A 5-year-old girl is brought to the office by her mother, who is concerned after observing her daughter speak to an empty chair in her room on several occasions. The girl's medical history is significant for preterm birth at 36 weeks gestation but is otherwise noncontributory. Her family history is significant for cerebrovascular accident and depression in her maternal grandfather and schizoaffective disorder in her father. When questioned, the patient says she sees her grandmother at night and likes to speak to her before she goes to bed. The grandmother died 2 months ago and had lived in the family home. For a few weeks following the death, the girl would become tearful and frequently ask her parents when her grandmother would be coming back. Which of the following is the most likely diagnosis in this patient?

Question

A 5-year-old girl is brought to the office by her mother, who is concerned after observing her daughter speak to an empty chair in her room on several occasions.  The girl's medical history is significant for preterm birth at 36 weeks gestation but is otherwise noncontributory.  Her family history is significant for cerebrovascular accident and depression in her maternal grandfather and schizoaffective disorder in her father.  When questioned, the patient says she sees her grandmother at night and likes to speak to her before she goes to bed.  The grandmother died 2 months ago and had lived in the family home.  For a few weeks following the death, the girl would become tearful and frequently ask her parents when her grandmother would be coming back.  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

This child is experiencing hallucinations of her recently deceased grandmother that appear to be comforting. Studies suggest that behavioral disturbances are common in children the year following the death of a loved one and that children try to maintain a connection with the lost loved one as a way of coping with loss. In the absence of other psychiatric symptoms (eg, other psychotic symptoms, severe mood symptoms, social or academic problems), these hallucinations are unlikely to be a symptom of mental illness and are likely a way of holding on to the grandmother during the bereavement process. The mother should be reassured that this is a normal response to loss. Children under age 6 do not understand the finality of death and may believe that it is temporary or reversible. By the age of 7, children usually understand that death is permanent but may have difficulty understanding abstract concepts (eg, soul, heaven) until adolescence. Parents can help young children mourn by supporting their expression about the deceased, maintaining routine, reassuring them that the death and other people's reactions are not their fault, and responding truthfully to their children's questions in a concrete fashion. (Choices A and E) Hallucinations should be differentiated from nightmares and flashbacks that may occur in acute stress disorder and post-traumatic stress disorder (PTSD). These disorders typically involve exposure to actual or threatened death, serious injury, or sexual violence followed by development of characteristic symptoms (eg, intrusive flashbacks, nightmares, avoidance, detachment, hyperarousal). Acute stress disorder lasts from 3 days to 1 month, and PTSD lasts more than 1 month. (Choices B and F) Childhood-onset psychotic disorders are rare, and this child exhibits no other psychotic symptoms (eg, delusions, disorganization, negative symptoms). Psychotic disorders can be differentiated by duration; brief psychotic disorder lasts for less than 1 month, schizophreniform disorder lasts 1-6 months, and schizophrenia lasts 6 months or more. (Choice C) This patient exhibits no persistent depressive symptoms that would be required to diagnose major depressive disorder with psychotic features. Educational objective: Transient behavioral disturbances are common in children after the death of a loved one. Hallucinations of recently deceased relatives are part of a normal grief reaction and may not be indicative of major psychiatric illness. __________ References: Hallucinations in children and adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/15935131) Grief and loss of a caregiver in children: a developmental perspective. (http://www.ncbi.nlm.nih.gov/pubmed/21846078)

A 5-Year-Old Girl Is Brought to the Office by Her