Psychosis case management

Dr. Majid Al-DesoukiConsultant & Clinical Assistant

Professor

Schizophrenia and Other Psychotic Disorders

• Onset most frequently is in late teens, but can become evident in 20s or 30s

• From some disease is chronic, for others there are periods of exacerbation & remission, and for others it can be one time occurrence.

• Illness affects perceptions, cognition, and affect

Most Common Symptoms

• Hallucinations• Delusions• Disorganized speech• Bizarre behavior• Inappropriate affect• Confusion/ Disorientation• “Negative” symptoms

Hallucinations• Auditory are most common form of hallucinations

associated with psychosis• Voices – generally taunting or saying negative things to

person• Command hallucinations – Hallucinations which tell

the individual to perform certain tasks• Rare for command hallucinations to tell individual to

commit crimes – unless the crime is incorporated into a delusional belief system

• Visual, olfactory, and sensory hallucinations can be associated with neurological disorders, occasionally with genuine psychosis, or may be feigned.

Delusions

• Fixed, false beliefs that individual holds despite evidence to contrary

• Can be bizarre or non-bizarre• Content may include a variety of themes (e.g.

persecutory, referential, somatic, religious, or grandiose)

• Persecutory delusions are most common – being tormented, tricked, spied on, subjected to ridicule

Disorganized Speech/Thinking

• Loose Associations – ping ponging from one subject to another with no clear string of thoughts connecting the two

• Tangential – responses to questions only remotely related to question at hand

• Word salad – incomprehensible, disorganized, incoherent speech.

Bizarre Behavior

• Disheveled• Dress inappropriately (multiple layers of

clothing)• Putting tin foil in strategic places• Engaging in purposeless behavior repeatedly• Catatonia

Inappropriate Affect

• Laughing at inappropriate times• Labile Affect – up and down rapidly• Smiling or silly facial expression without any

apparent reason

Confusion/Disorientation

• Can’t seem to hold and recall concepts after repeated instruction

• Can’t remember date, location despite repeated prompts

• Can’t recall who you are

Differential Diagnosis: Psychosis

• Psychosis due to medical disorder?

• Psychosis due to medication?

• Psychosis due to drug/alcohol intoxication or withdrawal?

• Psychotic depression or mania?

• Psychosis of schizophrenia?

• Delusional disorder?

Clues that client may be psychotic and/or has a history of psychosis

• Cotton or toilet paper in ears• Disheveled and poor attention to hygiene• Speech incoherent• Voices convoluted delusional belief system and is

unresponsive to alternative explanations• Looks around as if he/she might be hearing

something or is suspicious of surroundings• Mentions medications such as Haldol, Prolixin,

Thorazine, Geodone, Risperdal, Clozaril,

Case Study

• A 23 YO man came to an outpatient clinic for symptoms of psychosis. He has always been a loner who shows very little emotion and prefers not to become involved with people. Since high school, he has had no close friends and prefers solitary tasks. He chose computers as a major in junior college because he feels that "computers are more rational and easier to deal with than people" and after graduation obtained employment as a computer programmer.

Case Study• He has no friends or hobbies, except working on

his computer, and has little contact with co-workers or his family. Eight months ago, his performance at work, which was marginal but adequate, began to decline. About this same time, he began to believe that his computer was trying to communicate with him. Several times, he heard a voice that he is convinced was the computer talking to him. This did not disturb him at first until he began to believe that the computer was trying to control his thoughts.

Case Study

• He was referred for inpatient admission, was treated with antipsychotic medication, but showed little improvement. Currently, it has been four months since the onset of his overt psychotic symptoms; he continues to take antipsychotics on an outpatient basis but still believes that his computer is trying to communicate with him. He has not returned to work and his parents have been paying his bills for him.

Case Study

• He presents as a quiet, shy, and aloof young man who shows little if any emotion. Although it was suggested that he also start individual therapy to work on establishing relationships and learning to express feelings, he refused. There are no medical problems or history of substance abuse.

Case Study

• DSM-IV– Axis I - Schizophrenia, Paranoid Type – Axis II - Schizoid Personality Disorder (premorbid) – Axis III - None reported – Axis IV - Unemployment, inadequate social

support – Axis V - GAF = 30 (current)

• DSM-5 Schizophrenia – 301.20 Schizoid Personality Disorder (premorbid)

CASE PRESENTATION

• A 21-year old male, single, college student, suddenly runs out of his classroom. He shouts, ‘ back off ’ at a friend who follows him. He is convinced that his teachers and classmates intend to kill him. He hears the mocking voices of his teachers coming from the electric fan and on the classroom walls, talking about him and calling him nasty names.

