17-08-23 case presentation Schizophrenia.pptx

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1. CASE PRESENTATION DR.P. PRAGNYA SECOND YEAR PG DEPT OF PSYCHIATRY 1

2. NAME MR. NARAYANA REDDY AGE 46 yrs SEX Male MARITAL STATUS Married RELIGION Hindu ECONOMIC STATUS Low SES ADDRESS Jommalamodugu EDUCATION STATUS No formal education OCCUPATION Agricultural labour Informant wife 2

3. Source of information Wife Information is reliable and adequate 3

4. Presenting complaints Acc. to Patient Hearing of voices from 4 years Sleep disturbances from 6 months. Acc. to Informants Suspiciousness Talking to self/ muttering to self Decreased work function Decreased self care Sleep disturbances. 4 From 6 months From 4 years

5. Onset - Insidious Course - continuous and progressive in nature Predisposing factor - Social - Low socio-economic status Precipitating factor - Social - Trauma. Perpetuating factor - Poor adherence to medication 5

6. HOPI Patient was apparently normal until 4 years back with intact work function and a regular sleeping and eating pattern and normal interactions with family members. The present illness started around 4 years back when there was a spat between the patient and his neighbors over a construction of a new property. The property was equally shared between both the families i.e. the patient and his neighbors. The feud began regarding a common shared wall that was created adjoining the property which though was wanted by the patient and his family, the neighbors wanted to get rid of. As the wall was already constructed, the patient and his family members did not insist further on removing it. One fine day, when the patient was all alone at house, due to this petty argument between the patient and his neighbors over the construction issue, the relatives of the neighbors physically abused the patient , specifically 2 members. No arms or ammunitions were used and the patient sustained a few minor injuries over the face and body. Eventually the wall was broken down by the neighbors and his relatives within a few months and the issue was resolved. 6

7. Following this incident, around a week later, patient’s wife began to notice a significant change in his behavior where he was observed moving his lips with inaudible sounds as if he is talking to someone or replying to someone, while making some gestures in the air , but there was no one in sight. Patient appeared scared and horrified most of the time as if someone is approaching to harm him or kill him. On repeated inquiry, the patient revealed he is hearing voices, 2 male voices in specific, known to him, continuously, in a threatening manner and sometimes as a running commentary. The voices would threaten him by saying that he should leave the property or he will be caused harm. He would also hear these voices discussing among themselves of ways to harm him or plotting against him which would make him more fearful. In one such incident, while passing by his neighbors, he confronted them that they are talking about him and got into quarrel with them due to the same. Since then he came to the conclusion that these voices are his neighbor’s relatives. These voices also commanded him to stop going to work, and passed comments like he is good for nothing and abused him due to which he stopped continued to go to his work at all. 7

8. Due to these voices, patient gradually grew suspiciousness in the form that his neighbors relatives are planning and plotting against him. He even believed that they are following his moves and keeping an eye on him when he is alone. Patient’s wife started noticing that the patient used to go frequently toward the door and windows of his house and look outside for 5 to 10 minutes standing motionlessly, and insist the family members to keep quiet. And on inquiry, the patient would reply saying that he is keeping a watch if the neighbours are following him or talking about him. He also told his wife to keep all the jewelries and valuables safely inside a locker as the neighbor’s relatives are definitely stealing from them when no one is at home and started monitoring what his neighbors are doing via his window. Though his wife repeatedly tried to convince him that this isn’t true and that they are safe, it was all in vain. One day, the patient noticed some lemons lying outside his door and told his wife that it’s the neighbor’s relatives who are trying to do a black magic over him even though he was repeatedly assured that the lemons belonged to her, he did not listen to her. Another day, there was a political volunteer who had come to visit their house, but the patient got into a quarrel with him too and shooed him saying that he has been sent by his neighbour's relatives for the purpose of harming him or killing him. 8

