Chinese cultural bound syndrome?

[Merovinge]

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Recently saw a 17 yo F from China at a US boarding school w/o any PMH (has only seen therapists at boarding schools, no other healthcare) presenting for a wide array of complaints:
Feels she is being watched when alone, sometimes by people she does not like, other times unable to tell by who, when in room alone, showering, etc.
Hears people saying she is doing badly in class, even when these peers are not present in school
Reports roommate saying bad things about her when she appears asleep and to others
Feels she will know an answer to a test question but answer with the opposite (gives example of knowing an answer to be non-binomial but will select binomial)
Struggles concentrating (reports dramatic drop off, around 90% of cognitive ability), fatigue, napping 4 hours/day, sleeping around 7 hours/night
In the last month has had 3 nights, never consecutively of staying up all night, feeling "really good" while laying in bed and not worrying about school/tests
Mood is low, had passive SI last month after failing a quiz "what's the point"
Relatively frequent panic attacks (these have preceded the above sx and been present for years but worsened in intensity)
Reports doing poorly in school but counselor notes pt has continued to do well in classes, poor performance seems to be distorted by pt
Reports doing "terribly" on the SAT taken 2 months ago, score was a 1400
Family is very supportive of pt, has flown to the US for 2 months to support her, are confused why this is happening now
Switched boarding schools 1 year ago, last therapist at last school had concerns over bipolar d/o but no sx of this witnessed at current school of 1 year

Beyond MDD w/ psychotic features, GAD, possible mixed to bipolar spectrum underlying things, the persecutory nature of both AH and delusions stands out to me. Any thought this has anything to do with Chinese culture? Plan would be admit to PHP, SSRI + Atypical. Open to any other thoughts/suggestions.

Edit: I work in a very diverse area and have taken care of a lot of Asian families, but they are typically 2nd or 3rd generation and did not grow up in Asia, just want to make sure I am not missing anything as I have almost no experience with 1st generation Asian teenagers.

 

[FlowRate]

I'm on board with your thought process so far. Bipolarish vs stress reaction/anxious personality vs early psychosis. She overlaps too many symptom domains/behaviors to fit neatly into anything I can think of. I'm not reading anything I'd imagine to be particularly unique to Chinese/East Asian cultures other than to say I saw one or two similar presentations during residency during ED/inpatient shifts, but never as pts that I followed longitudinally. (Lots of Chinese students in Boston + our system being the one with a more direct feed from area colleges.)

 

[Sushirolls]

Psychosis still gets psychosis workup.
imaging
labs
EEG 1 hr at minimum

 

[Sushirolls]

Brief psychosis / schizophrenia trajectory is still on differential too
Its okay to just put
Unsp Depression
Unsp Psychosis
Unsp Anxiety

down as the diagnosis while working things up

 

[Merovinge]

Brief psychosis / schizophrenia trajectory is still on differential too
Its okay to just put
Unsp Depression
Unsp Psychosis
Unsp Anxiety

down as the diagnosis while working things up

I agree it is on the differential, however her linear thought process and strong academic achievement speaks less to this being a first break. She is telling me she is doing worse at school then she is actually doing and she is at a competitive boarding school with highly rigorous coursework that would be neigh impossible for most during a first break.

She will get a full set of labs upon admission but I would not routinely brain image someone like this, nor get an EEG without any instances of LoC or other signs of ictyl pathology. I am not aware of any evidence that suggests this should be done when other neurologic signs are not present (in fact my understanding of the literature is an active recommendation against brain imagining in this type of situation). Always open to literature that suggests different than my current understanding.

 

[forchinet121]

Psychosis still gets psychosis workup.
imaging
labs
EEG 1 hr at minimum

At my community hospital, no one gets this work up for psychosis they just assume psychosis if the symptoms fit but no imaging or EEG once labs are clean

 

[Bartelby]

This does not seem likely to be a culture bound syndrome.

First break psychosis, and quite possibly schizophrenia, would be high on the differential. I have seen some young people with schizophrenia that have a range of positive symptoms but are not disorganized and maintain reasonable job or school performance (though with affective flattening and a drop off of more subtle abilities like concentration and abstract thinking). Of course MDD with psychosis and bipolar disorder are very possible as well. Your plan of AD + antipsychotics and PHP seems very reasonable. I would also strongly consider a referral for CBT for psychosis if symptoms persist.

 

[Sushirolls]

Community hospitals drop the ball. Psychiatrists and especially ARNPs drop the ball on this, too.

Lack of classic post ictal doesn't mean it can't be epilepsy. That's why we have 2 months of neurology in our training. There is a reason why neurologists have a 1 year fellowship for just epilepsy.

As @Bartelby points out, poor functioning isn't a requisite to raise concern for Schizophrenia differential. I've had enough over the years be very adept at school, work, etc until symptoms fully manifest.

I did a quick UpToDate review to see if I had gotten disconnected from literature, and perhaps I was outdated, nope, I haven't. The honous isn't on me to prove the standard of care, but y'all to show it ain't.

Imaging + Labs + EEG are standard of care. Yes, it's a pain to get these ordered, authorized and completed. Or to get consults with neurology, etc.

 

[forchinet121]

Community hospitals drop the ball. Psychiatrists and especially ARNPs drop the ball on this, too.

Lack of classic post ictal doesn't mean it can't be epilepsy. That's why we have 2 months of neurology in our training. There is a reason why neurologists have a 1 year fellowship for just epilepsy.

As @Bartelby points out, poor functioning isn't a requisite to raise concern for Schizophrenia differential. I've had enough over the years be very adept at school, work, etc until symptoms fully manifest.

I did a quick UpToDate review to see if I had gotten disconnected from literature, and perhaps I was outdated, nope, I haven't. The honous isn't on me to prove the standard of care, but y'all to show it ain't.

Imaging + Labs + EEG are standard of care. Yes, it's a pain to get these ordered, authorized and completed. Or to get consults with neurology, etc.

So you order an MRI and EEG? Or have neurology do it?

 

[Sushirolls]

I'll order up MRI or at minimum CT head. EEG I try to enlist help of PCP or Neurology to order up.
But it's always a logistical mess to get these done with the various health systems and clinics.
When I can, I try to get neurology onboard and have them order, because it gets done so much quicker and faster than when I'm going it alone.

