14 year old girl brought with complaints of absent interactions with peers and teachers in school .Sitting eyes apparently closed inside class room .Not making eye contact with anyone. Deterioration in academic functioning also noticed. Decline started since four years which is gradual and interest in extracurricular activities is also coming down and absent now. Inside family atmosphere she functions well and takes initiatives to do outside trip to play areas,parks, cinemas. Irritability and occasional destructive behaviour also present inside house ,no change in biological functioning reported. Whenever her school mates visited her house she was in distress and there was irritability.Recently she seems to wear a scarf over head when she goes to outside house where there is likely to meet her school mates.Some excessive concern about cleanliness also noticed. Family history of depression in mother delusional disorder in father and suicide and substance use disorder in second degree relatives.Interpersonal issues between parents present. MSE revealed Poor but possible rapport, Slightly reduced range of affect, slightly reduced reactivity, low mood , sibling rivalry,no egodystonic distress regarding her problems also noticed.No hallucinations or delusion .No depressive or suicidal ideation. Unable to self appreciate fully her dysfunctions and unable to elaborate on reasons. physical examination nil significant.No history of abuse reported. How you proceed with the case ?


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There might be some underlying psychological trauma. We need to find out the same. There are multi-dimensional factors. There is a strong family history of various psychiatric disorders, interpersonal issues in parents, decline in academic activities, also in relating to peers and teachers also. Establishing a good rapport is the first thing. Medications have little or no role in this case except for some irritability issues. Concern regarding cleanliness is to be evaluated further. Psychological counseling is the main stay of treatment. Step by step she will reveal her issues, address them accordingly. Follow her up very frequently, at short intervals.

May be childhood psychosis or Rett syndrome

Thanks this can be a case of sexual exploitation by others or TV or pronography or video conferencing ....or you tube - which results into confusion about sexuality or role of sexuality or hatred towards with preoccupation in mind ...about that sexual ... act .. for which at this age she is not aware of or given the thinking that it is a bad touch ..... or in some cases they have seen parents into compromising position for which she is unable to understand . this might lead to such deterioration if mental state is normal .... to rule out childhood schizophrenia .. n other neuro disorder

Bullying/school phobia Counselling individual/ with parents/feedback from teachers /to find out the cause may be helpful, D/d separation anxiety /learning disorder

Proper counselling . Detailed history regarding domestic violence/sexual abuse . Such a common scenario in our country . Where female choose to keep quite n suffer due to social pressure .

At second session rapport seems improving and she expressed an idea that some bad will happen to her if she talks to them but unable to elaborate further and lack of concern for the dysfunctions is striking .IQ and adaptive functioning is good and LD is to be probed.Family intervention partially failed because father is not willing to attend sessions.Started on fluoxetine and mother was asked to keep close watch for any personally significant stressors.By four weeks it seems irritability and distructive behaviour is significantly reduced and patient subjectively report she feels more comfortable now.Morher was given psychoeducation .Lack of clarity in diagnosis and need for regular follow up and serial MSE explained to her .As she was from a far distant place a report provided to her stating differential diagnosis of 1 )OC , Depression, Anxiety spectrum disorders 2) Prodrome of Psychosis 3) Dysfunction related to Possible ongoing Abuse or personally significant stressors. Report may be helpful if she turn up to any other therapist.

With due regards Sir, I think she is somewhere in between OCD with poor insight and a frank psychosis. I ve seen many such cases in PG days, where we also started the patient on fluoxetine, but later most patients were functional with olanzapine or risperidone.

Current picture may resemble depression with some anxiety and OC features. But onset at such a young age(10) and somewhat atypical features with bizarre​ behaviours point to psychosis very likely in future. We may go for psychological tests in addition to serial MSE. I think treatment may be started with antipsychotics with antidepressant action ( like olanzapine) with special attention to OC symptoms.

Very much agree with u

It is a case of Depression with psychosis Rx 1. Anti depressants antipsychotic drugs under the guidance of a psychiatrist 2. psychological counselling

I think its important to rule out whether shes a slow learner ..borderline to dull normal intelligence. Or specific learning disability. The apparent inattentiveness in class and staring into space may be related to academic difficulties. And the irritability and destructiveness at home may be when she is pressurized to study and feels misunderstood. The fact that academic 'decline' is noted since around class 5 may be linked to the fact that till this time many children can compensate for their deficits if they study very hard or their parents sit with them..after this the increasing complexity of academics makes it impossible for them to keep up. The scarf may be an effort to remain unrecognized by schoolfriends, she may have been bullied. The fact that MSE is not yielding much may be another pointer to the presence of subnormal intelligence. Comorbid depression/dysthymia in v/o academic and interpersonal stressors is highly likely. IQ and SLD assessment can be considered. SSRI may be helpful. She would benefit from focusing on her strengths and appropriate vocational training.

B4 to start medication for her problem, it is better to establish confidence in her AND find out the hidden cause of"not going to school and wearing a scarf ".

Rule out autisim encourage school play friends making play activity in family

Preferably ... go for Psychological test like CAT or TAT
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