A 16-year-old girl is brought to the office by her mother due to concern about her behavior and grades. Her mother says, "She used to be a good student, but over the past few months, her grades have dropped, and she doesn't seem to care." The patient has been in the annual school play since first grade but recently quit the drama club because "I am not into it anymore; I can't even remember the lines anyway." She avoids her friends and spends a great deal of time in her room with the door locked. She goes to bed early, wakes up late, and takes naps of 1-2 hours when she gets home from school because she feels tired. Her mother reports that the patient has been more irritable, fighting frequently with her younger siblings. The patient responds, "I'm the oldest and my brothers annoy me all the time. I just don't have any privacy at home!" She has no medical conditions and does not use tobacco, alcohol, or illicit drugs. Physical examination shows no abnormalities. The patient is cooperative but appears distracted at times and asks for several questions to be repeated. She appears fidgety and restless, frequently shifting in her seat and shaking her right leg. Which of the following is the most likely diagnosis?

Question

A 16-year-old girl is brought to the office by her mother due to concern about her behavior and grades.  Her mother says, "She used to be a good student, but over the past few months, her grades have dropped, and she doesn't seem to care."  The patient has been in the annual school play since first grade but recently quit the drama club because "I am not into it anymore; I can't even remember the lines anyway."  She avoids her friends and spends a great deal of time in her room with the door locked.  She goes to bed early, wakes up late, and takes naps of 1-2 hours when she gets home from school because she feels tired.  Her mother reports that the patient has been more irritable, fighting frequently with her younger siblings.  The patient responds, "I'm the oldest and my brothers annoy me all the time.  I just don't have any privacy at home!"  She has no medical conditions and does not use tobacco, alcohol, or illicit drugs.  Physical examination shows no abnormalities.  The patient is cooperative but appears distracted at times and asks for several questions to be repeated.  She appears fidgety and restless, frequently shifting in her seat and shaking her right leg.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: 11ec25c8_d7ae_d990_bc81_ff85a66e7402_MD0003_00 This patient has several findings suggestive of major depressive disorder, including the following: Loss of motivation and decreased interest (anhedonia) in school and activities she used to enjoy (eg, drama club, time with peers) Sleep changes (eg, hypersomnia) Lack of energy (eg, fatigue despite sleeping more) Poor concentration (difficulty remembering lines, need for questions to be repeated) Extreme irritability Psychomotor agitation (fidgeting, restlessness) Like this patient, depressed adolescents may be irritable rather than sad. The degree of functional impairment at school and in relationships must be assessed in adolescents with suspected major depressive disorder. Although adolescents are frequently moody and desire privacy, this patient's behavior represents a marked change from her baseline. Her symptoms are causing significant academic dysfunction and social impairment inconsistent with normal adolescent behavior (Choice E). Other symptoms of major depressive disorder include changes in appetite or weight loss/gain, excessive guilt/feelings of worthlessness, and suicidal ideation. Treatment of adolescent depression consists of psychotherapy and, in severe cases, antidepressants (eg, fluoxetine). (Choice A) Although stressful life events often play a role in precipitating behavioral changes, adjustment disorder is not diagnosed if the symptoms are severe enough to meet the criteria for major depressive disorder. (Choice B) Attention deficit hyperactivity disorder has a chronic course and requires onset of symptoms prior to age 12. This patient's impaired concentration and fidgeting are symptoms of her depression. (Choice C) Disruptive mood dysregulation disorder is characterized by persistent irritability and frequent temper outbursts that begin prior to age 10; they are grossly out of proportion to the situation and inconsistent with developmental level. This disorder is not diagnosed when irritability and outbursts occur as part of a depressive episode. Educational objective: Adolescent depression may be characterized by irritability; loss of interest in previously enjoyed activities; fatigue; disturbances in sleep, concentration, and appetite; excessive guilt/feelings of worthlessness; and suicidal ideation. The severity of symptoms and related impairment can help differentiate depression from adjustment disorder and normal adolescent behavior. References: Beyond a diagnosis: the experience of depression among clinically-referred adolescents. (http://www.ncbi.nlm.nih.gov/pubmed/26325067) Major depression in the national comorbidity survey-adolescent supplement: prevalence, correlates, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/25524788) Adolescent depression: clinical features and therapeutic strategies. (http://www.ncbi.nlm.nih.gov/pubmed/23771545)

A 16-Year-Old Girl Is Brought to the Office by Her