(When I was at a Big Box shop, they had an RN in the dept, and this person would make it happen behind the scenes. )

Then the imaging will often have prior auth hoops when the dx is psychosis. When you explain to the insurance company nurse who does the review, they are like "heck, yeah, let's authorize this" and then they'll apologize that psychosis isn't on an auto approval like "headache" is.

 

[brosa]

Imaging + Labs + EEG are standard of care. Yes, it's a pain to get these ordered, authorized and completed. Or to get consults with neurology, etc.

No it is not. You should not order imaging for everyone as this is just a huge waste of resources and useless. There was a study recently that found the finding rate was like 0.6%. I could not find it now, but just found this other paper that says the same:

The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review - PubMed

There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking...

pubmed.ncbi.nlm.nih.gov

"There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment."

 

[Sushirolls]

With the OP vignette, MDD + Psychosis is most likely the Dx. But we don't have the patient, we don't have the chart, this could still be a wide open differential. schizophrenia spectrum, lower on differential, still is on it.

I had one young person who first presentation was doing well, job, school, etc. Maybe... maybe was just cannabis induced. Delayed the imaging/EEG/labs full press work up until cannabis stopped. Symptoms got better some, but came back. Schizophrenia most likely diagnosis. Parents/patient very suspicious. Did labs - negative. Makes the discussion with family that much more reassuring when you declare diagnosis is XYZ; "Doc, are you sure this is right? Could there not be some other explanation?" Parents wanted a sort of second opinion, and took to a specific "first break psychosis" program. There, at the specialized program, told "not schizophrenia" don't need our services, person is too high functioning. I stuck to my original assessment, outlined the why, and correlated to diagnostic criteria with family regarding the diverging 2nd opinion. Encouraged the antipsychotic med, even injectables etc.

Fast forward in time. diagnosis certainly was schizophrenia, patient is non-compliant, and homeless on the streets of Big City. Family tries to drive around and locate once a month to check in on person.

That is one study, urging that national guidelines change. Have they changed yet?

0.6% finding is still good enough reason for me to order them.

Publications came out suggesting changes or advocating XYZ.

Example, I'm anti benzo. I rail against them. Brits have guidelines minimizing, and only for short courses, not routine use. US doesn't (last I checked) and its still within standard of care to start and use benzos, even chronically. Publications come out urging against it, but I don't think things have changed (yet).

 

[Sushirolls]

Here is the APA guidelines on schiozphrenia. Not exactly Psychosis but we'll run with it:

Regarding imaging here is the asterisk addendum:
Factors that suggest a possible need for imaging include focal neurological signs, new onset of seizures, later age at symptom onset, symptoms suggestive of intracranial pathology (e.g., chronic or severe headaches, nausea, vomiting), and symptoms suggestive of au-toimmune encephalitis (e.g., rapid progression of working memory deficits over less than 3 months; decreased or altered level of con-sciousness, lethargy, or personality change; Graus et al. 2016). In the absence of such indications, decisions about imaging should consider that the yield of routine brain imaging is low, with < 1% of studies showing potentially serious incidental findings or abnormal-ities that would influence treatment (Cunqueiro et al. 2019; Falkenberg et al. 2017; Forbes et al. 2019; Gibson et al. 2018). On the other hand, routine imaging is a low-risk procedure, and a negative finding can be reassuring to patients and to families. If imaging is ordered, it is rarely necessary to delay other treatment or hospitalization while awaiting imaging results.

That's not exactly a very convincing guideline. I practice on what I would want for my own family, and I most definitely want the imaging and EEG if it were me, my nieces/nephews, own kids, etc.


Lawyer: Dr. Sushee, it says here in these guidelines change in personality warrants imaging? does it not?
Sushee: sure does, law dog
Lawyer: Did the parents not say their baby bear has not been themselves, has had a change in personality?
Sushee: Um, possible. I don't document verbatim parental collateral.
Lawyer: I have their testimony here saying they did.
Sushee: Damn dude. Why you so harsh?
Lawyer: So you weren't practicing the standard of care?
....
Sushee: Law dog, you know my liability insurance company digits right? They'll square you away.

I don't intend to be Sushee.

Now in patients that have psychosis, or slight atypical variations that I'm clinically certain don't have a need for imaging or EEG workup, etc. I discuss that with that patient. I say we can. These are things we might find. It's very low to have positive findings. Clinically I think these could be better explations, but you don't know if you don't check. what do you want for your care, do you want to proceed with this imaging and/or EEG?

nope. I then document the discussion and patient deferral at this time...

 

[ObsequiousAplomb]

No it is not. You should not order imaging for everyone as this is just a huge waste of resources and useless. There was a study recently that found the finding rate was like 0.6%. I could not find it now, but just found this other paper that says the same:

The clinical utility of structural neuroimaging in first-episode psychosis: A systematic review - PubMed

There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment. The appropriate screening procedure for structural brain lesions is conventional history-taking...

pubmed.ncbi.nlm.nih.gov

"There is insufficient evidence to suggest that brain imaging should be routinely ordered for patients presenting with first-episode psychosis without associated neurological or cognitive impairment."

"Abstract​

Background: Australian and US guidelines recommend routine brain imaging, either computed tomography or magnetic resonance imaging, to exclude structural lesions in presentations for first-episode psychosis. The aim of this review was to examine the evidence for the appropriateness and clinical utility of this recommendation by assessing the frequency of abnormal radiological findings in computed tomography and magnetic resonance imaging scans among patients with first-episode psychosis."

It's worth acknowledging that the article you posted is proposing a change to the guideline. Per the article, the guidelines specify that imaging should be routine. They also specify that the imaging should be deferred until an adequate neurological examination is conducted, which despite my 2 months on neurology I am not qualified to rule out all intracranial pathology with my physical examination. So they would end up with a referral for a neurological examination at the least.

 

[brosa]

With the OP vignette, MDD + Psychosis is most likely the Dx. But we don't have the patient, we don't have the chart, this could still be a wide open differential. schizophrenia spectrum, lower on differential, still is on it.