9. Patient who is an agricultural labour, used to go to work previously early morning and do all his works. But since past 4 years, he was most of the day guarding his house and scared to leave his wife alone too which is interfering with his work functioning and patient has completely stopped going to work at all from past 4 years. 2 years ago, due to these deteriorating nature of complaints, patient was taken to a faith healer initially ( as he convinced his wife that the neighbour’s relatives are doing black magic over him), but it was all in vain as no improvement was marked. Following that, the wife took him to a private consultant where he was started on medications (exact details not known). The patient continued the treatment for less than a week and stopped abruptly due to these suspiciousness and even denied to go further for any consultations due to his fearfulness about being harmed or killed. 9

10. From the past 6 months, patient completely stopped going outside of house with completely neglected self-care. From the past 6 months, patient is having sleep disturbances. Before the onset of the illness, he used to sleep at 9pm and wake up at 5 am and go to field for work. But since past 3 months, he was staying awake till 12 am or 1 am and sleeping at that time. He used to wake up at 3 am and would wake his wife also. He used to become fearful saying that his neighbors might come over when they are asleep and steal away something or cause harm to them and hence would again go near the door and windows to keep a watch on the neighbors. He would hardly sleep for a total of 3 to 4 hours duration. For these increased intensity and severity of complaints, patient was brought to the psychiatry OPD. 10

11. No H/O thought being known to others NO H/O new thoughts inserted in to him. No H/O Delusions of control or influence/ somatic passivity. No h/o neologisms, irrelevant speech, catatonic behavior/ echolalia/ echopraxia. No h/o giggling/self absorbed smiling/ grimace/ posturing. No h/o intrusive repetitive thoughts, images, behaviors. No h/o sad mood/ weeping spells/ elated mood No h/o recent illicit/psychoactive substance abuse NO H/O chronic headache/ head injury with loss of consciousness/ altered sensorium. 11

12. PAST PSYCHIATRIC HISTORY NIL. TREATMENT HISTORY H/O previous psychiatric consultation, from where continued the medications for less than a week and then stopped. (Exact medication details not known). No h/o any adverse side effects like sedation, weight gain, dry mouth, constipation, sexual difficulties etc. on using those drugs. No h/o developing any EPS. No h/o any ECT sessions. 12

13. Past medical history : No H/O HTN/ DM/TB/Thyroid abnormalities/Asthma/ epilepsy/ seizure disorder/skin problems/ fever/ headaches/ head injury. 13

14. Family history Nuclear family/ low socio economic status, Born out of Non- consanguineous marriage. Father: expired 31 years ago (at the age of 40 years), due to a sudden cardiac arrest. Mother: 70 years old, healthy and alive Siblings: 1 elder sister of 50y/o. 1 younger Brother of 42 years old. No h/o any medical or psychiatric comorbidities in the immediate family. Current living arrangements: Living with his wife in their own house. 14

15. Pedigree chart 15

16. Personal history According to the information given by patient and informant: Mother’s health during pregnancy was normal, normal vaginal delivery at home, being healthy during prenatal, natal, and post natal periods. Milestones attained according to age. No neurotic symptoms in childhood. Immunized Education: No formal education (Illiterate) Occupation: Agricultural labour 16

17. Sexual history Adequate knowledge of sex. Heterosexually inclined. No love affairs, no homosexual experiences, no exposure to STDs. Marital history : Arranged, Non consanguineous marriage. Married at the age of 25 Years. Has 2 children; 1 daughter of 23Y/O, married. 1 son of 20 Y/O, software engineer. SPOUSE Age - 40y/o Occupation - Housewife. No physical or mental illnesses. Sexual life: compatible and satisfactory. Contraceptive measures: Tubectomy done after 2 nd child birth. 17

18. Premorbid personality An ambitious and optimistic, healthy and adjustable with family members and friends Hobbies: watching movie, listening to music. Mood: predominantly cheerful and calm. Attitude towards work and responsibility : Responsible towards work. Interpersonal relationships: Good. High standards in morals, highly religious and concerned about health. Energy: Energetic with normal fantasy life and day dreaming. Habits: No habits of any illicit/ psychoactive substance use. 18

