Symptom Analysis Evaluation
Symptom: physical aggression, anger, impulsive
A. History Probing Questions
1. Onset and duration:
Tell me a bit about what growing up was like for you? I am interested in learning about what sort
of person you have been since your teenage years, not only how you have been over the last few
weeks?
2. Characteristics and lingering:
I would like to ask a few more questions about your personality and the ways that you tend to react
to certain situations.
Do you tend to have few friends in your life? Would say that the few friends are because you did
not want to or is it for fear of getting close to someone who might reject you?
Do you tend to think of people in general as being disloyal or dishonest?
What sort of jobs have you had and what usually happens with these jobs?
Have people often disappointed you in your life?
When something goes wrong in your life, such as losing a job or getting rejected, have you often
done something to hurt yourself, such as cutting yourself or overdosing?
Have you generally been clear about your goals in life, or do you have trouble knowing who Dan
is?
Would you say that you are a moody person?
Do you often feel empty inside?
When you are under stress, do you feel you lose touch with your environment or with yourself?
During those times, do you feel as if people are ganging up on you?
When someone abandons or rejects you, how do you react?
Do you see yourself as an overly impulsive person? Have you ever done things that can get you
into trouble, such as spending all your money, driving like a maniac, using a lot of drugs, having a
lot of sex, and so forth?
What do you do when you get angry? Do you hold it inside or let loose with it so that everybody
knows how you are feeling?
Do your relationships tend to be calm, stable, stormy, or unstable, with lots of ups and downs?
Do you admire a good scam when you see it? Have you ever done anything that could have gotten
you in trouble with the law?
Tell me more about your dreams? Would you relate the dreams to a terrible experience that you
have had in the past? What sort of experience was it? Do you think the World in general is a good
place or a bad place?
3. Stressors/precipitating factors/triggers:
Tell me about some of the stressors you have dealt with in the past couple of weeks? Have there
been any events that caused you problem or made it worse (Carlat, 2017)?
4. Stressors/precipitating factors/triggers:
Tell me about some of the stressors you have dealt with in the past couple of weeks? Have there
been any events that caused you problem or made it worse (Carlat, 2017)?
B. Differential Diagnoses
C. Mental Status Exam
Differential 1 1. Oppositional Defiant Disorder (ODD) DSM-V 313.81(F91.3)
As the primary diagnosis is supported by argumentative behavior as
evidenced by physical aggression towards staff members on separate
occasions; defiant behavior as evidenced by defilement of rules in the group
facility where he is residing requiring temporal detention by the court; and
vindictive behavior as evidenced by the unremorseful attack on a staff
member who confronted him for being disrespectful.
Differential 2 2. Intermittent Explosive Disorder DSM-V 312.34 (F63.81)
As supported by recurrent behavioral outburst evidenced by: report of
behavioral problems with aggression towards peers in preschool, physical
assault charge while in middle school which he was required to attend an
anger management program; and physical assault charge in which a furniture
was broken and injuries inflicted on the staff attacked, requiring him to be
admitted in the inpatient unit as a temporal detention by the court.
Differential 3 3. Post-Traumatic Stress Disorder (PTSD) DSM-V 309.81 (F43.10)
As supported by history of childhood trauma evidenced by report of
emotional and physical abuse by his father; history of bad dreams and
nightmares; pattern of irritable behavior and angry outburst as evidenced by
physical assault charge while in middle school which he was required to
attend an anger management program; and occasional experience of
derealization as evidenced by report of hearing his name being yelled out
sometimes.
Differential 4 4. Disruptive Mood Dysregulation Disorder DSM-V 296.99 (F34.8):