CASE PRESENTATION

• The patient is brought to a GP. PE and lab tests for illegal drugs are normal. He looks blankly at the walls. He is inattentive and responds irrelevantly to questions. He mumbles incoherently, “A,B, (ZTE) F,G”. He accuses his parents and the doctor to be in a plot to kill him. He cannot be convinced otherwise.

• Judgement, impulse control, and insight are poor. Sensorium is intact.

CASE PRESENTATION

• Background: socially withdrawn and avoids group activities; with few friends and lacks initiative. An only child who relates poorly to parents who are very busy. Father is very critical and mother is overprotective. Mother had a history of similar difficulties. current episode is his second in two years. No meds for three months

CASE PRESENTATION

• A young man’s second episode of behavioural changes like blank stares, hearing voices, fixed ideas of being harmed, and irrelevant speech. These occur in the background of poor family bonding and lack of social interactions. There is a positive family history of psychiatric illness. No maintenance meds.

LECTCASE PRESENTATION

Identifying Core Symptoms of Psychosis

• Positive Symptoms: HDL method *

Hallucinations – most important ; usually auditory, multiple voices talking about the patient

Delusions - persecutory, bizarre, systematized Looseness of associations – irrelevant speech, hard

to understand * hallucinations and delusions should be present

LECTCASE PRESENTATIONE

• Negative Symptoms: 4 As *

Alogia - limited speech ; tendency to mutism Affective blunting – flat; blank stares; no emotion Avolition – unexplained lack of initiative Anhedonia – pervasive lack of interest / pleasure

unrelated to depression

* 2 or more enhance the diagnosis

LECTUCASE PRESENTATIONRETTE

• Other Features: (exclusion criteria) *

At least six months duration Social/occupational dysfunction

No mood disorder *No substance abuse / medical condition *

INTERACTIVE SESSION

• Positive symptoms of our patient:

What is the H? What is the D? What is the L?

INTERACTIVE SESSION

• Negative symptoms of the patient:

Name at least 2 As:

A? A?

LECTUCASE PRESENTATIONRETTE

• Other features present in our patient:

Poor functioning: school, parents, peers Positive family history (mother) Second episode in two years

High emotional expressivity (or ‘High EE’)- overcritical and overprotective parents

PSYCHOTIC?Positive and negative symptoms plusimpaired functioning but no mood symptoms

Due to substance ←↓→ Due to medical illness?abuse? If no

↓Ask duration

< 1month ← ↓ → < 6 monthsBrief Psychotic Schizophreniform Disorder

Disorder> 6 months

Schizophrenia

Paintings by artist with worsening psychosis –

perceptual disturbances

Case Report

• 30-year-old Saudi female, who had a normal childhood and up- bringing. She enjoyed social and leisure activities. She was an “A” student and then went to medical school in Jeddah and completed 6 years, but upon return to the Riyadh, she could not keep complete her internship or pass any exams. In addition to her academic decline, she was noted to be withdrawn, suspicious, and exhibiting bizarre body gestures for a few years without any medical or psychiatric evaluation. The sub-psychotic symptoms appeared gradually and the time frame was unclear.

Case Report

• The patient had her first psychiatric hospitalization at the age of 29 following an argument with her father when she tried to jump out of the car. She was hospitalized and she presented with episodes of shaking his entire body, lying on the floor and inability to stop her trembles. During the episodes, she was trying to pull her head backward, stating that he wanted to break her neck or someone was pulling her.

Case Report

• During hospital stay, the patient was disorganized, paranoid, and believed that she was being judged by the public. She was socially isolative with flat affect and neglecting her personal hygiene. She denied any perceptual disturbances. There was no history of mood symptoms, substance use or medical illness. The patient never self-medicated with drugs.

Case Report

• There was no family history of neurologic condition or psychiatric illness. Her physical examination was unremarkable. Neurology consultation revealed nonspecific tic movements. EEG was noncontributory and seizure disorder ruled out. Organic pathology was excluded with normal CT head, MRI brain, blood work and negative urine toxicology.

