Psychiatry Case Conference 1 III-B Buyucan, Kathleen – Diaz, Mark Fernan

Psychiatry Case Conference 1

III-B

Buyucan, Kathleen – Diaz, Mark Fernan

General Data L.M.P35 y/omarriedBorn Again Christian2nd in a brood of 3BS Nursing Graduateunemployedborn & raised in Capizadmitted 1st time on April 4, 2005

Infomants: Patient: 75%Husband: 85%Sister: 85%

History of Present Illness

2001 * very active, sings in the choir

2004 * negative feelings towards members and ministry

December

2005 * persistent negative feelings towards members and

January ministry, delusion of reference

2005 * auditory hallucination, loss of appetite, reduced

February sleep, negative feeling towards her husband

2005 * auditory hallucination, odd behavior, blank stares

1st wk March anxious

History of Present Illness

2005 * quiet, unresponsive

3rd wk March

2005 * verbal aggression, delusion of reference

March 25

2005 * felt guilty of what she said to the members,

March 26 delusion of persecution

2005 * neglected her chores and children, delusion

March 27 of persecution/anxiety

2005 * singing songs, speaking incomprehensible words

March 31

History of Present Illness

2005 * suspicious w/her surroundings

April 1 * brought to Las Pinas Doctors Hospital

* injected w/unrecalled medication

* admitted @ USTH while sedated

Review of Systems

(-) Headache, loss of consciousness, convulsions

(-) fever

(+) anorexia , weight loss

(+) HPN – mother

(+) stroke – mother

(+) heart disease, PUD – father

(+) alcohol dependence – father

(?) nervous breakdown – great grandmother

Non-smoker

Non-alcoholic beverage drinker

Denies use of any prohibited drugs

Born to 23 y/o G2P1 (1001); NSD at home

By traditional birth attendant

No prenatal or postnatal complications

Neuro-developmental milestones at par with age

Lived with parents and three siblings

Family owns a small grocery store

Left in the care of the father, an alcoholic

Father had occasional fights with his wife

Patient admits his father had his “weaknesses” but was very affectionate and loving

Patient grew-up closer to her father and siblings

Primary education at Malubog-lubog Elementary School in Capiz

Average student and had very few friends

6th grade - father died which caused extreme sadness and felt that a big part of her was lost with the passing

Left in the care of the eldest sibling (Gina)

Gina confided of being overprotective of her younger siblings

Family Relationship

after father’s death, mother married a policeman

Siblings were against the marriage at first

Patient felt that the mother betrayed her father

According to the patient, she had a harmonious relationship with stepfather and stepsiblings

Stepfather did not impose himself on the stepchildren was kind and approachable and was readily

approachable when they need him

Social Relationships

Claimed to have a number of friends stayed at home on weekends because mother

would not allow her to go out with friends

School History

Attended high school in FLAIMER Christian Institute in Capiz

Wanted to take up AB Philosophy forced by mother to take up BS Nursing Graduated on time

Academic Achievement

failed Nursing Board Exams (1990)

failure due to “poor preparation”

Worked as an assistant nurse in a small clinic while waiting for the next board exams

took the boards in Manila and passed with high marks (1992)

Did not work at once because she was waiting for her petition from her maternal aunt to work in Germany

After some time worked as a ticketing supervisor at Ever Gotesco Cinema

Resigned after 2 months, thinking she was not ready to work yet

Learned that her petition was declined

1993 - nurse in Capiz and resigned after 6 months

Felt bad in an incident when a patient deteriorated infront of her

According to sister: Patient was pious and hardworking

Gave portion of salary to patients

1994- went back to Manila and stayed with sister

Meaningful Long-term Relationship

met Norman and married him after two years (1996)

- Stayed with husband’s family (Cavite)

After a few months, husband flew to Abu Dhabi

Patient got pregnant and went back to Capiz

Had difficult pregnancy

- 1997 – CSD with her 1st child (Paul Christian)

