A 12-year-old boy is referred to the psychiatric nurse pract…
A 12-year-old boy is referred to the psychiatric nurse practitioner in an adolescent partial hospitalization program due to repeated conflicts that have frightened both classmates and family members. According to his parents, the boy was generally “moody and irritable” with frequent episodes of “being a raging monster.” It has become almost impossible to set limits. Most recently he had smashed the closet door to gain access to a videogame that has been withheld to encourage him to do homework. At school he was noted to have a “hair-trigger temper,” and he had recently been suspended for punching another boy in the face after losing a chess match. He has been an “extremely active” young boy “running all the time,” he was also a “sensitive kid” who constantly worried that things might go wrong. His tolerance for frustration has been less than that of his peers, and his parents quit taking him shopping because he would predictably become upset whenever they did not buy him the toy he wanted. School reports indicated that he was fidgety, had wondering attention and was impulsive. When he was 10, a psychiatrist diagnosed him with ADHD combined type. He was referred to a behavioral therapist and started taking methylphenidate with an improvement in symptoms. By the fourth grade, his moodiness became more pronounced and persistent. He was generally “surly” complaining, “life is unfair.” He and his parents begin daily limit setting battles begin at breakfast, by delaying getting ready for school and the arguments continued after school about homework videogames and bedtime. The arguments often included screaming and throwing nearby objects. By the time he reached 6th grade, his parents were tired and his siblings avoided him. According to Wyatt’s parents, he had no problems with appetite, and although they fought about when he would go to bed, he did not appear to have a sleep disturbance. He appeared to find pleasure in his usual activities, maintained good energy and had no history of elation, grandiosity or decreased need for sleep lasting more than a day. Although they described him as “moody, isolated and lonely” his parents did not see him as depressed. They denied any history of hallucinations, abuse, trauma, suicidality, homicidality, or self-harm or premeditated harm to others. He and his parents denied drugs or alcohol use. His medical history was unremarkable. His family history and was notable for anxiety and depression in the father, alcoholism in the paternal grandparents, and possibly untreated ADHD in the mother. On interview, he was mildly anxious but easy to engage. His body twisted back-and-forth as he sat in the chair. In reviewing his temper outbursts and physical aggression, is said, “it’s like a can’t help myself I don’t mean to do these things but when I get mad I don’t think about any of that. It’s like my mind goes blank.” When asked how he felt about his outburst, he looked very sad and said, “I hate when I’m that way.” If he could change three things in his life he replied, “I would have more friends, I would do better in school, and I would stop getting mad so much.” What is the most appropriate primary psychiatric diagnosis?
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