I had one young person who first presentation was doing well, job, school, etc. Maybe... maybe was just cannabis induced. Delayed the imaging/EEG/labs full press work up until cannabis stopped. Symptoms got better some, but came back. Schizophrenia most likely diagnosis. Parents/patient very suspicious. Did labs - negative. Makes the discussion with family that much more reassuring when you declare diagnosis is XYZ; "Doc, are you sure this is right? Could there not be some other explanation?" Parents wanted a sort of second opinion, and took to a specific "first break psychosis" program. There, at the specialized program, told "not schizophrenia" don't need our services, person is too high functioning. I stuck to my original assessment, outlined the why, and correlated to diagnostic criteria with family regarding the diverging 2nd opinion. Encouraged the antipsychotic med, even injectables etc.

Fast forward in time. diagnosis certainly was schizophrenia, patient is non-compliant, and homeless on the streets of Big City. Family tries to drive around and locate once a month to check in on person.

That is one study, urging that national guidelines change. Have they changed yet?

0.6% finding is still good enough reason for me to order them.

Publications came out suggesting changes or advocating XYZ.

Example, I'm anti benzo. I rail against them. Brits have guidelines minimizing, and only for short courses, not routine use. US doesn't (last I checked) and its still within standard of care to start and use benzos, even chronically. Publications come out urging against it, but I don't think things have changed (yet).

What guideline are you referring to, tho?

I just opened the APA guideline for schizo and it says this: "Brain imaging (CT or MRI, with MRI being preferred), if indicated based on neurological exam or history". Did not find a specific guideline for psychosis, it's a legit question. My hospital could not afford doing images on everyone, so it is not like I am changing my practice anyway, but good to know if guidelines are saying otherwise.

Your story is very sad, although common, but an MRI would not change anything in the case.

EDIT: wait I am confused, we are both referencing the same guideline. I guess it is a question of interpretation, but for me it is clear the guideline does not indicate routine MRI.

 

[Sushirolls]

My hospital could not afford doing images on everyone...

Yes, yes they can. The only real cost of imaging, is the X-Ray technician time and radiologist read. The intangibles of the MRI cost, or CT machine cost, the electricity, the depart certification through the state, electricity, cleaning supplies for imaging tables, signage for safety precautions in exam suite, etc are neglible and already covered. Oh, and hospitals are not for profit. Don't kid yourself, cost as reason to not order imaging, should not be on your radar - ever. Out of pocket cost for patient perhaps, definitely, but not cost to hospital.

 

[the5thelement]

I assume that cannabis use has been ruled out?

 

[clozareal]

I'm on board with MDD with psychotic features. Answering the opposite sounds similar to ganser syndrome found in prison inmates. I wouldn't rule out prodromal schizophrenia/schizophreniform just yet as the disorganized thought process/behavior and negative symptoms can come later. Need to rule out panic disorder as well with the frequent panic attacks.

There could be a component of OCPD in terms of high expectations for self but I think that rejection sensitivity associated with a depressed mood state would better capture some of this patient's experience.

The cultural component is how stressful the transition from China to the US to boarding school could be depending on the patient's experience of this. Was it a traumatic send off by her parents? How long ago did she get sent over? What struggles with the transition did she have? What support system does she have here? What are the expectations from her parents about being sent away to do well in school?

 

[Merovinge]

Here is the APA guidelines on schiozphrenia. Not exactly Psychosis but we'll run with it:

Regarding imaging here is the asterisk addendum:
Factors that suggest a possible need for imaging include focal neurological signs, new onset of seizures, later age at symptom onset, symptoms suggestive of intracranial pathology (e.g., chronic or severe headaches, nausea, vomiting), and symptoms suggestive of au-toimmune encephalitis (e.g., rapid progression of working memory deficits over less than 3 months; decreased or altered level of con-sciousness, lethargy, or personality change; Graus et al. 2016). In the absence of such indications, decisions about imaging should consider that the yield of routine brain imaging is low, with < 1% of studies showing potentially serious incidental findings or abnormal-ities that would influence treatment (Cunqueiro et al. 2019; Falkenberg et al. 2017; Forbes et al. 2019; Gibson et al. 2018). On the other hand, routine imaging is a low-risk procedure, and a negative finding can be reassuring to patients and to families. If imaging is ordered, it is rarely necessary to delay other treatment or hospitalization while awaiting imaging results.

That's not exactly a very convincing guideline. I practice on what I would want for my own family, and I most definitely want the imaging and EEG if it were me, my nieces/nephews, own kids, etc.


Lawyer: Dr. Sushee, it says here in these guidelines change in personality warrants imaging? does it not?
Sushee: sure does, law dog
Lawyer: Did the parents not say their baby bear has not been themselves, has had a change in personality?
Sushee: Um, possible. I don't document verbatim parental collateral.
Lawyer: I have their testimony here saying they did.
Sushee: Damn dude. Why you so harsh?
Lawyer: So you weren't practicing the standard of care?
....
Sushee: Law dog, you know my liability insurance company digits right? They'll square you away.

I don't intend to be Sushee.

Now in patients that have psychosis, or slight atypical variations that I'm clinically certain don't have a need for imaging or EEG workup, etc. I discuss that with that patient. I say we can. These are things we might find. It's very low to have positive findings. Clinically I think these could be better explations, but you don't know if you don't check. what do you want for your care, do you want to proceed with this imaging and/or EEG?

nope. I then document the discussion and patient deferral at this time...

Here are AACAP's guidelines. We tend to be even more risk adverse than adult psychiatrists for the record.

DEFINE_ME

Or to save you the clicking: "Assessments are obtained based on specific medical indications, e.g., neuroimaging studies when neurologic symptoms are present or an electroencephalogram for a clinical history suggestive of seizures. Toxicology screens are indicated for acute onset or exacerbations of psychosis when exposure to drugs of abuse cannot otherwise be ruled out. Genetic testing is indicated if there are associated dysmorphic or syndromic features. Similarly, tests to rule out specific syndromes or diseases (e.g., amino acid screens for inborn errors of metabolism, ceruloplasmin for Wilson disease, porphobilinogen for acute intermittent porphyria) are indicated for clinical presentations suggestive of the specific syndrome in question. Broad screening for rare medical conditions is not likely to be informative in individuals with psychosis who do not present with other neurologic or medical concerns" Bolding done by me.

 

[forchinet121]

Here are AACAP's guidelines. We tend to be even more risk adverse than adult psychiatrists for the record.