1998 – went to Abu Dhabi with husband and had no difficulty in adjusting

Worked as sales clerk in a pharmacy

December 1999 – decided to return to Philippines due to 2nd pregnancy

2000 – gave birth to second child (Patricia Lois)

Stayed with her mother, who sometimes helped out with her grandchildren

Longed for her husband

2001 – returned to UAE with her children because of argument with mother

Was baptized to a ALL Nations FULL GOSPEL, a Born Again Christian group

Planned to work as a nurse however got pregnant with her 3rd child

First worked as an assistant nurse

Very little compensation while waiting for the next board exams

resigned to take 2nd board exam

Worked as Ticketing supervisor and resigned after 2 mos

Petition by her maternal aunt was declined by the German Embassy

1998 - sales clerk in a pharmacy in Abu Dhabi

1999 - resigned because of 2nd pregnancy

No difficulty adapting to new environment

No difficulty adjusting to new role as mother

Cesar- father

Died of “heart attack” at 45 An elementary graduate Came from a well off family in Capiz Alcoholic since 20 y/o

Drank gin (? amount) almost everyday usually alone or with friends

Patient regards him as loving and kind father Patient claims she got her talent from him

He usually sang with her

Minerva- mother

58 y/o, elementary graduate

Strict disciplinarian in the family

Managed mini-grocery store with Cesar

Patient would have arguments with her

Ricardo Delfin – stepfather

60 y/o, retired policeman

Treated his stepchildren as his own

Takes care of Minerva very well

Gina – sister

38 y/o, BS Music undergraduate

Married, currently unemployed

Previously worked as a singer in Japan

Currently lives with husband and 5 children in Caloocan

Very close to the patient; patient’s confidant

Julius- brother

33 y/o, college undergraduate

Married with 2 children

Previously worked as a seafarer

Stays at Panitan, Capiz with their mother

Suffered stroke

Small business – selling prepaid cards

Norman- husband

38 y/o, aeronautics graduate

Trainer at Estilat Telecom Co. in UAE

Member of ALL Nations FULL GOSPEL for 10 years

Very loving and supportive husband and father

Paul Christian – son

8 y/o, Grade 2 student

Good relationship with parents and siblings

Has problems in school Hyperactive and lazy to copy notes

Patricia Lois – daughter

5 y/o, Kinder II student

Very bright daughter

Consistent honor student

Has good relationship with parents and siblings

Tim Albert- son

2 y/o

Tim Albert2

Cesar45

Gina38

Paul Christian

8

Patricia Lois

5

L35

Norman38

1996

Minerva58

4

LEGEND Heart attack

Stroke

PUD

HPN

Ricardo Delfin

60

Julius33

5 2

SALIENT FEATURES 35 y/o

Female

Born again Christian

Unemployed

Preoccupation with at least 2 delusions (Jan-March2005)

Auditory hallucination

Aggressive/agitated behavior (March 2005)

Avolition-apathy (3rd wk & 27 Mar)

SALIENT FEATURES

Incomprehensible speech

Impaired social functioning

Physiologic disturbance: anorexia and insomnia

Family history: great grandmother had nervous breakdown

Non-smoker, non-alcoholic, denies use of prohibited drugs

Poor relation with mother

Diagnosis and Discussion

• chronic psychotic disorder with onset typically occurring in adolescence or young adulthood

• results in fluctuating, gradually deteriorating, or relatively stable disturbances in thinking, behavior, and perception

• severity can range from mild and subtle with very good adaptation to everyday life, to severely disabling requiring constant supervision in a restricted environment.

Classification of Longitudinal Course

Epidemiology

US lifetime prevalence: 1%

DSM-IV-TR: annual incidence 0.5-5.0 per 10,000

Equally prevalent in men and women.

