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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!