DEFINE_ME

Or to save you the clicking: "Assessments are obtained based on specific medical indications, e.g., neuroimaging studies when neurologic symptoms are present or an electroencephalogram for a clinical history suggestive of seizures. Toxicology screens are indicated for acute onset or exacerbations of psychosis when exposure to drugs of abuse cannot otherwise be ruled out. Genetic testing is indicated if there are associated dysmorphic or syndromic features. Similarly, tests to rule out specific syndromes or diseases (e.g., amino acid screens for inborn errors of metabolism, ceruloplasmin for Wilson disease, porphobilinogen for acute intermittent porphyria) are indicated for clinical presentations suggestive of the specific syndrome in question. Broad screening for rare medical conditions is not likely to be informative in individuals with psychosis who do not present with other neurologic or medical concerns" Bolding done by me.

That’s what I thought..so no need for imaging thanks

 

[calvnandhobbs68]

Community hospitals drop the ball. Psychiatrists and especially ARNPs drop the ball on this, too.

Lack of classic post ictal doesn't mean it can't be epilepsy. That's why we have 2 months of neurology in our training. There is a reason why neurologists have a 1 year fellowship for just epilepsy.

As @Bartelby points out, poor functioning isn't a requisite to raise concern for Schizophrenia differential. I've had enough over the years be very adept at school, work, etc until symptoms fully manifest.

I did a quick UpToDate review to see if I had gotten disconnected from literature, and perhaps I was outdated, nope, I haven't. The honous isn't on me to prove the standard of care, but y'all to show it ain't.

Imaging + Labs + EEG are standard of care. Yes, it's a pain to get these ordered, authorized and completed. Or to get consults with neurology, etc.

Did you actually do a "quick uptodate review"? Cause I have the uptodate article for "psychosis in adults- epidemiology, clinical manifestations and diagnostic evaluation" right in front of me. She's 17, so well within typical age range for first break psychosis or bipolar d/o, so I'd argue workup as an adult, it's not real deal new onset psychosis in a 12yo.

Initial medical screening and laboratory testing — Medical comorbidities should be identified prior to starting antipsychotic therapy. This is done through general physical examination and laboratory screening. For all patients with new onset of psychosis or in cases where antipsychotic medications are to be started or restarted, we suggest the following screening:
Vital signs, height, weight, body mass index, general physical examination
Chemistry panel – To evaluate for disturbances in fluid or electrolytes
Complete blood count with differential
Lipid panel
Electrocardiogram – To evaluate for arrhythmia or QTc interval lengthening Urine pregnancy test in persons of childbearing potential

For cases where a medically related cause of psychosis is of further consideration, we recommend the following panel of tests. These tests can rule out some of the more common medical etiologies that can be associated with delirium and psychosis. These include hepatic encephalopathy, hyperthyroidism, and vitamin deficiency.

Evaluation for medical causes — Psychosis can be associated with many underlying medical causes, including
neurologic disorders, infectious or inflammatory processes, endocrinologic, hepatic, or other systemic illness. In some
cases, these are revealed on initial screening; however, in other cases, imaging or further laboratory testing may be
warranted based on the clinical presentation. As examples:

In patients presenting with focal weakness or acute language dysfunction (ie, aphasia), a structural brain problem such
such as magnetic resonance imaging (MRI) or computed tomography (CT). (See "Overview of the clinical features and In patients with a history of progressive cognitive decline (eg, short-term memory loss) or functional decline, or in
as stroke, tumor, other mass, or active demyelination should be considered. In these cases, we obtain neuroimaging, diagnosis of brain tumors in adults" and "Evaluation and diagnosis of multiple sclerosis in adults".)

In patients with a progressive language deficit (eg, word finding difficulty or aphasia), a neurodegenerative disorder
should be considered. In these cases, we obtain neuroimaging (MRI or CT, if not already done) and neurocognitive testing.

In patients presenting with a head injury, a seizure or movements consistent with a seizure, or in cases with acute,
subacute, or unexplained change in level of arousal and awareness, a seizure or interictal phenomena should be
considered. In these cases, we obtain an electroencephalogram (EEG) in addition to imaging studies.

In patients presenting with fever or rapidly progressive symptoms, a central nervous system inflammatory,
paraneoplastic, or infectious process should be considered. In such patients, when clinically appropriate, lumbar
puncture and cerebral spinal fluid analysis should be considered after imaging studies such as MRI or CT scan.
Additionally, in these cases, further rheumatologic evaluation may be indicated depending on the clinical presentation.
(See "Overview of paraneoplastic syndromes of the nervous system" and "Viral encephalitis in adults" and "Herpes
simplex virus type 1 encephalitis".)

Testing for other, less common causes of psychosis should be considered in select cases. As examples:

In patients presenting with neurologic symptoms, such as gait disturbance, dysarthria, and seizures, and liver disease,
ceruloplasmin and copper studies should be obtained. (See "Wilson disease: Clinical manifestations, diagnosis, and
natural history".)

In patients presenting with neurovisceral symptoms (eg, abdominal pain, peripheral neuropathy, cognitive deficits), urine porphyrins should be obtained. (See "Porphyrias: An overview".)

In patients with tremor, headache, gastrointestinal symptoms, and exposure to heavy metals, a heavy metal screen should be obtained. (See "Lead exposure and poisoning in adults".)

 

[Alemo]

Imaging + Labs + EEG are standard of care. Yes, it's a pain to get these ordered, authorized and completed. Or to get consults with neurology, etc.

It’s not medical standard of care to do EEG or imaging without neurologic findings and it sure as hell isn’t the legal standard of care in most states. The legal standard of care is NOT equal to professional guidelines (it’s usually lower) and is determined by statute or case law. Inherent problems in this set-up have been discussed at some recent APA and AAPL meetings.

I’m not child trained but we all wouldn’t consider this woman out of the age range for a schizophrenia spectrum prodrome.

By all means order those tests on a hunch (they’re probably not inappropriate here) but standard of care they aren’t.

 

[Alemo]

Also what about her family history?

 

[G Sheb]

Interesting case.
Not to downplay the other stuff on the differential, but it strikes me a bit of an obsessive case, particularly with wanting to answer the wrong way even though she feels she knows the answer, so it would be important to screen out for OCD.
What's her reality testing like for "hearing people talking about her even though they are not there". Does she actually hears them as clear voices? Does she show any ambivalence about thsi being real or not?
I'm not that impressed by the mania/hypomania; sometimes poor sleep itself can trigger mild grandiosity/euphoria.
In my experience, the depression in MDD w/ psychosis is pretty severe, and pts are not likely to remain fully functional.
overall I think you're right this is much less likely a case of first episode psychosis than it is a mood episode with lots of anxiety, obsessive dimension to it.