Earlier onset in men (10-25 yrs old), women (25-35)

Men are more likely to be impaired with negative symptoms

Women have better social functioning prior to disease onset

ETIOLOGY

PathophysiologyDopamine Hypothesis

Examples of Positive and Negative Symptoms in

Schizophrenia

Increased rate among the biological relatives of patients with schizophrenia

Correlated with the closeness of the relationship to an affected relative

Population Prevalence (%)

General population

1

Non-twin sibling of a schizophrenia patient

8

Child with one parent with schizophrenia

12

Dizygotic twin of a schizophrenia patient

12

Child of two parents with schizophrenia

40

Monozygotic twin of a schizophrenia patient

47

Neuropathology

Loss of brain volume results from reduced density of the axons, dendrites and synapses that mediate associative functions of the brain.

CLINICAL FEATURES

No clinical sign or symptom is pathognomonic for schizophrenia

Patient’s symptoms change with time

Clinicians must take into account the patient’s educational level, intellectual ability and cultural and subcultural membership.

Premorbid Signs and Symptoms

Appear before the prodromal phase of the illness

Patients had schizoid or schizotypal personalities.

Quiet, passive, and introverted

As children, they had few friends

Signs may have started with complaints about somatic symptoms

Headache, back and muscle pain, weakness and digestive problems

Family and friends may notice that the patient has changed and no longer functioning well in occupational, social, and personal activities.

May begin to develop an interest in abstract ideas, philosophy and the occult or religious questions

Include markedly peculiar behavior, abnormal affect, unusual speech, bizarre ideas and strange perceptual experiences.

Psychiatric Diagnostic Exams

MENTAL STATUS EXAM

important part of the clinical assessment process in psychiatric practice.

structured way of observing and describing a patient's current state of mind, under the domains of appearance, attitude, behavior, mood and affect, speech, thought process, thought content, perception, cognition, insight and judgment

Trzepacz, PT; Baker RW (1993). The Psychiatric Mental Status Examination. Oxford, U.K.: Oxford

University Press. p. 202.

Mental Status Exam Appearance

Attitude

Behavior

Mood and affect

Speech

Thought and Process

Thought content

Perceptions

Cognition

Insight

Judgment

MENTAL STATUS EXAM

DOMAIN In The Patient

APPEARANCE Awake, but agitated

With appropriate manner of dressing and grooming

ATTITUDE Uncooperative

BEHAVIOR No noted abnormal movements but (+)

hallucinations; good eye contact but inattentive

when interviewed

MENTAL STATUS EXAM

DOMAIN In The Patient

MOOD AND AFFECT Affect appropriate but mood was anxious

SPEECH “speaking in tongues”, incomprehensible

spontaneous speech;

THOUGHT PROCESS Logically incoherent

MENTAL STATUS EXAMDOMAIN In The Patient

THOUGHT CONTENT Delusions that “someone” is plotting against her and her family; Preoccupation

against her Christian Community

PERCEPTIONS Positive auditory hallucinations and

illusions

COGNITION Oriented to time, place and person; alert

MENTAL STATUS EXAMDOMAIN In the Patient..

INSIGHT Seems to be unaware of her mental illness

JUDGMENT Paranoid and suspicious of her surroundings

Perceptual Disturbances

Diagnostic Tests

HALLUCINATIONS

Any of the five senses may be affected

Auditory most common hallucinations

Patient She felts that God’s voice was telling her to do

something about the church

God communicated with her through “discerning spirit”

Visual hallucinations

Illusions

They are distortions of real images or sensations

active phases, prodromal phases and during periods of remission

substance-related cause for the symptoms

Thought :

Thought Content

Patient's ideas, beliefs, and interpretations of stimuli

Delusions Patient

“ Pinaghihiwalay ang family namin ng ministry”

“Huhulihin ka nyan, magtago na tayo”

Thought Form of Thought

patients' spoken and written language looseness of

associations derailment incoherence tangentiality circumstantiality neologisms echolalia verbigeration word salad mutism

Patient “speaking in tongues”

Thought Thought Process

way ideas and languages are formulated observe the patients behavior, especially in carrying

out discrete tasks flight of ideas thought blocking impaired attention poverty of thought content poor abstraction abilities perseveration idiosyncratic associations over inclusion circumstantiality

Impulsiveness, Violence,

Suicide and Homicide IMSULSIVENESS

Agitated, little impulse control

Decreased social sensitivity

Suicide and homicide attempts in response to hallucinations

Impulsiveness, Violence,

Suicide and Homicide VIOLENCE.