As supported by recurrent temper outburst evidenced by: report of behavioral
problems with aggression towards peers in preschool; physical assault charge
while in middle school which he was required to attend an anger management
program; and physical assault charge in which a furniture was broken and
i j i i fli d h ff k d i i hi b d i d i h
D. Physiology, Pathophysiology and/or Etiology Associated with each Hypothesis?
Differential 1 Oppositional Defiant Disorder
Appearance- Ranges from normal, hostile, to restlessness appearance
Speech- Ranges from normal, increased rate, pressured, to loud speech
Affect- impulsivity, intense rage, heightened, dramatic, irritable
Behavior- difficulty controlling anger, mood swings, argumentative,
uncooperative, resentful, temper tantrum, vindictive, negativistic, hostile
Thought process: irrational problem solving
Thought content- delusion, distorted perception
Attention and concentration- flight of ideas, distractibility
Memory- Normal
Orientation- Normal
Differential 2 Intermittent Explosive Disorder
Appearance- Ranges from normal to restlessness appearance
Speech- Range from normal to increased rate and usually loud
Affect- impulsivity, intense rage, heightened, dramatic, irritable
Behavior- difficulty controlling anger, mood swings, argumentative,
uncooperative, resentful, temper tantrum, vindictive, negativistic, hostile
Thought process: irrational problem solving
Thought content- delusion, distorted perception
Attention and concentration- flight of ideas, distractibility
Memory- Normal
Orientation- Normal
Differential 3 Post-Traumatic Stress Disorder
Appearance-Ranges from normal, apprehensive, restless, anxious, to fidgety
Speech- increased latency of response, rapid speech
Affect- frightened, apprehensive, tense,
Behavior- easily startled, hyperarousal, nervous, negative emotion
Thought process- loose association,
Diagnostic Tests and Screening Tools
Differential 1 Oppositional Defiant Disorder
This disorder is said to arise as a result of structural abnormalities and the reduction
in the frontal lobe, temporal lobe amygdala and insulin part of the brain which underlies the
much neurocognitive impairment and neurocognitive functions. The etiology is associated
with the co-occurrence with other mental health disorder such as bipolar at about 40% rate
(Noordermeer, et al., 2017). There is strong evidence of the genetic predisposition in the
development of ODD, yet no specific evidence has been identified. There is also the
environmental component such as familial and extrafamilial predisposition, and both
interactions of the gene/environment continue to be explored (Ghosh, et al., 2017).
Differential 2 Intermittent Explosive Disorder (IED).
Unknown pathogenesis but said to be a combination of genetic, psychosocial, and social
factors with etiology of about 1-7 percent. The structure and functions of the brain are
altered specifically the amygdala which is involved in emotional functioning. This results in
negative impulsive and aggressive behaviors (Coccaro, 2020).
Differential 3 Post-Traumatic Stress Disorder (PTSD)
During childhood, it is estimated that 15-43% of girls and 14-43% of boys experience at
least one form of trauma ranging from neglect, physical and/or sexual abuse and
psychological abuse. Out of these statistics, approximately 3-15% of girls and 1-6% of boys
go on to develop PTSD. In the United States, about 3 million reports involving up to 5.5
million children are reported by the Child Protective Services (CPS) and one third of these
reported cases are confirmed cases of abuse that result in PTSD (Barbozo, et al., 2017).
The pathophysiology or etiology of PTSD is relatively unknown, but this disorder is a
combination of genetic, and environmental abnormalities as well as changes in the
Tropomyosin Receptor Kinase B (TrKB), the Brain-Derived Neurotrophic Factor (BDNF).
There are alterations in the signaling pathways of these receptors, and as a results, lead to
changes in the anatomy, functions, and heightened activation in the hippocampus, anterior
cingulate cortex, ventromedial prefrontal cortex, amygdala and the nucleus accumbens,
thereby predisposing patients to clinical manifestations of PTSD (Noordermeer, et al.,2017).
E. Analysis:
This patient has a history of aggression since his preschool years. In elementary school, he
struggled academically, along with bedwetting, defiant behavior, bossiness, and difficulty with
sleep. At that time, he was evaluated by psychiatry and prescribed a high-dose stimulant, as well
as clonidine and imipramine. Clonidine was likely prescribed to reduce his aggressive behavior,
as well as ADHD symptoms, however, it is unclear what screening tools were used for a
diagnosis. Medications used to treat symptoms of ADHD may actually exacerbate aggressive
behavior in patients with ODD (Hood et al., 2015). The imipramine was likely prescribed to
treat aggressive behavior, as well as bedwetting. His symptoms did not improve, and behavioral
issues continued to escalate.
