psychotic disorders a case presentation oliver chan avian co march 2011
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Outline
• Case Presentation
• History
• PE
• Discussion
• Differentials
• Diagnosis
• Diagnostics
• Management
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Identifying Data
• CB, 19/M, SingleCB, 19/M, Single
• 44thth year High School year High School
• Eldest of 2 siblingsEldest of 2 siblings
• Lives with father and younger Lives with father and younger
brotherbrother
• Roman CatholicRoman Catholic
• From Binan, LagunaFrom Binan, Laguna
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Source of Information
• Patient – poor reliability Patient – poor reliability
• Father – good reliabilityFather – good reliability
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Chief Complaint
• According to patient: According to patient: “Bakit ba ako nandito?”“Bakit ba ako nandito?”
• According to father: According to father: “Nakakadinig siya ng mga “Nakakadinig siya ng mga boses”boses”
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History of Present Illness
• Previously well, friendly, Previously well, friendly, achiever in school, close with achiever in school, close with relatives (mother and cousins)relatives (mother and cousins)
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4 months PTC4 months PTC • Hearing voices of Hearing voices of ghosts whispering in ghosts whispering in his earhis ear• “Ang sipag mo”
• “Pangit ka”
• “Mag-ingat ka”
• Fights with father• “Hayop ka”
• He is an AngelHe is an Angel
• Television is a portal Television is a portal to a realityto a reality
History of Present Illness
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• Admit at Mandaluyong Admit at Mandaluyong Psychiatric HospitalPsychiatric Hospital• Unrecalled medications without
relief
• 2-3 days
• Private MD – NeurologistPrivate MD – Neurologist• Unrecalled anti-psychotic
medications without relief
• Admit at MMCAdmit at MMC• Unrecalled anti-psychotic
medications without relief
• 3 days
• Would not take medicationsWould not take medications
History of Present Illness
4 months PTC4 months PTC
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• Mother hospitalized due Mother hospitalized due to kidney complications of to kidney complications of hypertensionhypertension
• Patient was depressedPatient was depressed• Admits to being sadAdmits to being sad
3 months PTC3 months PTC
History of Present Illness
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• Mother passed awayMother passed away
• Patient: “mother ate dirty Patient: “mother ate dirty food food dirty blood” dirty blood”
2 months PTC2 months PTC
History of Present Illness
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• Patient wouldn’t go homePatient wouldn’t go home
• Threaten to kill father and Threaten to kill father and hurt selfhurt self
• Still hear voicesStill hear voices
• Still believes he is an Still believes he is an AngelAngel
Admit to TMCAdmit to TMC
Few weeks PTCFew weeks PTC
History of Present Illness
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Review of Systems
• (+) knee pain
• (+) weakness
• No headache, no dizziness, no fever, no cough, no chest pain
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Past Medical History
• Healthy with no childhood Healthy with no childhood illnessesillnesses
• No history of surgeryNo history of surgery
• No co-morbiditiesNo co-morbidities
• Allergic to chickenAllergic to chicken
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Family Medical History
• Renal complication from Renal complication from hypertension – Motherhypertension – Mother
• Diabetes mellitus - FatherDiabetes mellitus - Father
• Psychiatric condition – Psychiatric condition – MotherMother
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Personal History(Anamnesis)
• Early childhoodEarly childhood• Born via NSD to a healthy
mother
• No complications during pregnancy and childbirth
• Eldest of 2 siblings
• Grew up in the care of grandmother
• Earliest childhood memory: drowning then was saved by aunt
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Personal History(Anamnesis)
• Middle childhood:• Close relationship with
cousins and mother
• Prefers few close friends
• Raped by uncle at 7 y/o
• First friend at grade 11 y/o
• Sleep walking at 12 y/o – would look for mother
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Personal History(Anamnesis)
• Middle Childhood• Mother over father
• Close to younger brother
• Homosexual
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Personal History(Anamnesis)
• Later childhood
• Honor student in Binan National High School
• Badminton
• Girl best friend
• Tried drinking (Red Horse)
• Denies smoking and drug use
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Personal History(Anamnesis)
• AdulthoodAmbition: Architect,
teacher, comedian for GMA7
Denies girl/boyfriendWould like to have a
family in the futureNon practicing Catholic
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Physical Examination
• Vital signs:
• BP: 120/80 mmHg
• HR: 84 bpm
• RR: 20 bpm
• Temp: 36oC
• Height: 168 cm
• Weight: 65 kg
• BMI: 23 (Normal)
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• HEENT: anicteric sclerae, pink palpebral conjunctiva, no TPC, No CLAD, flat neck veins
• Pulmo: symmetrical chest expansion, (-) retractions, clear breath sounds
• Cardio: apex beat at 5th left ICS MCL, normal rate, regular rhythm, no murmur
Objective Findings
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• Abdomen: Normoactive bowel sounds. Soft, flabby. No abdominal tenderness
• Extremities: full and equal pulses, no edema, no cyanosis
• Skin: good color, good turgor, no lesions
Objective Findings
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Neurologic Examination
• Cranial Nerves:• CN I - not tested
• CN II – 2-3 mm equal and briskly reactive to light
• CN III, IV, VI – intact EOMs
• CN V – motor and sensory intact
• CN VII – symmetric facial expression
• CN VIII – no hearing deficits
• CN IX & X – able to swallow
• CN XI – good shoulder shrug
• CN XII – tongue midline
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• Young adult male with a thin built and medium height
• Dresses appropriate for chronological age
• Irritable but would answer questions
• Speech is clear, tangential, and hyperproductive
• Mood is irritable to agitated with frequent shouting bouts
• Appropriate affect
Mental Status Exam
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Mental Status Exam
• Auditory hallucinationsGhost whispering in his ear to not take his
medications.
