Negative Symptoms in a Depressed Teen? Primary Hyperparathyroidism and its Psychiatric Manifestations

[Author Affiliation]Timothy Rice. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Svetlana Azova. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, New York, New York.Barbara J. Coffey. Icahn School of Medicine at Mount Sinai, Department of Psychiatry, 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, New York 10029, E-mail: Barbara.coffey@mssm.eduChief Complaint and Presenting ProblemL. was a 14-year-old girl, the younger of two sisters, admitted to an inpatient psychiatric unit for treatment of major depressive disorder following a recurrence of suicidal ideation.History of Present IllnessL. reported that she first experienced depressive symptoms following her fourteenth birthday. She described feeling slow, fatigued, and exhausted. Formerly an A student, her grades declined and her self-esteem dropped. She began working with her school counselor to improve homework completion with little success. She became unable to get out of bed in the morning and missed school. She ceased socializing with friends, became isolated from her parents, and experienced feeling out of control and unable to change the trajectory of her downward trend. She began to fail to maintain basic hygiene and hit herself out of frustration and exasperation.Approximately 4 months after the onset of these symptoms L. developed suicidal ideation with a plan to jump in front of traffic. She reported this to her counselor who referred her for an emergency psychiatric evaluation. L. was subsequently admitted to a psychiatric inpatient unit where she was treated with fluoxetine and amphetamine salts, which were titrated up to 20 mg and 10 mg, respectively, prior to discharge. As a result, her energy and depressive symptoms improved. She was discharged after two weeks with a diagnosis of major depressive disorder (MDD), with a plan to initiate outpatient mental health services.After about a month, L. stopped taking amphetamine salts, due to the development of gastrointestinal upset and a fine hand tremor. She continued to take fluoxetine, but often missed doses, and her depressive symptoms once again began to worsen. One day prior to a second admission, her father found her in her room attempting to choke herself by squeezing her throat with her hands. There was sufficient force to leave marks. She claimed that she felt she had no control over any decisions.L. was admitted to a second inpatient unit where she was started on 5 mg of escitalopram and titrated to a maximum dose of 20 mg. This regimen resulted in moderate improvement in her symptoms. However, she continued to have persistently blunted affect, poor eye contact, delayed response latency, and severe psychomotor retardation. She slept long hours and often missed school and group activities. Her mentation was profoundly slowed to an extent that there was concern for thought blocking.The inpatient treatment team was concerned that she had developed negative symptoms suggestive of a psychotic process, and augmentation of escitalopram with an antipsychotic was considered. However, L. had no positive signs of psychosis, no indication of paranoid thought content or disorganization of thought process. Additionally, it was noted that L. had persistent mild to moderate hypotension, with systolic blood pressures ranging from the 80 mm Hg to 110 mm Hg, and a mild but persistent tachycardia, with pulse ranging from 90 beats per minute to 120 beats per minute. L. had mild symptoms of hypotension, including lightheadedness on rising, and it was noted that this symptom often increased her tendency to stay in bed. In further exploration of symptoms, she revealed that for many months she had been constipated and defecated once every three days.To address these symptoms, a full review of L. …