnormalities. On mental status examination, the patient is irritable and sarcastic, frequently interrupting when her mother is speaking. Which of the following is the most likely diagnosis?

Question

A 15-year-old girl is brought to the office by her mother for evaluation of moodiness and behavioral concerns over the past year.  Her mother says, "She always stays out past curfew.  I've already tried grounding her, but she doesn't seem to care.  When I ask her to do household chores, she gets extremely annoyed and slams her bedroom door in my face."  The patient is failing multiple classes at school and blames her grades on "boring teachers" and being unfairly penalized for handing in assignments late.  A few months ago, the patient was sent to the principal's office after refusing to put away her cell phone during a test.  When the principal said her phone would be confiscated, she started arguing and impulsively cursed at him, resulting in suspension from school.  Family history is significant for bipolar disorder in the patient's maternal aunt and depression in her sister.  Physical examination shows no abnormalities.  On mental status examination, the patient is irritable and sarcastic, frequently interrupting when her mother is speaking.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec25c8_d7db_8f04_bc81_3bb5d007baf7_MD0003_00 This patient's pattern of defiance of rules and authority figures, irritable mood, and blaming failures on others is suggestive of oppositional defiant disorder (ODD). For a diagnosis of ODD, the oppositional behaviors must be excessive compared to normative, age-appropriate behaviors and observed during interactions with individuals other than siblings. ODD should also be differentiated from conduct disorder, which is characterized by more severe and aggressive behaviors (eg, physical aggression or cruelty toward people or animals, destruction of property, stealing, lying) (Choice C). However, ODD can precede the development of conduct disorder, and it increases the risk of adult antisocial behavior, impaired impulse control, substance abuse, anxiety, and depression. Treatment of ODD consists of management programs in which parents are trained to reward prosocial behavior and use brief, nonaversive consequences for misbehavior. Individual or group psychotherapy focusing on anger management, problem-solving, and social skills is also beneficial. (Choice A) This patient's behavior represents a general pattern of oppositional behavior rather than a response to a specific psychosocial stressor. In addition, adjustment disorder is not diagnosed when symptoms are better explained by a more specific disorder, such as ODD. (Choice B) A diagnosis of bipolar disorder requires distinct episodes of major depression and mania/hypomania, which are not seen in this patient. This patient's moodiness is more likely related to annoyance at adult rules and demands. Angry/irritable mood is a key feature of ODD. (Choice D) Intermittent explosive disorder is characterized by failure to control aggressive impulses and presents with recurrent, physical, or verbal outbursts. These patients do not display generalized moodiness, argumentative and intentionally defiant behavior, as in ODD. (Choice E) Although some adolescents may occasionally challenge rules and authority in the process of asserting their independence, this patient's behavior is persistent and impairing. School suspension, significant academic dysfunction, and chronic parent-child communication/relationship concerns differentiate this patient's behavior from normal adolescent development. Educational objective: Oppositional defiant disorder is characterized by a pervasive pattern of argumentative and defiant behavior toward authority figures. It does not involve the more severe violations of basic rights of others seen in conduct disorder. References: Common questions about oppositional defiant disorder. (http://www.ncbi.nlm.nih.gov/pubmed/27035043) Oppositional defiant disorder: current insight. (http://www.ncbi.nlm.nih.gov/pubmed/29238235)

A 15-Year-Old Girl Is Brought to the Office by Her