Another recent question in AIPGE 2005 has been a topic for intense discussion
in RxPG community. This is an interesting question related to both the subjects
of Psychiatry and Neurology, but looks innocuous enough to deceive anyone who is
not up to date with latest research (you can use rxpgnews.com which covers all
the latest research from medical journals world over and presents the summary in
a readable news format). RxPG Team has scanned some quick facts and came up with
an explanation for the correct answer. First of all let us see the question and
review the discussion till date.
An 18 yr old student complains of lack of interest in studies for last 6 months.
He has frequent quarrels with his parents & has frequent headaches. The most
appropriate clinical approach would be to:
1.leave him as normal adolescent problem
2.rule out depression
3.rule out migraine
4.rule out an oppositional defiant disorder
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Replies To This Question in
previouspapers.com
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rule out depression
Author: vaibhav
Date: 12-01-05 07:01
so/of lack of interest and associated somatic complaints so/a headaches
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Author: pratima
Date: 12-01-05 09:55
frequent quarrels with parents in a 18 yr old boy with so headache+lack of
interest in studies strongly indicates to rule out oppositional defiant disorder
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depression
Author: rajn
Date: 13-01-05 11:40
for ODD maximum age limit is 10 years according to icd-10
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Oppositional Defiant Disorder
Author: Bouncer
Date: 14-01-05 12:29
-----------------------------
Ref Kaplan and Saddock in which the dsm 4 criteria specifically mentions "6
months" duration and " 18 years"
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According the above discussions, students are undecided between Oppositional
Defiant Disorder and Depression. Looking at the question, one can see that the
Student is having the following symptoms:
-No interest in goal directed activities (lack of interest in studies for last 6
months)
-Irritability ( frequent quarrels with his parents)
-Headaches
We can not leave him as normal adolescent problem as there is an organic
component to his problems (headache). The other "Lack of interest" points
towards depression (option 2), Irritability is usually a behavioural symptom and
points towards Oppositional Defiant Disorder (ODD) Option 4). Headaches points
towards migraine (option 3) although no description of the type and character of
the headache is given. Now pondering over the question again with the point of
view of the examiner, you will realise that it is a cleverly formulated MCQ with
enough armoury of confusa (RxPG calls confusing and wrong options confusa in its
books) and balanced options. First of all let us look at what is oppositional
defiant disorder.
In children with Oppositional Defiant Disorder (ODD), there is an ongoing
pattern of uncooperative, defiant, and hostile behaviour toward authority
figures that seriously interferes with the youngster's day to day functioning.
Biological and environmental factors may have a role. Symptoms of ODD may
include:
* frequent temper tantrums
* excessive arguing with adults
* active defiance and refusal to comply with adult requests and rules
* deliberate attempts to annoy or upset people
* blaming others for his or her mistakes or misbehaviour
* often being touchy or easily annoyed by others
* frequent anger and resentment
* mean and hateful talking when upset
* seeking revenge
Clearly there is an indication of probable ODD in this case. One student in
discussion on previouspapers.com mentioned that "for ODD maximum age limit is 10
years according to icd-10", which is clearly wrong. ICD classifies ODD in two
categories, childhood onset type and adolescent onset type. Only for the
childhood onset type the maximum age limit is stated as 10 years. Our subject is
18 years old and can qualify as adolescent onset ODD after taking a careful
history.
Depression can not be diagnosed only on the basis of one symptom "lack of
interest". We need some biological evidence of sleep problems, appetite
irregularities, weight loss and most importantly "Lack of pleasure" in engaging
in otherwise pleasurable things (Anhedonia).
So, we can not diagnose anything for certain with this little information. Then
what should we do? A handy tip will be to look at the same presentation as if
you are seeing him in your outpatients clinic with only this information. You
are then thinking about diagnosing a behavioural problem or perhaps ODD. To
diagnose behavioural problem, you need to rule out all other factors which can
lead to same presentations, most important being organic problems. This
gentleman is presenting with a symptom of headache too. So you will first rule
out migraine and that will the correct answer.
Well the deduction of the answer above was based on common sense and a few of
RxPG students must be baffled by the apparently flimsy way we took a symptom of
headache to consider migraine which itself is a diagnosis and not just a
symptom. Well, this is where the well informed students ace the exams. If you
have read this article (Link
Between Migraines and Behavioral Disorders In Children)
in 2004, you would have been marking the same answer with certainty rather than considering the "migraine" option as an intelligent guess. Remember the success rate of 10 certain answers is about 100% whereas in case of 10 intelligent
guesses it is 60-80%.
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