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Case Study: Emotional Dysregulation and Sleep Disorder

🕑 5 minutes read
Posted February 25, 2016

Submitted by:
Craig D. Weiss, Ph.D.

Name of Organization:
Sywulak and Weiss Psychological Associates, L.L.C.

Presenting Problem:
“Anne” was initially seen at age 6 years, 10 months for irritability, oppositional behavior and tantrums lasting hours on end. Her parents reported trying almost every approach recommended by her pediatrician and what they read in books and online, with no improvement. The meltdowns occurred almost daily at home, but in school, with friends and in public, Anne held it together. Triggers included, but were not limited to, tactile sensitivity (clothing, touch, getting hair and nails cut); minor frustrations; redirection and attempts to calm or distract her; most any transition or changes in routine; and any perceived criticism. She was an active girl and a thrill seeker who was preoccupied with spinning and somersaults, and became overly excited during and after movement activity. Mood would rapidly change from expansive to rage and tearfulness. At times she shared feelings of self-loathing and guilt, but for the most part she blamed others or circumstances for setting her off.

Therapeutic Goals:

  • Correctly diagnose symptoms
  • Decrease and eliminate tantrums, mood swings, and low self-esteem.
  • Refer to appropriate physicians and other health care professionals to address symptoms beyond my purview (e.g., tactile sensitivity)

From infancy through about five “Anne” was seen for significant sleep difficulties; as time progressed the above symptoms began to appear. A pediatric neurologist who specialized in sleep disorders believed the symptoms could be a harbinger for childhood psychiatric concerns including ADHD, Bipolar and ODD. On mother’s side there is a family history of childhood sleep disorders, anxiety and a relative with significant psychiatric issues likely Bipolar in nature.

Consultation with the physician reviewed the possibility of a childhood Bipolar diagnosis, which was verified by an extensive literature review. About a year ago she was provisionally diagnosed with childhood OCD and ODD at Children’s Hospital. She was placed on a low dose of an antidepressant which also had anti-anxiety properties.

Treatment at my office included Child Centered Play Therapy, Filial Therapy and Eye Movement Desensitization and Reprocessing (EMDR), which utilizes bilateral stimulation (sound, tapping or eye movement). We utilized some behavior modification, as needed. The family system was observed and by all accounts Anne’s parents and household were well functioning. Her mother suffered from chronic anxiety and her father tended to categorize her behavior as childhood willfulness. Yet, both agreed there was a serious problem and both followed through with all treatment recommendations.

18 months into treatment a final diagnosis of a Bipolar Disorder was obtained through professional consultation, further tests and literature review.

The doctors at Children’s Hospital waffled over her diagnosis vacillating between OCD, ODD and ADHD as possibilities. The resident I spoke with “wasn’t comfortable with a bipolar diagnosis” and indicated any one of Anne’s symptoms applied to the other disorders. Taken as a whole, they met the childhood bipolar criteria and Anne’s parents were frustrated they refused to consider it.

Significantly, after attending a weekend seminar earlier this month on Disruptive Mood Dysregulation Disorder (DMDD), the psychiatrist called the parents with the news that DMDD is a type of Childhood Bipolar Disorder and Anne’s symptoms match it.

iLs Program Used:
The Child Centered Play Therapy, Filial Therapy and EMDR were continued as iLs was introduced in September. Anne did the iLs Sensory Motor program during our once a week therapy sessions when we talked and did EMDR. We were pleased when she made incremental improvement despite the minimal frequency of once per week.

In early October Anne began using the iLs Pillow every night which produced excellent results. Almost immediately she began to have “good days” in which she was less reactive and able to tolerate triggers without having a tantrum.

Summary of Changes:
Unfortunately, it was not possible for Anne to do the recommended three to five times a week Sensory Motor Program at home. Fortunately, the addition of the nightly use of the iLs Pillow yielded excellent results. Before using the iLs Pillow Anne’s symptoms waxed and waned with periods of a week or so when she did well but the tantrums soon returned full-force. Almost immediately after using the iLs Pillow, Anne either wasn’t set off by triggers or when she began to escalate she was able to calm herself down. When she struggled, she was receptive and responsive to her parent’s interventions. Going two weeks without a significant episode was unprecedented; two months later Anne has had only a handful of rages.

Most of these occurred in the aftermath of the Mid-Atlantic storm, Sandy. They had no electricity for about a week; school was closed; they had to live with a relative; the household and her routines were upset. She had a few small episodes and a major occurrence which lasted an hour or so. She reconstituted fully, apologized to her parents and moved on. This was also unprecedented.

Conclusions & Recommendations:
This child came into therapy with marked emotional dysregulation. She had an immediate positive response to the iLs Pillow. She loves the iLs Pillow and is relieved by the excellent results. I hope to have her utilize the iLs Focus system at home as I believe it may help to achieve even further gains.

Anne will continue with the iLs Pillow and our weekly psychotherapy sessions. I’m in touch with the Children’s Hospital psychiatrist and awaiting their recommendations under the new DMDD diagnosis. Mother and father told the psychiatrist about Anne’s treatment here, but received a lukewarm response. The best case scenario would be for the Children’s Hospital to utilize iLs and the iLs Pillow at their clinic.

Dr. Minson’s Comments:
Dr. Weiss is to be complimented on his persistence in getting a definitive diagnosis. The new diagnosis of Disruptive Mood Dysregulation Disorder (DMDD) replaced Bipolar Disorder in the new DSM V coming in May 2013. This case well illustrates the confusion that arises when symptoms are common to multiple diagnostic categories.

I want to draw our attention to what happened following the use of the iLs pillow. It is unlikely that the iLs pillow had a direct effect on the primary diagnosis, but rather illustrates powerfully how important sleep is in emotional regulation. For example, it is reported that anywhere from 45 to 75 percent of ADHD children have disrupted and poor quality sleep. Further when the sleep is restored to normal, the ADHD symptoms in many cases are either reduced significantly or go away all together. This raises the interesting question as to how frequently poor sleep may be a primary factor in emotional regulation, attention and behavioral control in many diverse diagnoses.

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