Cases That Test Your Skills

The ‘date’ that changed her life

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Once sociable and fun-loving, 12-year-old Julie suddenly has depressive episodes, fights with her mother, has trouble sleeping, and is suicidal. For 3 years, psychiatrists can’t find the underlying cause. Can you?


 

References

History: From sociable to sullen

Julie, a Hispanic/Native American, was adopted by a Caucasian couple when she was 6 weeks old. Before age 12, she had no psychiatric problems and was medically healthy though slightly overweight.

At age 12, Julie started having episodes of brooding depression, verbal and physical aggression, and impulsive suicidal behavior. She also began suffering intermittent migraines and having trouble falling asleep. She insisted on sleeping with her parents or with a nightlight in her room.

Once a sociable girl who enjoyed being in the middle school chorus and band, Julie suddenly became sullen and defiant. She dropped out of afterschool activities and stopped socializing with peers except for her best friend, Sheila, age 12, and Mark, age 13, an “almost boyfriend” who lived next door.

Julie also started arguing with her mother, often yelling and screaming when approached with minor requests. Sometimes, Julie hit and pushed her. A psychiatrist diagnosed the 12-year-old with major depressive disorder and prescribed fluoxetine, dosage unknown.

Soon after Julie’s symptoms surfaced, her adoptive father, a sales representative, was laid off. He found work in another state; the family left an ethnically diverse city for a predominantly Caucasian rural area. There, Julie completed middle school and her freshman year of high school, and lost contact with Sheila and Mark.

Midway through her freshman year, Julie tried to induce vomiting after eating so that she would lose weight and “fit in better with the other girls.” She stopped this at the end of the school year.

The following fall, 5 weeks into her sophomore year, she dropped out of high school and was ultimately enrolled in home school.

Treatment: 4 hospitalizations in 3 years

Between ages 12 and 15, Julie was hospitalized four times for outbursts of violence with impulsive self-harm. She “overdosed” on eight aceta-minophen/diphenhydramine tablets on one occasion and superficially cut her forearm on another. During these episodes, she said, she heard voices telling her to harm her mother and herself.

During this period, Julie was diagnosed as having schizophrenia, major depressive disorder, attention-deficit/hyperactivity disorder (ADHD), and oppositional defiant disorder (ODD). Numerous antidepressant and mood stabilizer regimens produced no lasting improvement, though her angry and violent episodes became less frequent.

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The authors’ observations

Although Julie’s psychotic symptoms might suggest an evolving disorder such as schizophrenia, no clear pattern supports this diagnosis. Also:

  • Onset at age 12 is unusual. Schizophrenia typically begins in late teens to early adulthood.
  • Julie showed no premorbid personality problems—found in up to one-third of patients with chronic schizophrenia—and no premorbid adjustment difficulties resulting from negative symptoms, cognitive deficits, or poor social function.1
Julie’s angry behaviors and refusal to stay in school suggest ODD, but this disorder generally presents without self-harm or other impulsive behaviors and occurs apart from psychosis or mood disorder episodes.1 Her low mood, withdrawal from activities, and suicidal actions may suggest major depressive disorder with psychotic features, but this diagnosis does not explain the sudden dramatic transformation in her baseline personality.

Julie’s birth parents’ mental health history would offer crucial information, but this was not available.

Continued history: ‘I left my body’

Shortly after her 15th birthday, Julie broke down and told her parents that 3 years earlier, four boys had gang-raped her while she was “on a first date” with one of them at a school football game. She said one attacker held a knife to her throat, and they threatened to kill her friend Sheila if anyone was told. Julie said she felt so terrorized that “I left my body and watched what was happening.”

After the rape, Julie went home, showered, and went to bed. She said she felt “emotionally numb” for 2 months, during which she threw herself into schoolwork, stopped attending after-school events, and began arguing with her parents. She developed nightmares of the trauma and, eventually, auditory command hallucinations. When stressed, she has “out of body” feelings lasting several minutes.

The parents, though angry at Julie‘s attackers, did not seek legal counsel or report the rape to authorities because they felt too much time had passed. They sought support from a counselor, who referred their daughter to a male psychiatrist for medication management. Julie, now age 16, preferred to be treated by a woman, so her care was transferred to our clinic.

Based on clinical observations, Julie gets along well with her father. She complains that her mother is overprotective yet Julie cannot bear to be separated from her for even a couple hours. She resents her mother’s overinvolvement but relies on it for emotional regulation. Her mother has been treated for major depressive disorder, generalized anxiety disorder, and alcohol dependence. These were in sustained remission when Julie presented to us.

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