Case Report

• The psychiatric team felt that her body gestures and shaking movements were stereotyped and of a psychotic nature. Interestingly, these episodes responded well to olanzapine. The patient was discharged to an outpatient clinic; however, she was noncompliant with her medication and appointments after discharge. This resulted in one other hospitalization with similar presentation.

Case Report

• Following discharge, she presented to the outpatient clinic. She responded fairly well to olanzapine, with a noticeable decrease in her shakes, paranoia, and social isolation.

Case Report

• Within the next two months, despite increasing olanzapine, the patient complained of a new symptom which he called “pelvic thrusts.” This involved shaking of the pelvic area accompanied with tremors and upper body movements. Her compliance with medication was questionable. As per family, the patient was agitated, pacing the house, sleeping poorly, and exhibiting frequent episodes of bizarre body gestures.

Case Report

• Quetiapine was added and titrated with some benefits. She was also tried on lorazepam and clonazepam to relieve her anxiety and help her sleep. A referral to a movement disorders outpatient clinic was made; nevertheless, the patient did not follow through. Eventually, she stopped all her medications and refused to come for appointments.

Case scenario

• Sami• Sami is a 16-year-old, who has been taken to a psychiatrist by his mother.

She is concerned that for the past 2 months he has been isolating himself. His family have noticed he is staying awake most nights and seems to be talking to himself. He admits to hearing voices that others cannot hear. He says he has been using cannabis on a regular basis.

• Question:

• The psychiatrist suspects he has psychosis with comorbid substance misuse. How should they assess Sami?

Case scenario

• Answer:

• He should ask Sami about his use of cannabis and conduct an assessment of dependency.

•  The Psychiatrist should take time when assessing Sami, using a flexible and motivational approach.

• Question:

• After assessment, the psychiatrist confirms that Mark has auditory hallucinations and finds that he has been using SR60 worth of hashish on most days for the last 3 months. What should happen next?

Case scenario

• Answer:

• Sami should be referred to his local child and adolescent mental health service to receive care and treatment for both his psychosis and his substance misuse.

• When working with Sami, mental health workers should ensure that all discussions take place within a confidential setting and that clinical language is avoided.

• Sami’s mental health workers should ensure they are familiar with the legal framework that applies to young people.

Case scenario

• Answer continued:

• Sami and his family should be provided with written and verbal information about both his psychosis and his substance misuse, and they should be informed of the risks associated with substance misuse.

• Services provided for Sami should be age appropriate. 

• Sami’s family should be encouraged to be involved in his treatment to help promote recovery.

Case study

• You have been seeing a 36-year-old male client in therapy for several months. The client has been diagnosed with schizophrenia and, for some time, has been taking phenothiazines that were prescribed when he was in an in-patient psychiatric facility.

Case study

• He has been in and out of such facilities since the age of 27. He now lives in a halfway house and you are helping him readjust to life in the community. The client has been progressing well and is becoming less and less anxious about coping outside the hospital, but one day you notice that he is experiencing involuntary rhythmic facial tics and movements in his legs.

Case study • You should:

a. refer him to his psychiatrist since you suspect he has stopped taking his medicationsb. refer him to his psychiatrist since this may be a side effect of his medicationc. understand that this is a side effect of the phenothiazines and therefore reassure the clientd. for now attribute the tics to the client's anxiety about readjusting to life outside of a hospital but refer him to his psychiatrist if the symptoms persist

Case study

•What is the major difference between schizophreniform disorder and schizophrenia:a. schizophrenia is not accompanied by a flat affect b. the duration of the disorderc. schizophreniform does not involve the loss of adaptive functioningd. age of onset

Case study

• A social worker on the staff of a community clinic evaluates a person brought in by the police. The patient is a 75-year-old member of the Navajo nation who was found sleeping on top of a hill in a park. He told police he had been in the park for two days and that he was speaking to the spirits in preparation for his death.

Case study

• The most appropriate diagnosis for this patent is probably:a. schizophreniab. schizoaffective disorderc. adjustment disorderd. no diagnosis

Question

• Restlessness, psychomotor agitation, flushed face, diuresis, rambling speech, and muscle twitching are most suggestive of:a. alcohol withdrawalb. caffeine intoxicationc. cocaine intoxicationd. hyperthyroidism