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Abstract
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10 year old girl admitted to a paediatric hospital for medical workup following acute presentation of bizarre behaviours of one month duration. Behaviours included writing lines on her face with crayons, putting ketchup in her hair, writing words on her body, excessive writing of short sentences/words on paper, irritability and aggressive behaviour, deteriorating self-care, stuffing clothing under her clothes to appear fat and wearing several layers of men’s underwear, smearing faeces, overeating and deteriorating sleep. The themes of her notes included wanting to be fat, posh girls, sexualised references to private body parts and excrement, and wanting help. There was also a strong emotional fixation with a male character from a children’s TV programme. Her teacher became worried about an inappropriate note she circulated. On assessment, she appeared very unkempt, lice infested hair; mood was irritable. She became distressed at the idea she was unwell. No psychotic symptoms were observed. She denied any problems and explained she was “messing”, “eccentric” and her parents were “paranoid”. She lives with parents and 14 year old brother whom she has a good relationship with. Her parents work long hours which impacts negatively on the home routine. She attends music lessons, however no sports and has a few friends outside school. Her parents describe ongoing issues in school with an episode of bullying preceding onset of symptoms. There was no disclosure of physical or sexual abuse. No abnormal trauma marks were observed on her body. She has no previous psychiatric or medical history. There is a family history of Autism and depression. Her parents have a mostly relaxed parenting approach and contributing factors included her brother’s own unruly behaviour. During her admission, all her medical tests were negative including brain CT and EEG; routine blood tests and autoimmune profile. She continued to wear several layers of underwear and write on her arms. She continued to deny any issue with her mood or her behaviours, however spoke more regarding her feelings. She was discharged home as ongoing hospital admission was felt to be counter therapeutic and her parents felt confident they could manage at home. She was reviewed in outpatient appointments and continued to be distressed, irritable with limited engagement when discussing her parents’ concerns regarding her behaviour. A differential diagnosis, case formulation and management plan will be discussed.
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