Always good to keep personality traits/dx in the picture, especially if you're treating long term. I think there is some literature out there that narcissistic/cluster B personality dimensions unravel under intense pressure particularly with paranoia. My gut feeling is that this is probably what's going on here.
I'd probably still go with psychosis unsp as part of the dx, even though I think it's less likely she has a full blown psychotic disorder.
It's definitely the prudent thing to start an AP, though personally I'd go with a drop of AP and hold on, and see how she does on the SSRI, PHP and intensive therapy.
I guess you can call it a cultural bound syndrome if parental high expectations are part of the etiology. (j/k)

 

[FlowRate]

I guess you can call it a cultural bound syndrome if parental high expectations are part of the etiology. (j/k)

Just as a random factoid, probably one of the more described culturally relevant syndromes for patients of East-Asian decent is high rate of role conflict between liberal Western ideals in general society and very conservative Eastern household expectations (more around chastity, parental responsibility, traditional gender roles, less about school pressure) in second-generation adolescent and young adult East Asian women. Whereas women are generally a lower risk suicide group, this is a particularly high risk group which could potentially influence disposition decisions, if the overall picture is relevant to a given case.

 

[Liquid8]

Interesting case. Not too convinced by the psychotic symptoms, although for obvious reasons the nature of the hallucinations should be explored in more depth first and differentiated from say intrusive OCD/anxious thinking or repetitive thoughts.

My initial instinct is it is more likely a major depressive disorder with anxiety related to the challenge of migration, adapting to a foreign culture with underlying parental pressure and academic expectations. Burnout a possibly too, especially when she “feels good” when not worrying about school.

I’d be interested to know what is her relationship like with her parents, and would not be surprised if they are traditional, controlling with inflated academic expectations. Other things to consider include the impact of cultural isolation, home sickness and bullying. Sexuality also worth exploring, as often a taboo subject in Asian cultures especially if deviating from acceptable cultural norms, and possibly something that can't be divulged to parents or friends either. With that in mind, it might provide an angle to approach some of her reported issues. With answering the wrong questions despite knowing the right answer, one could enquire what does it mean to get things wrong or fail, and are there any consequences. If she does poorly, will her parents take her home, and would that be a bad thing? Etc.

 

[annoyedpsychiatrist]

MDD with psychotic features isnt impossible but based upon everything you're saying, i suspect a component of BPD. I see many of BPDers with very similiar vague psychotic symptoms. Passive SI after failing a quiz makes me her mood shifts to extremes over small situations giving me a more BPD than bipolar feel. Often I see BPD with a kind of chronic fatigue syndrome as well, and other vague illnesses. Doesnt stand out as bipolar to me. Possible prodromal schizophrenia but im not convinced on that, just throwing out all possibilities. My initial thoughts are BPD and maybe a component of MDD/GAD. Does she have an abuse history or history of self harm?

I would also do an SSRI+SGA on her as well, i think that is a very logical approach in this case. Sometimes in cases like these if the patient is thin, not eating, sleeping and its vague psychotic sx that i think may be BPD i have good luck with prozac+low dose zyprexa in kind of a symbyax fashion

 

[Merovinge]

Interesting case. Not too convinced by the psychotic symptoms, although for obvious reasons the nature of the hallucinations should be explored in more depth first and differentiated from say intrusive OCD/anxious thinking or repetitive thoughts.

My initial instinct is it is more likely a major depressive disorder with anxiety related to the challenge of migration, adapting to a foreign culture with underlying parental pressure and academic expectations. Burnout a possibly too, especially when she “feels good” when not worrying about school.

I’d be interested to know what is her relationship like with her parents, and would not be surprised if they are traditional, controlling with inflated academic expectations. Other things to consider include the impact of cultural isolation, home sickness and bullying. Sexuality also worth exploring, as often a taboo subject in Asian cultures especially if deviating from acceptable cultural norms, and possibly something that can't be divulged to parents or friends either. With that in mind, it might provide an angle to approach some of her reported issues. With answering the wrong questions despite knowing the right answer, one could enquire what does it mean to get things wrong or fail, and are there any consequences. If she does poorly, will her parents take her home, and would that be a bad thing? Etc.

She gets scared when she hears these voices and was struggling to explain them to me in a way that she could understand and articulate. She has described the same experience to her school therapist who was surprised to hear this given her normal presentation last semester.

Parents were very supportive, non-dramatic, no history of abuse per pt. She wants to go to an Ivy league school but her parents have encouraged her to apply to more modest universities. Her boarding school has a high % of people from China although she does not get along particularly well with most of them. She lived in the US at an all white boarding school for a year prior to this one.

Good thoughts about sexuality, reports cis-het 0 lifetime partners but may not be forthright about this.

 

[Merovinge]

Also what about her family history?

Entirely negative per family. Keeping in mind this is an only child and female (and the decision to keep a girl during a 1 child time) with what appears to be relatively progressive parents so it might be accurate to their understanding.

 

[Merovinge]

MDD with psychotic features isnt impossible but based upon everything you're saying, i suspect a component of BPD. I see many of BPDers with very similiar vague psychotic symptoms. Passive SI after failing a quiz makes me her mood shifts to extremes over small situations giving me a more BPD than bipolar feel. Often I see BPD with a kind of chronic fatigue syndrome as well, and other vague illnesses. Doesnt stand out as bipolar to me. Possible prodromal schizophrenia but im not convinced on that, just throwing out all possibilities. My initial thoughts are BPD and maybe a component of MDD/GAD. Does she have an abuse history or history of self harm?

I would also do an SSRI+SGA on her as well, i think that is a very logical approach in this case. Sometimes in cases like these if the patient is thin, not eating, sleeping and its vague psychotic sx that i think may be BPD i have good luck with prozac+low dose zyprexa in kind of a symbyax fashion

This was the first time she ever experienced SI, no hx of cutting, no return of SI since that time (she has thoughts of "giving up" at school but not dying, feeling that she may have missed her change at ever getting into an Ivy League school).

I do see the vague psychotic persecutory sx as a red flag for emerging PD but she otherwise does not have features suggestive of this. No hx of physical/sexual abuse, but subject to extremely competitive schooling from an early age in China and what came along with that emotionally.

