Psychotic DisordersA Case Presentation

Oliver ChanAvian 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

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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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PRIMARY IMPRESSION

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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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DIFFERENTIALS

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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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FINAL IMPRESSION

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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

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Pathophysiology

• Unknown cause

• Theories:

1. Stress-Diathesis Model

2. Neurotransmitters• Dopamine Hypothesis

• Role of Serotonin

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DIAGNOSTICS

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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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MANAGEMENT

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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

Psychotic DisordersA Case Presentation

Oliver ChanAvian Co

March 2011