Excluding homicide

Risk factors:

Delusions of persecutory behavior

Previous episodes of violence

Neurologic deficits

SUICIDE

50% of all schizophrenia patients attempt suicide (10-15% die by suicide)

Precipitants of suicide: Misdiagnosed depression

Feelings of absolute emptiness

Need to escape from mental torture

Auditory hallucinations

Impulsiveness, Violence,

Suicide and Homicide SUICIDE

Risk factors: Awareness of the illness, Male sex, College education, Young age A change in the course of the disease Improvement after a relapse Dependence on the hospital Overly high ambitions Previous suicide attempts early in the course of the disease Living alone

Impulsiveness, Violence,

Suicide and Homicide HOMICIDE

Same incidence as in general population

Unpredictable or bizarre reasons based on hallucinations or delusions

Possible predictors:

History of previous violence

Dangerous behavior while hospitalized

Hallucinations or delusions involving such violence

Sensorium and Cognition

Diagnostic Tests

Orientation

Usually oriented to person, time, and place

Some may give incorrect or bizarre answers

“I am Christ; this is heaven; and it is AD 35.”

Memory

Usually intact.

BUT, there can be minor cognitive deficiencies.

Also, it may be impossible to have the patient to attend closely enough to the memory tests for it to be assesed adequately.

Judgment and Insight

Classically, schizophrenic patients are described to have:

(1) poor insight of the nature of their disease.

(2) poor insight of the severity of their disorder.

Associated with poor compliance of treatments.

Clinician must also examine various aspects of insight (awareness of symptoms, social adeptness and reasons for problem).

(a) Treatment of Strategy

(b) Affected Brain Area (parietal lobes » lack of insight)

Reliability

Schizophrenic patients are no less reliable than other psychiatric patients.

Examiner is required to verify important information through additional sources -- given the nature of the disorder.

Neurological Signs

Nonlocalizing Signs

Dysdiadochokinesia

Astereognosis

Primitive Reflex

Diminished dexterity

Abnormal motor tones

Impaired fine motor skills

Abnormal movements

Neurological Signs

Eye Examination

Disorder of smooth occular pursuit (Blank stares)*

Elevated Blink rate

Speech

Incomprehensible words *

Aphasia (Disturbances in language output)*

* Seen in patient

Other Physical Findings

Embryonic and Fetal Growth anomaly

Genetics

Complications

Compulsive water intake (hyponatremia)

TREATMENT

OVER-ALL TREATMENT GOALS

Reduce or eliminate the symptoms

Maximize quality of life and adaptive functioning

Promote and maintain recovery from the delibitating effects of illness to the maximum extent as possible

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

Phases of Treatment

Acute Phase

Stabilization Phase

Maintenance Phase

TREATMENT: ACUTE PHASE

ACUTE PHASE TREATMENT

Goals:

Prevent harm

Control disturbed behavior

Reduce severity of symptoms

Identify factors that led to recurrence of acute episode

Effect a rapid return to the best level of functioning

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS

• immediate blockade of dopamine D2 receptors • ↓ release of dopamine from presynaptic terminals

Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18

FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS

• Disadvantages• Positive symptoms only• Only 20% of patients recover to normal functioning• Side effects:

• Akathisia, Parkinsonian-like symptoms• Tardive dyskinesia, Neuroleptic Malignant

syndrome

FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS

• Examples• Chlorpromazine• Haloperidol

2nd – Generation - Atypical Antipsychotics

Serotonin – Dopamine Antagonist

> exert more beneficial effects in the reduction of negative symptoms

> greatly reduced occurrence of acute extrapyramidal side effects & reduced incidence of tardive dyskenisia

> decrease affective symptoms and suicidality

Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18

Bridler, Rene, Daniel Umbricht. 2003. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly. 133: 53-76.

