Autoimmune Thyroiditis in an Adolescent Girl on Lithium.

[Author Affiliation]John A. Pesavento. 1 Department of Psychiatry, Creighton University School of Medicine, Omaha, Nebraska.Venkata Kolli. 1 Department of Psychiatry, Creighton University School of Medicine, Omaha, Nebraska.Blanca Garcia-Delgar. 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.Barbara J. Coffey. 2 Department of Psychiatry, Icahn School of Medicine at Mount Sinai, New York, New York.Address correspondence to: Barbara J. Coffey, MD, MS, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1230, New York, NY 10029, E-mail: barbara.coffey@mssm.eduChief Complaint and Presenting ProblemT. was a 14-year-old adolescent girl with a history of prediabetes and hypothyroidism admitted to a residential treatment center (RTC) with symptoms of depression and recurrent suicidal ideation.History of Present IllnessAt the time of admission, T. reported depressive symptoms that had been worsening over the preceding two months. During that time, she had had difficulties in maintaining her daily activities as she was feeling sad, tired, and had problems concentrating. She was also struggling with falling and staying asleep and had reduced appetite, although she had gained up to 20 pounds over the six months before her admission. In that context, she had felt herself perseverating on the idea that she was causing a lot of problems to her mother and that life was not worth living.T. experienced onset of depression at age 12 years, soon after her stepfather was deported and her mother began a subsequent escalation in use of alcohol. At that time, T. exhibited low mood, fatigue, concentration difficulties, insomnia, and suicidal ideation, which led to her first psychiatric hospitalization. During her first admission she was started on sertraline, which was titrated up to 100 mg. T. did not experience any benefit from this medication, so she was switched to duloxetine 60 mg with partial improvement of the depressive symptoms.During the year that followed her first admission, T. had six other inpatient psychiatric hospitalizations for high risk of suicide. On two occasions, she was hospitalized after a suicide attempt by medication overdose.Five months before residential admission, T. reported having had episodes during which she experienced an elated mood and an increased sense of self-confidence. During these episodes, which lasted 2-3 days, T. was more sociable and participated in activities that were unusual for her, such as cooking and painting. Although symptoms were noticeable to T.'s peers, they had not yet resulted in any clear functional impact. With suspicion of bipolar disorder, she was started on aripiprazole 10 mg by her outpatient psychiatrist.In addition to her mood symptoms, T. also reported intrusive memories, recurrent flashbacks, and nightmares related to a history of sexual abuse. T. was first victimized when she was 6 years old by a family member who was 11 years old at the time. In addition, she reported sexual molestation by a family member at age 12 and being raped at age 13. She was diagnosed with posttraumatic stress disorder (PTSD) a few days before RTC admission, and was started on melatonin 3 mg at bedtime for insomnia and prazosin 1 mg at night with some improvement of nightmares.Over the year before RCT admission, T. had also experienced increased anxiety, especially in social situations. She often worried about being judged, avoided meeting new people, and was extremely anxious when she had to talk in front of people. She had a history of truancy, and claimed she had missed more than 20 days of school over the prior year because of an intense fear of being embarrassed in class. Four weeks before RTC admission, she was started on buspirone 10 mg twice a day and lorazepam 0.5 mg every morning for anxiety symptoms by her outpatient psychiatrist. …