A previously healthy 13-year-old girl is brought to the physician by her mother because of a change in behavior. The mother reports that over the past 6 months, her daughter has had frequent mood swings. Sometimes, she is irritable for several days and loses her temper easily. In between these episodes, she behaves “normal,” spends time with her friends, and participates in gymnastics training twice a week. The mother has also noticed that her daughter needs more time than usual to get ready for school. Sometimes, she puts on excessive make-up. One month ago, her teacher had informed the parents that their daughter had skipped school and was seen at the local mall with one of her classmates instead. The patient reports that she often feels tired, especially when she has to wake up early for school. On the weekends, she sleeps until 1 pm. Menses have occurred at 15- to 45-day intervals since menarche at the age of 12 years; they are not associated with abdominal discomfort or functional impairment. Physical examination shows no abnormalities. Which of the following is the most likely explanation for the patient's behavior?

Borderline personality disorder

A 32-year-old woman is brought to the physician by her husband, who is concerned about her ability to care for herself. Three weeks ago, she quit her marketing job to start a clothing company. Since then, she has not slept more than 4 hours per night because she has been working on her business plans. She used a significant portion of their savings to fund business trips to Switzerland in order to buy “only the best quality fabrics in the world.” She has not showered and has eaten little during the past 3 days. She has had 2 similar episodes a few years back that required hospitalization and treatment in a psychiatry unit. She has also suffered from periods of depression. She is currently not taking any medications. She appears unkempt and agitated, pacing up and down the room. She speaks very fast without interruption about her business ideas. She has no suicidal ideation or ideas of self-harm. Toxicology screening is negative. Which of the following is the most appropriate pharmacotherapy for the management of this patient?

Clonazepam therapy for one year

Sertraline therapy for one year

A 29-year-old man comes to the physician with his wife because she has noticed a change in his behavior over the past 2 weeks. His wife reports that he is very distracted and irritable. His colleagues have voiced concerns that he has not been turning up for work regularly and behaves erratically when he does. Previously, her husband had been a reliable and reasonable person. The patient says that he feels “fantastic”; he only needs 4 hours of sleep each night and wakes up cheerful and full of energy each morning. He thinks that his wife is overreacting. The patient has been healthy except for a major depressive episode 5 years ago that was treated with paroxetine. He currently takes no medications. His pulse is 98/min, respirations are 12/min, and blood pressure is 128/62 mm Hg. Mental status examination shows frenzied speech and a flight of ideas. Which of the following is the strongest predisposing factor for this patient's condition?

Maternal obstetric complications

An 11-year-old boy’s parents brought him to a psychologist upon referral from the boy’s school teacher. The boy frequently bullies his younger classmates despite having been punished several times for this. His mother also reported that a year prior, she received complaints that the boy shoplifted from local shops in his neighborhood. The boy frequently stays out at night despite strict instructions by his parents to return home by 10 PM. Detailed history reveals that apart from such behavior, he is usually not angry or irritable. Although his abnormal behavior continues despite warnings and punishments, he neither argues with his parents nor teachers and does not display verbal or physical aggression. Which of the following is the most likely diagnosis?

Attention-deficit/hyperactivity disorder, hyperactivity-impulsivity type

Intermittent explosive disorder

A previously healthy 16-year-old boy is brought to the physician by his parents for evaluation because of extreme irritability, fatigue, and loss of appetite for 3 weeks. Five months ago, his grandfather, whom he was very close to, passed away from chronic lymphocytic leukemia. He used to enjoy playing soccer but quit his soccer team last week. When he comes home from school he goes straight to bed and sleeps for 11–12 hours each night. He previously had good grades, but his teachers report that he has been disrespectful and distracted in class and failed an exam last week. He tried alcohol twice at a party last year and he has never smoked cigarettes. Vital signs are within normal limits. On mental status examination, he avoids making eye contact but cooperates with the exam. His affect is limited and he describes an irritable mood. He is easily distracted and has a difficult time focusing for an extended conversation. Which of the following is the most likely diagnosis?

Attention deficit hyperactivity disorder

Adjustment disorder with depressed mood

A mother brings her 3-year-old son to his pediatrician because he is having tantrums. The boy has no history of serious illness and is on track with developmental milestones. His mother recently returned to work 2 weeks ago. She explains that, since then, her son has had a tantrum roughly every other morning, usually when she is getting him dressed or dropping him off at daycare. He cries loudly for about 5 minutes, saying that he does not want to go to daycare while thrashing his arms and legs. According to the daycare staff, he is well-behaved during the day. In the evenings, he has tantrums about twice per week, typically when he is told he must finish his dinner or that it is time for bed. These tantrums have been occurring for about 6 months. The mother is concerned her son may have a behavioral disorder. Which of the following is the most likely cause of the boy's behavior?

Attention deficit hyperactivity disorder

A 25-year-old woman comes to the physician because of sadness that started 3 weeks after her daughter was born. Her daughter is now 9 months old and usually sleeps through the night, but the patient still has difficulty staying asleep. She has not returned to work since the birth. She is easily distracted from normal daily tasks. She used to enjoy cooking, but only orders delivery or take-out now. She says that she always feels too exhausted to do so and does not feel hungry much anyway. The pregnancy of the patient's child was complicated by gestational diabetes. The child was born at 36-weeks' gestation and has had no medical issues. The patient has no contact with the child's father. She is not sexually active. She does not smoke, drink alcohol, or use illicit drugs. She is 157 cm (5 ft 1 in) tall and weighs 47 kg (105 lb); BMI is 20 kg/m2. Vital signs are within normal limits. She is alert and cooperative but makes little eye contact. Physical examination shows no abnormalities. Which of the following is the most likely diagnosis?