SIDE EFFECTS OF ATYPICAL ANTIPSYCHOTICS

Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349: 18

Serotonin – Dopamine antagonist

Examples:

Risperidone

Clozapine

Olanzapine

Sertindole

Quetispine

Ziprasidone

18

ADJUNCTIVE MEDICATIONBenzodiazepines / Lorazepam

Managing catatonia or to decrease anxiety and agitation; sleep disturbances

Anti-depressants

For co-morbid major depression & OC disorder

Beta-blockers

Decrease severity of recurrent hostility & aggression

Mood Stabilizers

Lithiumreduce symptoms up to 50%; for mood swings.

Decrease severity of recurrent hostility & aggression

Anticonvulsants (Valproic acid/ carbamazepine)

Reduce episodes of violence

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins:

USA.

What should we give to the patient?

Serotonine – Dopamine antagonist

RisperidoneIM – every 1 to 2 hours

Per orem – every 2 to 3 hours

PSYCHIATRIC MANAGEMENT

Structured and predictable environment

Low performance requirement

Tolerant, non demanding, supportive relationships

Promoting relaxation and reduced arousal

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

TREATMENT: STABILIZATION PHASE

STABILIZATION PHASE Goals

Reduce stress on patient & provide support to minimize likelihood of relapse

Enhance patient adaptation to life in community

Facilitate continued reduction in symptoms & consolidation of remission

Promote process of recovery

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

PHARMACOLOGICAL INTERVENTION

Continue medications for 6 months

Adjust dose or change drug to minimize side effects

Prevent premature lowering of dose or discontinuation Recurrence of symptoms & possible relapse

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

TREATMENT: MAINTENANCE PHASE

MAINTENANCE PHASE

Goals

enusure symptoms of remission or control is sustained

Improve or maintain level of functioning or QOL

Monitor side effects of treament

American Psychiatric Association. 2004. Practice Guideline for the Treatment of Patients With Schizophrenia, Second Edition.

PSYCHOSOCIAL THERAPIES

Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins:

USA.

SOCIAL SKILLS TRAINING

Also referred to as behavior therapy

Improve social abilities and interpersonal communication

Increase practical skills and self-sufficiency

Reduce the frequency of maladaptive or deviant behavior

FAMILY-ORIENTED THERAPY

Involves preparing the family and the patient going home

Includes postdischarge period, the recovery process, its length and its rate

Help the family and the patient learn about schizophrenia and its psychotic episode

Control emotional intensity of family sessions with the patient

CASE MANAGEMENT

• to have one person aware of all the forces (psychiatrists, social workers, occupational therapists, etc.) acting on the px

• case manager – ensures that their efforts are coordinated and the px keeps appointments and complies w/ tx plans- make home visits and even accompany px to work

Assertive Community Treatment (ACT)

for the delivery of services for persons with chronic mental illness

Team has a fixed caseload of pxs and delivers all services when & where needed by the px, 24/7.

Adv: decrease the risk of rehospitalization

Disadv: labor-intensive and expensive

GROUP THERAPY

focuses on real-life plans, problems, and relationships

may be behaviorally oriented, psychodynamically or insight oriented, or supportive

effective in reducing social isolation, increasing the sense of cohesiveness, and improving reality testing

• improve cognitive distortions• reduce distractibility• correct errors in judgment

COGNITIVE BEHAVIORAL

THERAPY

INDIVIDUAL PSYCHOTHERAPY

• therapist’s reliability, emotional distance & genuineness• long term• good outcomes at 2-year follow-up evaluations• personal therapy

Thank You!