• Grandiose delusions (shouts that he is an angel)
• Believes he is being raped everyday but no one believes him
• TV is a portal to a reality
• Poor attention
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Mental Status Exam
• Good immediate memory recall
• Good recent memory
• Good recent past memory
• Good long term memory
• Good concentration and calculation
• Poor judgment and abstract thinking
• Poor insight
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Salient features
• 19/M, single19/M, single
• Previously an honor studentPreviously an honor student
• 4 month history of auditory hallucinations of 4 month history of auditory hallucinations of ghosts whisperingghosts whispering
• Believes he is an AngelBelieves he is an Angel
• TV is a portal of a realityTV is a portal of a reality
• In and out of hospitals; given unrecalled anti-In and out of hospitals; given unrecalled anti-psychotic medications without relief – due to psychotic medications without relief – due to non-compliancenon-compliance
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Salient features
• (+) Family history of psychiatric condition – (+) Family history of psychiatric condition – MotherMother
• Mother passed away 2 months PTCMother passed away 2 months PTC
• Essentially normal Physical Exam and Essentially normal Physical Exam and Neurological ExamNeurological Exam
• Mental Status ExamMental Status ExamPoor judgmentPoor judgmentPoor abstract thinkingPoor abstract thinking
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Multi-Axial Assessment
AXIS I: Schizophreniform Disorder w/ good prognosticating factors (295.40)
AXIS II: V71.09
AXIS III: None
AXIS IV: Recent death of mother
AXIS V: 21
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DSM IV Criteria
A.Criteria A, D, and E of schizophrenia are met.
B.An episode of the disorder (including prodromal, active, and residual phases) lasts at least 1 month but less than 6 months. (When the diagnosis must be made without waiting for recovery, it should be qualified as “provisional”).
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DSM IV CriteriaSchizophrenia Disorder
A.Characteristic symptoms: two (or more) of the following, each present for a significant portion of time during a 1-month period• Delusions
• Hallucinations
• Disorganized speech
• Grossly disorganized or catatonic behavior
• Negative symptoms, i.e., affective flattening, alogia, or avolition
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DSM IV CriteriaSchizophrenia Disorder
D.Schizoaffective and mood disorder exclusion
E.Substance/general medical condition exclusion
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DSM IV CriteriaSchizophreniform Disorder
• Specify if:
• Without good prognostic features
• With good prognostic features: two (or more) of the ff:
• Onset of prominent psychotic symptoms within 4 weeks of the first noticeable change in usual behavior or functioning
• Confusion or perplexity at the height of the psychotic episode
Good premorbid social and occupational functioning
Absence of blunted or flat affect
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Differential Diagnosis
1. Schizophrenia
2. Bipolar I (with most recent manic episode) w/ psychotic features
3. Schizoaffective Disorder (Bipolar Type)
4. Delusional Disorder
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Multi-Axial Assessment
AXIS I: Schizophreniform Disorder w/ good prognosticating factors (295.40)
AXIS II: V71.09
AXIS III: None
AXIS IV: Recent death of mother
AXIS V: 21
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Pathophysiology
• Unknown cause
• Theories:
1. Stress-Diathesis Model
2. Neurotransmitters• Dopamine Hypothesis
• Role of Serotonin
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Diagnostics
• CBC, electrolytes
• UA
• ECG
• Liver Function Test• ALT, AST
• Kidney Function Test• BUN, Crea
• Thyroid Function Test• TSH, FT4
• Blood sugar
• Lipid Profile Test
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Pharmacotherapy
• Typical vs Atypical Antipsychotics
• Was given:
Risperidone (Risperidal) 4mg/tab BID
Olanzapine (Zyprexa) 10mg/im PRN
Biperiden (Akineton) 2mg/tab OD
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Psychosocial Interventions
• Admitted to psychiatric rehabilitation facility
• Establish therapeutic alliance
• Psychotherapies:• Vocational Rehabilitation
(OT time)
• Social Skills Rehabilitation
• As an adjunct:
• Supportive Psychotherapy
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Psychosocial Interventions
• Other psychotherapies that could be used:
•Psycho-education
•Cognitive Rehabilitation
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