Obtaining information from screenings, mental status exams to identify both cognitive and
emotional capacities that include regulation of affect, verbal skills, capacity for empathy, patient
interview, as well as interviewing adults involved in his care, is the first step to develop a
treatment plan (Gurnani et al., 2016).
Both parents have a history of psychiatric disorders, mother with undiagnosed PTSD and BPD
stemming from sexual abuse as a teenager, and father with untreated BPD, anger issues, and
multiple incarcerations. The patient was removed from his home due to neglect and abuse,
therefore, involving his parents in a treatment plan is not possible.
F. Pharmacotherapy and Non-Pharmacological Treatments for ODD
First-line treatment for ODD involves cognitive behavioral therapy, both individual and family.
If possible, it is optimal to involve parents and provide therapeutic measures, such as parent-
child interactive therapy, as well as parent management therapy. In this case, parents are not
involved, therefore, it is important to teach Dan’s caregivers to be clear in their communication,
maintain consistency with expectations and consequences, reward behavior that is positive, and
ignore negative, attention-seeking behavior (Hood et al., 2015).
There is no FDA approved pharmacological treatment for ODD, however, for those with
Differential 1 Diagnostic tests for ODD: Laboratory tests are usually not indicated to diagnosed, but tests
such as complete blood count (CBC), comprehensive metabolic panel (CMP), urinalysis
(UA), thyroid stimulating hormone (TSH), urine toxicology, lipid panel, vitamin B12 and
folate can be ordered to rule out other medical conditions.
Screening tools: Modified PHQ-9, Childhood Severity of Psychiatric illness (CSPI-2),
Adolescent Mood Disorder Questionnaire (MDQ), Conduct Disorder Scale (CDS), Kutcher
Adolescents Depression Scale (KADS) and HEEADSSS Psychosocial Interview
Differential 2 Diagnostic tests for IED: Neuropsychological testing.
Screening tools:
IEDSQ: Intermittent Explosive Disorder Screening Questionnaire, Questionairre-9
modified for teens, child behavior checklist, Patient Health
Differential 3 PTSD Screening tools:
CPSS: Child PTSD Symptom Scale.
Clinician-Administered PTSD scale for DSM-5 Child/Adolescent Version (CAPTSD)
UCLA Child/Adolescent PTSD Reaction Index for DSM-5
TESI-C: Traumatic Events Screening Inventory for Children
Children’s Revised Impact of Event Scale (CRIES-8)
LEC: Life Event Checklist
PCL-5: PTSD Checklist
Suicidal Risk Assessment
Diagnostic tests: laboratory tests are meant to rule out other conditions or to obtain baseline
kidney function like comprehensive metabolic panel (CMP). This will help before initiating
any medication.
Differential 4 DMDD Screening tools: Although there are no specific screening tools for DMDD,
however, these screening tools are meant to rule out other co-morbid conditions. These
include:
MFQ-Child: Mood and Feeling Questionnaire
P-MDQ: Parent Mood Disorder Questionnaire (for the parents)
persistent, severe symptoms despite therapies, antipsychotic medications, such as risperidone, or
aripiprazole can be used. If the patient is experiencing depressive or anxiety symptoms, an SSRI can be implemented
(Pringsheim et al., 2015).
In clinical trials, risperidone was the only medication that was shown to have an effect on
aggression and conduct problems in youth with ODD and both normal and below-average IQ
scores, with or without a diagnosis of ADHD (Pringsheim et al., 2015).
Risperidone: Adolescents – 0.25 mg once daily. May increase by 0.25 mg weekly. Maximum
dose of 2 mg per day (Safavi et al., 2016).
Aripiprazole: 2.5 mg daily initial dose. Increase by 2.5 mg weekly. Maximum dose 10 mg daily
(Safavi et al., 2016).
References
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American
Psychiatric Association
Barboza, G., & Dominguez, S. (2017). Longitudinal growth of post-traumatic stress and depressive symptoms
following a child maltreatment allegation: An experiment of violence exposure, family risk and placement
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PGBI-SF10: Parent General Behavior (for parents)
P-YMRS: Parent Young Mania Rating Scale (for parent) (Yearwood, et al., 2012)
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