Psychotic Disorders A Case Presentation Oliver Chan Avian Co March 2011

1. Psychotic DisordersA Case PresentationOliver ChanAvian CoMarch 2011

2. Case Presentation History PE Discussion Differentials Diagnosis Diagnostics Management Outline

3. CB, 19/M, Single 4th year High School Eldest of 2 siblings Lives with father and younger brother Roman Catholic From Binan, Laguna Identifying Data

4. Patient – poor reliability Father – good reliability Source of Information

5. According to patient: “Bakitbaakonandito?” According to father: “Nakakadinigsiyangmgaboses” Chief Complaint

6. Previously well, friendly, achiever in school, close with relatives (mother and cousins) History of Present Illness

7. History of Present Illness • Hearing voices of ghosts whispering in his ear • “Angsipag mo” • “Pangit ka” • “Mag-ingat ka” • Fights with father • “Hayop ka” • He is an Angel • Television is a portal to a reality 4 months PTC

8. History of Present Illness • Admit at Mandaluyong Psychiatric Hospital • Unrecalled medications without relief • 2-3 days • Private MD – Neurologist • Unrecalled anti-psychotic medications without relief • Admit at MMC • Unrecalled anti-psychotic medications without relief • 3 days • Would not take medications 4 months PTC

9. History of Present Illness 3 months PTC • Mother hospitalized due to kidney complications of hypertension • Patient was depressed • Admits to being sad

10. History of Present Illness 2 months PTC • Mother passed away • Patient: “mother ate dirty food  dirty blood”

11. History of Present Illness • Patient wouldn’t go home • Threaten to kill father and hurt self • Still hear voices • Still believes he is an Angel Few weeks PTC Admit to TMC

12. (+) knee pain (+) weakness No headache, no dizziness, no fever, no cough, no chest pain Review of Systems

13. Healthy with no childhood illnesses No history of surgery No co-morbidities Allergic to chicken Past Medical History

14. Renal complication from hypertension – Mother Diabetes mellitus - Father Psychiatric condition – Mother Family Medical History

15. Early 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 Personal History(Anamnesis)

16. 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 Personal History(Anamnesis)

17. Personal History(Anamnesis) • Middle Childhood • Mother over father • Close to younger brother • Homosexual

18. Later childhood Honor student in Binan National High School Badminton Girl best friend Tried drinking (Red Horse) Denies smoking and drug use Personal History(Anamnesis)

19. Adulthood Ambition: Architect, teacher, comedian for GMA7 Denies girl/boyfriend Would like to have a family in the future Non practicing Catholic Personal History(Anamnesis)

20. Vital signs: BP: 120/80 mmHg HR: 84 bpm RR: 20 bpm Temp: 36oC Height: 168 cm Weight: 65 kg BMI: 23 (Normal) Physical Examination

21. Objective Findings • 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

22. Objective Findings • 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

23. 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 Neurologic Examination

24. 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

25. Auditory hallucinations Ghost 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 Mental Status Exam

26. 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 Mental Status Exam

27. Salient Features

28. 19/M, single Previously an honor student 4 month history of auditory hallucinations of ghosts whispering Believes he is an Angel TV is a portal of a reality In and out of hospitals; given unrecalled anti-psychotic medications without relief – due to non-compliance Salient features

29. (+) Family history of psychiatric condition – Mother Mother passed away 2 months PTC Essentially normal Physical Exam and Neurological Exam Mental Status Exam Poor judgment Poor abstract thinking Salient features

30. Primary Impression

31. 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

32. DSM IV Criteria • Criteria A, D, and E of schizophrenia are met. • 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”).

33. DSM IV CriteriaSchizophrenia Disorder • 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

34. DSM IV CriteriaSchizophrenia Disorder • Schizoaffective and mood disorder exclusion • Substance/general medical condition exclusion

35. 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

36. Differentials

37. Differential Diagnosis • Schizophrenia • Bipolar I (with most recent manic episode) w/ psychotic features • Schizoaffective Disorder (Bipolar Type) • Delusional Disorder

38. Final Impression

39. 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

40. Pathophysiology

41. Pathophysiology • Unknown cause • Theories: • Stress-Diathesis Model • Neurotransmitters • Dopamine Hypothesis • Role of Serotonin

42. Diagnostics

43. 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

44. Management

45. Pharmacotherapy • Typical vs Atypical Antipsychotics • Was given: • Risperidone (Risperidal) 4mg/tab BID • Olanzapine (Zyprexa) 10mg/im PRN • Biperiden (Akineton) 2mg/tab OD

46. Psychosocial Interventions • Admitted to psychiatric rehabilitation facility • Establish therapeutic alliance • Psychotherapies: • Vocational Rehabilitation (OT time) • Social Skills Rehabilitation • As an adjunct: • Supportive Psychotherapy

47. Psychosocial Interventions • Other psychotherapies that could be used: • Psycho-education • Cognitive Rehabilitation

48. Psychotic DisordersA Case PresentationOliver ChanAvian CoMarch 2011