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Kommentarside
Learning points raised by this case include:

• Normality and deviation in youth

• Behavioural problems in youth
• Truancy from school (staying away from school)
• Depression during adolescence
• Other differential diagnoses (see point 1.1)
• Assessing suicide risk
• Psychiatric legislation
• Treating youths with psychiatric illnesses as a general practitioner

Presentation of problem

• 1.1 What kind of problems might be in the background of Berit's behaviour?

◦ Normal reaction to puberty?
◦ Diminishing concentration/problems at school -- beginning of a
vicious circle?
◦ Identity problems during early adolescence
◦ Reaction to family problems
◦ Reaction to traumatic experiences
◦ Somatic illness (headache)
◦ Behavioural disorder (asocial)
◦ Alcohol and/or drug abuse
◦ Depression
◦ Early signs of grave mental disorder (psychosis, bipolar disease)
• 1.2 What information is it important to gather?
◦ Berit`s development from birth to the present day
◦ Possible triggering factors
◦ Important information concerning the possible problems mentioned in
1.1
◦ Family anamnesis: mother, father, siblings, mental disorders in the
family, etc.

2. History of present illness

• 2.1 What differential diagnoses should be investigated?

Berit's problems seem to exceed what is considered a normal reaction to

puberty. Difficulties at school seem an unlikely triggering factor, since she
used to be a clever pupil. Her present difficulties at school are thus
considered to be secondary to her main problem.

Identity problems can't be excluded, but are not very likely to be her main
disorder.

The parents deny any family problems. That leaves these possible
diagnoses:

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◦ Reaction to a traumatic experience -- the parents haven't mentioned

any traumas, so you are dependent on Berit to tell you about any
assaults or other traumatic experiences.
◦ Somatic disease (headache, tiredness, diminishing concentration) --
in any case where there is a sudden change in behaviour, the
possibility of an onset of somatic disease has to be investigated.
Consider possibilities such as tumour cerebri, anaemia, endocrine
disturbance, etc.
◦ Behavioural disease (asociality) -- Berit is showing several
characteristics, and this remains a potential part of the diagnosis. But
it doesn't quite fit with the fact that Berit used to be a responsible and
quiet girl. Behavioural disease develops gradually, and it is often
possible to see features of the illness during prepuberty.
◦ Drug/alcohol problems -- you know that Berit drinks some alcohol.
The scale of the problem, and whether she also uses drugs, requires
further investigation.
◦ Depression -- this diagnosis is one of the most probable. Berit has
previously suffered periods of tiredness and poor concentration.
Recent changes in her personality include aggression towards others
and not taking care of herself (slow self-destruction). This might be a
"masked" depression ("sad not bad"). Somatic symptoms frequently
accompany depression in young people. Some depression runs in
families.
◦ First appearance of severe mental disorder (psychosis, manic-
depressive disorder) -- at present no suspicion of any psychotic
symptoms, but an affective disorder with a varying course can't be
excluded. Manic-depressive disorder can appear at exactly this age,
but it isn't possible to reach a firm diagnosis during the first
depressive cycle.

• 2.2 How can you take your investigation forward and make it possible to
help Berit?

To proceed with the investigation, it is vital to establish personal contact

and develop a relationship of trust. The students may discuss how this
could/should be achieved. Part 3 will suggest one way of doing it.

3. Further investigation

• 3.1 What do you intend to do now?

Berit is very unhappy and devoid of hope. The main issue in deciding on
the next move is: Is it safe for her to stay at home? That is, she has to be
assessed for suicide risk. The "suicidal ladder" may be useful here: degree
of depression -- thoughts of death -- death wish -- suicidal thoughts --
suicide attempts -- suicide plan.

If you estimate the risk to be small, you should start building a

foundation for further conversation with her: Take care not to come
across as domineering and authoritarian; she is already fed up with being
under adult supervision. Try to motivate her by finding some positive

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thoughts hidden behind her depressive perspective, so that you can

convince her that you are actually helping her. Emphasise that friends and
family care for her too.

• 3.2 What is the most probable diagnosis?

Cf. point 2.1. Of the listed psychiatric diagnoses, this is most likely a
depression with secondary behavioural problems, drug/alcohol abuse and
somatic symptoms. At this stage little is known about a possible triggering
factor. N.B. Somatic disorder can't be excluded without further examination.

• 3.3 What further examinations should be undertaken?

You need to elicit additional information from Berit that will increase your
understanding of her condition and suggest triggering factors. Find out
about her relationships to her mother, father and other close relations or
friends. You may use a self-reporting questionnaire (e.g. MFQ -- Mood and
Feelings Questionnaire for children/young people, or BDI -- Beck
Depression Inventory for older youths) to help assess the extent of her
depression. Both a clinical somatic and neurological examination should be
conducted.

Appropriate supplementary examinations include:

• Blood tests -- to look for diseases which may explain Berit's fatigue,
diminishing concentration, change in behaviour, depression, headaches,
etc.
• EEG
• Cerebral CT- or MRI-scan
• Other?

Further history:

Berit agreed to further contact with her GP. The doctor did a physical
examination, took some blood tests, and ordered EEG and CT. He found an iron-
deficiency anaemia, which was easily corrected. The rest of the tests were
normal.

Berit hadn't been sexually abused. Her symptoms had evolved slowly during
puberty. The doctor considered her behavioural problems to be secondary to
depression, and made a tentative diagnosis: F32.1 Moderate depressive episode.
She was considered not to be suicidal (her self-destruction was gradual).

After consulting the nearest child and youth psychiatric outpatients' department,
the doctor continued having regular conversations with Berit and prescribed anti-
depressive medication (SSRI -- fontex/fluoxetin). He also talked to Berit and her
parents together. The agreement with the child and youth psychiatric department
was that Berit could be referred if: a) her condition worsened, especially with
regard to suicide risk, b) the treatment he had initiated failed to produce an
improvement.

A referral wasn't necessary. Berit's depression was alleviated by the above-

mentioned measures. After some time she became more engaged and energetic,
applied herself to her schoolwork with some success, and started making plans

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for further education. She continued to struggle with her parents over a long
period, but little by little her aggression evolved into constructive self-assertion.
Among other things she was very disappointed in her mother, and this took a long
time to get over.

The doctor also diagnosed depression in Berit's mother, and achieved good
results with anti-depressive medication. Some time later, Berit's mother stated
that she had been suffering periodical depressions since she was young, and that
she was very depressed when Berit was little.

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