 

[Stagg737]

Agree with the plan of starting an SSRI + low dose SGA initially. Looking at this as a whole with info given this feels like an adjustment disorder that's become severe exacerbating underlying personality traits My top ddx would likely be MDD w/ psychotic features vs an anxious psychosis with neurotic personality traits, either of which SSRI+SGA is a reasonable start. First break psychosis is possible but the paranoia and "hallucinations" don't seem typical of true psychosis. Bipolar seems pretty unlikely, nothing really suggests mania or hypomania. BPD is worth working up imo and I think a lot of child therapists and psychiatrists are too hesitant to label personality traits in older teenagers. Obviously rule out substance use. I also don't think there's a culture bound issue going on here unless there's some kind of "Tiger Cub Syndrome" that I'm just not aware of.

There's more info I'd like to know though as there are some major gaps that I think could help with formulation quite a bit:

Recently saw a 17 yo F from China at a US boarding school w/o any PMH (has only seen therapists at boarding schools, no other healthcare) presenting for a wide array of complaints:

Family is very supportive of pt, has flown to the US for 2 months to support her, are confused why this is happening now
Switched boarding schools 1 year ago, last therapist at last school had concerns over bipolar d/o but no sx of this witnessed at current school of 1 year

How long has this girl been in the US? 1-2 years? 5 years? How was the initial transition? What does "family is very supportive" mean? Any insights into parenting style?

Feels she will know an answer to a test question but answer with the opposite (gives example of knowing an answer to be non-binomial but will select binomial)
Struggles concentrating (reports dramatic drop off, around 90% of cognitive ability), fatigue, napping 4 hours/day, sleeping around 7 hours/night
In the last month has had 3 nights, never consecutively of staying up all night, feeling "really good" while laying in bed and not worrying about school/tests
Mood is low, had passive SI last month after failing a quiz "what's the point"

The bolded sounds like major depression, but I think actually fits in better with demoralization from failure to meet her own standards. I'd guess that if you ask about her self-image and her abilities you'd find a very high level of subjective incompetence and hopelessness. The "what's the point?" thought process and the fact that she seems to intentionally answering questions incorrectly sounds a lot like frustration and a defeatist mindset that if she's going to fail it will at least be on her terms, which can be a coping mechanism to maintain some hope and sense of self-worth (if I answer wrong on purpose, then I didn't really try, so I didn't really fail).

Additionally, the few nights of staying up feeling "really good" isn't really consistent with major depression and would be more in line with atypical depression. It could also be brief periods of her being able to accept an "eff it" though process and brief periods of actual happiness until she is reminded of a stressor that sends her back into her previous state. I've personally experienced this, and I'd bet that if you ask she is grossly asymptomatic during those brief periods.

Feels she will know an answer to a test question but answer with the opposite (gives example of knowing an answer to be non-binomial but will select binomial)
Relatively frequent panic attacks (these have preceded the above sx and been present for years but worsened in intensity)

So she has an anxiety disorder at baseline which has progressively worsened. Tell me (a lot) more. Are they triggered? If so, related to similar thoughts or events? How much has it worsened? Is she experiencing these things even with her "depression"? What are the primary symptoms? Given the possibility of OCPD traits, general anxiety, and newer paranoia I want to know everything about her anxiety.

Finally, and this is something less obvious but I think potentially very relevant, has she ever been evaluated or screened for ADHD? Lack of hx suggesting BPD along with previous suspicions of bipolar disorder makes it worth looking into imo. Also, I've seen a few presentations of ADHD where a patient was admitted for "psychosis" or mania who didn't improve with any meds until we tried a stimulant and quickly became "normal". Turned out the psychosis and obsessive aspects were periods of ADHD exacerbation with hyperfocus and obsession towards random topics, sometimes to the level of paranoia.

 

[whopper]

Reports doing "terribly" on the SAT taken 2 months ago, score was a 1400

Is the SAT still using the maximum 1600 score? Reason why this could be important is if he did a 1400 out of 1600 which is an excellent score on the 1600 scale he's likely got some perfectionism issues.

 

[ObsequiousAplomb]

Is the SAT still using the maximum 1600 score?

Yes, and a 1400 is good but not Ivy League elite good for an Asian woman.

 

[Merovinge]

Yes, and a 1400 is good but not Ivy League elite good for an Asian woman.

Exactly, she's simultaneously correct and wrong at the same time. It's not even close to good enough for Ivy's being from the single most overrepresented demographic that has the most anti-affirmative action going against her, but it is also a very respectable score. I think she would certainly agree to having very high expectations/aspirations that are beyond what is likely or probable. That's also what people have said about many of the most visionary among us so I try to not let my realism enter the treatment paradigm.

 

[G Sheb]

She gets scared when she hears these voices and was struggling to explain them to me in a way that she could understand and articulate. She has described the same experience to her school therapist who was surprised to hear this given her normal presentation last semester.

That's interesting.
That makes her more likely to be on the psychotic spectrum as she's experiencing those voices as ego-dystonic, intrusive experiences that she isn't able to make sense of.
Doesn't mean she'll necessarily end up having full blown schizophrenia, but she's at a higher risk.
In reality even prodromal psychosis comes up in all sort of ways, and many patients will have bona fide psychotic symptoms without progressing to schizophrenia.
r/o MJ/other substances here is also important.

 

[Merovinge]

Agree with the plan of starting an SSRI + low dose SGA initially. Looking at this as a whole with info given this feels like an adjustment disorder that's become severe exacerbating underlying personality traits My top ddx would likely be MDD w/ psychotic features vs an anxious psychosis with neurotic personality traits, either of which SSRI+SGA is a reasonable start. First break psychosis is possible but the paranoia and "hallucinations" don't seem typical of true psychosis. Bipolar seems pretty unlikely, nothing really suggests mania or hypomania. BPD is worth working up imo and I think a lot of child therapists and psychiatrists are too hesitant to label personality traits in older teenagers. Obviously rule out substance use. I also don't think there's a culture bound issue going on here unless there's some kind of "Tiger Cub Syndrome" that I'm just not aware of.

There's more info I'd like to know though as there are some major gaps that I think could help with formulation quite a bit:



How long has this girl been in the US? 1-2 years? 5 years? How was the initial transition? What does "family is very supportive" mean? Any insights into parenting style?