Depression with peripartum-onset

A 12-year-old boy is brought in by his parents as they are concerned about his behavior. He is constantly arguing with his parents and blatantly defying their every request. In school, he is known for being intentionally tardy and for defying his teachers. Upon further questioning of the patient you learn about some of his recent behaviors such as beginning smoking to bother his parents. You also notice that he is disrespectful towards you. You then learn that he has also gotten into weekly fights with his peers at school with no apparent cause. In addition, last week he was seen hitting one of the local neighborhood cats with a baseball bat trying to kill it. The patient lives at home with his two parents in a pre-World War II house that was recently renovated. Physical exam is unremarkable. Laboratory values are as follows: Na: 140 mmol/L K: 4.5 mmol/L Cl: 100 mmol/L Glucose: 80 mg/dL Ca: 10 mmol/L Mg: 3 mEq/L Cr: 0.8 mg/dL BUN: 10 mg/dL Serum lead: < .01 µg/dL Hb: 15 g/dL Hct: 45% MCV: 95 Urine toxicology: negative As the patient leaves the office you notice him stealing all of the candy from the office candy bowl. The patient seems unconcerned about his behavior overall. Which of the following statements is most likely to be true in this patient?

The patient's symptoms could progress to antisocial personality disorder

This patient will likely function normally despite continuing to defy authority figures

Environmental exposures are likely causing this patient's behavior

This patient is suffering from antisocial personality disorder and will likely be incarcerated in adulthood

Strong D2 antagonists are first-line pharmacotherapy

Child and adolescent mood disorders for USMLE Step 2 CK: High-Yield Psychiatry Lessons

Overview - Kiddie Blues Basics

Presentation varies from adults; chronic irritability can be a core symptom instead of overt sadness.
Core neurovegetative symptoms (sleep, appetite, energy) are key, but look for school failure & social withdrawal.
High comorbidity: Anxiety, ADHD, ODD/Conduct Disorder.

⭐ A first major depressive episode in childhood/adolescence is a major risk factor for future suicide attempts and developing Bipolar I Disorder.

Major Depressive Disorder (MDD) - Grumpy Kid Syndrome

Hallmark pediatric symptom is persistent irritability instead of sadness. Diagnosis requires ≥5 symptoms over ≥2 weeks, significantly impairing function.

📌 Pediatric SIGECAPS:

Irritability / Anhedonia (at least one required)
Sleep disturbance
Guilt or worthlessness
Energy loss
Concentration difficulty
Appetite change or failure to make expected weight gains
Psychomotor agitation/retardation
Suicidal ideation

Child sitting alone, head in arms, while others play

⭐ A first episode of MDD in childhood or adolescence is a significant predictor for developing Bipolar I Disorder.

Mania Symptoms by Severity

Core Presentation: Unlike adult euphoria, pediatric cases often show severe, non-episodic irritability, temper tantrums, and aggressive outbursts. Mood is labile and reactive.
Key Differentiators:
- vs. ADHD: Look for distinct mood episodes (mania/hypomania, depression). ADHD has a more pervasive pattern of hyperactivity/inattention without clear mood cycles.
- vs. DMDD: DMDD features chronic irritability without the discrete manic/hypomanic episodes required for a bipolar diagnosis.

⭐ A family history of bipolar disorder in a first-degree relative is the strongest risk factor.

Disruptive Mood Dysregulation Disorder (DMDD) - Temper Tantrum Turmoil

Core: Severe recurrent temper outbursts (verbal/behavioral) grossly out of proportion to the situation, occurring ≥3 times/week.
Mood Baseline: Persistently irritable or angry nearly every day between outbursts.
Diagnostic Window: Symptom onset must be before age 10.

⭐ Key function is to reduce the overdiagnosis of pediatric bipolar disorder by distinguishing chronic irritability from the episodic mania seen in bipolar disorder.

Treatment Principles - Fixing the Feels

Initial treatment for Major Depressive Disorder (MDD) combines psychotherapy and pharmacotherapy. Bipolar disorder requires mood stabilization.

Bipolar Disorder:
- Mood Stabilizers: Lithium, Valproate, Lamotrigine.
- Atypical Antipsychotics: Risperidone, Aripiprazole, Olanzapine.

⭐ ⚠️ FDA Black Box Warning: Antidepressants may increase the risk of suicidal thinking and behavior in children, adolescents, and young adults up to age 24.

Irritability and anger are more common presentations of depression in children than classic sadness.

Frequent, non-specific somatic complaints (e.g., headaches, stomachaches) are a key sign of depression in youth.

Disruptive Mood Dysregulation Disorder (DMDD) involves severe, recurrent temper outbursts (≥3x/week) with a persistently irritable mood between episodes.

Pediatric bipolar disorder often presents with mixed features, rapid cycling, and episodic mood shifts.

SSRIs carry a black box warning for a potential increase in suicidal ideation in adolescents.

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