12-Year-Old Girl with Irritability and Insomnia

Posted by • May 24th, 2013

In the latest Case Record of the Massachusetts General Hospital, a 12-year-old girl with a history of celiac disease, anxiety, and depression was seen in the outpatient psychiatry clinic of this hospital because of irritability, hypersomnia, and multiple somatic symptoms. Psychotherapy and the administration of antidepressants were begun.

Pediatric patients with somatization are likely to have psychopathological symptoms, family dysfunction, and poor performance and attendance at school. Children with abdominal pain who have a negative medical workup may have been exposed to a traumatic event and may have underlying anxiety.

Clinical Pearls

• What are the manifestations and risk factors for childhood depression?           

Criteria for a major depressive episode includes persistent irritable mood for two or more weeks and five or more of the following neurovegetative symptoms: low energy, decreased appetite, hypersomnia, diminished interest in daily activities, psychomotor retardation, and decreased concentration. Children often have trouble recognizing and reporting their emotional state. Alexithymia (the inability to express one’s feelings) does not rule out depression.  Child psychiatrists base their diagnoses on observation and on reports from parents, as well as on the child’s self-report.  Prepubertal patients with depression commonly present with somatic symptoms, irritability, or social withdrawal, whereas adolescents are more likely to have hypersomnia or psychomotor retardation. Risk factors for a major depressive disorder include a family history of depression, the presence of another nonaffective psychiatric disorder predating the depression, female sex (after puberty), and multiple major life stressors. The more risk factors a patient has, the more likely it is that depression will develop.

Which selective serotonin-reuptake inhibitors (SSRIs) are currently approved by the Food and Drug Administration (FDA) to treat childhood depression?      

Only two SSRIs are approved by the FDA — fluoxetine for the treatment of children 8 years of age or older, and escitalopram for the treatment of children 12 years of age or older. The FDA issued a black-box warning in 2004 that some children, adolescents, and young adults may have an increased risk of suicidal thoughts or behavior while taking antidepressants. One meta-analysis showed that the increased risk in suicidal thoughts was between 1% and 3%. Another meta-analysis concluded that the clinical benefits associated with the use of antidepressants in children with depression outweighed the risks.

Morning Report Questions

Q: What are the clinical and laboratory features of adrenal insufficiency?   

A: Features of adrenal insufficiency include chronic weakness, fatigue, anorexia, nausea, vomiting, abdominal pain, dizziness, weight loss, hyperpigmentation, hypotension, hyponatremia, hyperkalemia, hypercalcemia, anemia, and eosinophilia. The diagnosis of Addison’s disease is often missed for some time. In one study, only 47% of the cases were diagnosed within 1 year after initial symptoms and more than 20% were diagnosed more than 5 years after initial symptoms.

Q: What laboratory values are consistent with a diagnosis of autoimmune primary adrenal failure?               

A: Undetectable plasma cortisol levels, elevated plasma corticotrophin level, elevated plasma renin activity, and elevated 21-hydroxylase antibody level are diagnostic of autoimmune primary adrenal failure. This results in a loss of adrenal glucocorticoid, mineralocorticoid, and androgen production because of destruction of the adrenal cortex by autoreactive T cells. As a result of the loss of negative feedback of cortisol on the hypothalamus and pituitary, corticotropin levels rise dramatically and levels of thyrotropin can rise mildly. Because of the loss of the effects of mineralocorticoids on salt and water balance, there is decreased renal perfusion pressure, which drives the production of plasma renin activity.

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