The bolded sounds like major depression, but I think actually fits in better with demoralization from failure to meet her own standards. I'd guess that if you ask about her self-image and her abilities you'd find a very high level of subjective incompetence and hopelessness. The "what's the point?" thought process and the fact that she seems to intentionally answering questions incorrectly sounds a lot like frustration and a defeatist mindset that if she's going to fail it will at least be on her terms, which can be a coping mechanism to maintain some hope and sense of self-worth (if I answer wrong on purpose, then I didn't really try, so I didn't really fail).

Additionally, the few nights of staying up feeling "really good" isn't really consistent with major depression and would be more in line with atypical depression. It could also be brief periods of her being able to accept an "eff it" though process and brief periods of actual happiness until she is reminded of a stressor that sends her back into her previous state. I've personally experienced this, and I'd bet that if you ask she is grossly asymptomatic during those brief periods.



So she has an anxiety disorder at baseline which has progressively worsened. Tell me (a lot) more. Are they triggered? If so, related to similar thoughts or events? How much has it worsened? Is she experiencing these things even with her "depression"? What are the primary symptoms? Given the possibility of OCPD traits, general anxiety, and newer paranoia I want to know everything about her anxiety.

Finally, and this is something less obvious but I think potentially very relevant, has she ever been evaluated or screened for ADHD? Lack of hx suggesting BPD along with previous suspicions of bipolar disorder makes it worth looking into imo. Also, I've seen a few presentations of ADHD where a patient was admitted for "psychosis" or mania who didn't improve with any meds until we tried a stimulant and quickly became "normal". Turned out the psychosis and obsessive aspects were periods of ADHD exacerbation with hyperfocus and obsession towards random topics, sometimes to the level of paranoia.

Thanks for your thoughts.

I will say the way she describes answering the questions wrong was a bit fascinating, she initially made it seem like she was transposing the words on the page (in an acute manner, had never happened before or since) but then almost made it sound like a negativism response. I will be honest that 40 minutes with this patient is just not enough time (rest spent interviewing the parents through a bad Mandarin interpreter) and I will get a second visit before deciding on meds.

Anxiety was related to generalized experiences of grades, future, being liked, etc. Remarkably the same as all the US born patients I treat on a daily basis. She was having panic attacks last semester when she was doing well, a few a month and those had also occurred at her last boarding school. She cannot identify precipitants for these most of the time, occasionally occur due to a "bad" grade.

I was briefly thinking about missed ADHD because she really struggled to concentrate for 12 hours of studying a day needed as a 7th grader in her elite Chinese middle school. She entered 7th grade at the top of her class but ended at the bottom. However as recent as spring of 2022 was able to do 12 hours of class/studying in a day without any difficulty so I think this is much less likely.

 

[Merovinge]

That's interesting.
That makes her more likely to be on the psychotic spectrum as she's experiencing those voices as ego-dystonic, intrusive experiences that she isn't able to make sense of.
Doesn't mean she'll necessarily end up having full blown schizophrenia, but she's at a higher risk.
In reality even prodromal psychosis comes up in all sort of ways, and many patients will have bona fide psychotic symptoms without progressing to schizophrenia.
r/o MJ/other substances here is also important.

I agree, that's my initial feel for it, the psychotic experiences were brief but quite ego-dystonic that she has been trying to make sense of. She's very open to medications for this as well (so are parents).

She has a very aversive description to any substances when asked (and denied) that seems extremely believable. That said, she's hopefully coming to my program that specializes in SUDs so no doubt there will be utoxes involved. I agree that most CAP and even general psychiatrists can miss substances when purely going by report, I am glad to work somewhere that pee is collected on a regular basis in a normative manner.

 

[G Sheb]

I agree, that's my initial feel for it, the psychotic experiences were brief but quite ego-dystonic that she has been trying to make sense of. She's very open to medications for this as well (so are parents).

She has a very aversive description to any substances when asked (and denied) that seems extremely believable. That said, she's hopefully coming to my program that specializes in SUDs so no doubt there will be utoxes involved. I agree that most CAP and even general psychiatrists can miss substances when purely going by report, I am glad to work somewhere that pee is collected on a regular basis in a normative manner.

She's potentially a great candidate for an early psychosis outpatient program.
The researcher in me would like her to get scanned before starting the AP, lol.

 

[Stagg737]

Thanks for your thoughts.

I will say the way she describes answering the questions wrong was a bit fascinating, she initially made it seem like she was transposing the words on the page (in an acute manner, had never happened before or since) but then almost made it sound like a negativism response. I will be honest that 40 minutes with this patient is just not enough time (rest spent interviewing the parents through a bad Mandarin interpreter) and I will get a second visit before deciding on meds.

Anxiety was related to generalized experiences of grades, future, being liked, etc. Remarkably the same as all the US born patients I treat on a daily basis. She was having panic attacks last semester when she was doing well, a few a month and those had also occurred at her last boarding school. She cannot identify precipitants for these most of the time, occasionally occur due to a "bad" grade.

I was briefly thinking about missed ADHD because she really struggled to concentrate for 12 hours of studying a day needed as a 7th grader in her elite Chinese middle school. She entered 7th grade at the top of her class but ended at the bottom. However as recent as spring of 2022 was able to do 12 hours of class/studying in a day without any difficulty so I think this is much less likely.

This makes me even more curious about the anxiety. What is her mental state right before and during the periods of AH? Is she experiencing increased anxiety and then becoming more paranoid/psychotic or is it the other way around? WHY is she anxious, meaning what are the cognitive distortions? Catastrophizing? Overgeneralization? Should statements and control fallacies? Trying to get at the logic of the anxiety may be helpful in understanding her overall cognitive state and even get at the paranoia/psychosis better.

That does sound less like ADHD, but I'd ask what her studying looks like. Is she sitting down for 45-60 minutes at a time and taking short breaks or is she doing 3 things at once and taking frequent breaks? It would be interesting to fast forward a few years and see how she does with more challenging academic work.

Agree with Sheb that this does sound more concerning for actual psychosis with more info, but I'd still explore the nature of her actual distress more. I also wonder how much the cultural aspect may be involved as you said her previous boarding school was all white and her current school has more Asian people. Is she having any identity crisis? Maybe a trauma-like stress reaction to reminders of earlier schooling in China? I'd be curious to see PAI results and ratings with the new AMPD traits.

Thanks for sharing this, it's interesting and I'm curious to hear where it goes.

 

[ObsequiousAplomb]

What about narcolepsy? I hadn't thought much of it in the differential at first, but she is sleeping a lot and some of these situations seem like times she could be on the cusp of sleep - when she appears to be sleeping (wasn't sure if that meant her or her roommate, but either way if one of them appears to be sleeping, then being about to sleep makes sense). Feeling on the edge of sleep would definitely make it harder to pay attention and would result in a mood drop in a high achiever.

One of my residency peers had a similar presentation that resolved completely with high dose Ritalin TID (after a formal narcolepsy diagnosis and several trials before the Ritalin).

 

[Desired Member]

I agree, that's my initial feel for it, the psychotic experiences were brief but quite ego-dystonic that she has been trying to make sense of. She's very open to medications for this as well (so are parents).

She has a very aversive description to any substances when asked (and denied) that seems extremely believable. That said, she's hopefully coming to my program that specializes in SUDs so no doubt there will be utoxes involved. I agree that most CAP and even general psychiatrists can miss substances when purely going by report, I am glad to work somewhere that pee is collected on a regular basis in a normative manner.

Not answering your actual question as I have never treated any patients of Chinese descent...
But anyway I've had patients become permanently psychotic and anxious after trying cannabis 1 time and so I wonder if she tried cannabis once but didn't think that was worth mentioning, or felt ashamed about it.

Not sure how you typically ask about abuse/trauma, but as you know it can be kind of subjective the way people interpret that question. If she was having panic attacks in childhood...that's just not normal and I bet there was some type of trauma there...maybe a teacher or classmate that was verbally abusive to her, or something that could be normalized/not considered trauma but actually is. I think what Stagg said about her environment changing and causing her to subconsciously recall past trauma/stress is an interesting thought. Also narcolepsy may be a good thought, I've heard that narcolepsy can cause psychosis but never seen a patient with it and will do more research about that now.

 

[Liquid8]

She gets scared when she hears these voices and was struggling to explain them to me in a way that she could understand and articulate. She has described the same experience to her school therapist who was surprised to hear this given her normal presentation last semester.

This is sounding a bit more like subacute/prodromal phase symptoms, as the hallucinations can initially be more vague and nonspecific - would agree with your initial management plan of SSRI + SGA.

Parents were very supportive, non-dramatic, no history of abuse per pt. She wants to go to an Ivy league school but her parents have encouraged her to apply to more modest universities.

Sounds like the parents are quite reasonable, as opposed to Tiger parents demanding their kids only do med/law or another course just for prestige (see plenty of that, but being of a similar background probably makes it easier for patients to discuss it more openly). Seems the patient is putting a lot of pressure on herself, and going through a very competitive school system does take its toll. Then people question themselves when they reaches a stage where just working hard does not seem to be enough and the reality is that there will always be others who are more intelligent or seem to get things done much more easily.

Her boarding school has a high % of people from China although she does not get along particularly well with most of them. She lived in the US at an all white boarding school for a year prior to this one.

As well as usual issues relating to existing school cliques, the Chinese are not homogenous, and while it’d be safe to assume that one needs a lot of wealth to study overseas, there are also degrees to that too which can also fuel exclusion and resentment.

 

[Candidate2017]

To me, this is a child (i.e., a non-fully formed person) from an affluent background, high achieving, sent far away to a boarding school. Chinese or not, all her concerns are similar to other children sent away to board. Whether the voices are dementia precox or anxiety or something else is hard to say without seeing her in person.

I wouldn't be opposed to coding adjustment disorder with mixed anxiety and depressed mood or MDD with mood congruent psychotic features. Tim will tell. Since we are no longer allowed to admit and observe patients for 12 straight months in an asylum, a trial of SSRIs (then escalated to SGA if needed) to see if the voices go away would be helpful.

I wouldn't be opposed to brain imaging, if symptoms persist. I recall a Chinese student in a similar situation, turned to out to be brain tumor. I don't know the specifics as it was someone else's patient. I used to see a number of Chinese college students in the inpatient setting with similar issues of depression + anxiety + SI + pseudo psychosis. The common denominator seemed to be they were affluent, but not super affluent and did not fit in with the super affluent Chinese college crowd (i.e, they didn't have multiple $150k+ cars, $1k tee shirts, etc like the other Chinese college kids).

 

[watto]

Hypnagogic hallucinations are part of the narcolepsy tetrad. And anxiety is frequently comorbid.

 

[clausewitz2]

Hypnagogic hallucinations are part of the narcolepsy tetrad. And anxiety is frequently comorbid.

Oh man, I can't believe I missed the combination of sleeping a relatively normative amount most nights + daytime naps + interspersed nights of what sound like profound insomnia in addition to these hallucinations. This is the age where you might see it start, right?

 

[watto]

The symptoms can be there much earlier, but they tend to reveal themselves when the stakes are higher in life. Cataplexy can be very subtle as well and is often missed.

 

[clausewitz2]

b

Cataplexy can be very subtle as well and is often missed.

Can you expand on how you tend to probe for this? I never feel like I've done a very good job assessing for cataplexy.

 

[watto]

I use the Swiss Narcolepsy Scale, but drill down if there is a suspicion for cataplexy. Slight drooping of eyelids during emotional expression, versus weakness in large muscle groups, also I believe the research shows that fear and laughter tend to be the two experiences that provoke muscle weakness in cataleptics with the greatest frequency. The Narcolepsy Severity Scale can also be used.

I also ask about general experience of REM intrusion into wakefulness. There are so many common comorbidities as well - obesity, anxiety / depression (nice that venlafaxine also helps cataplexy), CVD...

 

[Alemo]

Oh man, I can't believe I missed the combination of sleeping a relatively normative amount most nights + daytime naps + interspersed nights of what sound like profound insomnia in addition to these hallucinations. This is the age where you might see it start, right?

Yeah…I can totally believe I missed that.

 

[whopper]

The original question is too open-ended.

The bottom line is any mental illness, anything, could cause someone to academically perform worse. There are issues brought up that make investigating some things lower hanging fruit to explore first, but as-is it's really open.

E.g. prodromal schizophrenia, a recent change in schools is emotionally traumatizing for anyone especially if they liked their prior school, pressure to over-perform, drug abuse.