19. Physical examination Moderately built/moderately nourished. BMI: 24.9 kg/m 2 (approx.) Afebrile, 90beats/min regular rhythm, 130/90 mm of Hg recorded in the left upper arm in sitting posture by auscultatory method. No pallor, icterus, clubbing, pedal oedema, cyanosis, lymphadenopathy, neck swelling or enlargement. Right handedness Pupils B/L symmetrical and reactive to light Fundus Normal 19

20. Systemic examination CVS: s1,s2 heard, no murmurs RS: normal B/L vesicular breathing sounds heard, B/L equal expansion, no added sounds. ABDOMEN: soft, non-tender, no hepatomegaly, no splenomegaly, no guarding rigidity, no hernia, umbilicus normal, bowel sounds present. GENITOURINARY SYSTEM: Normal Bowel sounds heard. N o UTIS and burning micturition. No genital abnormalities. MUSCULOSKELETAL SYSTEM: No restriction of Range of movements. No Crepts or tenderness of joints. 20

21. 21 Cranial nerve examination. Olfactory nerve ( able to identify the smell of coffee when asked to smell with eyes closed)- in both nostrils. Optic nerve- visual acuity- normal in both eyes field of vision- normal 3&4&6 nerves- extraocular movements- present pupillary reflex- direct and indirect- +. Trigeminal nerve- sensation over face+ clenching of teeth-+

22. 22 Facial nerve Motor – wrinkles of forehead-+ closing of eyelids-+ showing of teeth- + blowing of cheeks-+ Sensory- taste of ant 2/3 rd of tongue- + sensation over tongue- + Vestibulocochlear nerve Rinne’s test- Positive (AC>BC) Weber’s test –Positive (Heard in midline)

23. Glassopharyngeal nerve and vagus nerve. gag reflex – present spinal accesory nerve Turning head against resistance- present Hypoglossal nerve Protrusion of tongue- absent INFERENCE: ALL CRANIAL NERVES INTACT 23

24. 24 Right Upper limbs Right Lower limbs Left Upper limbs Left Lower limbs Sensory system In tact Intact Intact Intact Motor system Intact Intact Intact Intact Tone Normal Normal Normal Normal Power 5/5 5/5 5/5 5/5 Deep tendon reflexes Normal Normal Normal Normal

25. No abnormal involuntary movements Sensations: touch, pain, temperature, position, vibration, stereognosis, tactile localization, and tactile discrimination all are normal No signs of meningeal irritation. No cerebellar signs or gait abnormalities. 25

26. Mental status examination (while presenting to the OPD) General observation: Conscious, Appearing age appropriate, partially kempt, dressed appropriately to social and cultural background, cooperative during examination. Facial expressions- Hesitant and appears fearful. Eye to eye contact – Initiated but Fleeting. Rapport – established. Psychomotor activity: Increased (restless, fidgety behavior, looking around the room and not maintaining an erect posture). No abnormal movements like tics or mannerisms noted. 26

27. Speech : Non spontaneous (only in response to repeated questioning), Amount-Normal, Tone – High; Rate, reaction time, response time - normal. Prosody maintained. Relevant and coherent. No deviations such as rhyming, punning, echolalia, neologisms, verbigeration. Thought : Form: No formal thought disorder. (No loosening of association, neologisms, circumstantiality, tangentiality) Stream: No disorder in stream of thought. (No flight of ideas, retardation of thinking, perseveration, thought blocking). No disorder of Possession of thought. (No thought insertion, withdrawal or broadcasting). Content: Delusions of persecution and Delusions of reference. Content of delusions: Neighbour’s relatives are trying to cause harm to him/ plotting against him/ keeping a watch on him and his moves/ stealing from their house when they are alone. They are discussing and talking amongst themselves about ways to plot against him. 27

28. Characteristic of delusions : Affective response+ Bizarreness – Conviction + Disorganization/internal consistency + Deviant Behaviour/ Acting out + Extension + Pressure/ preoccupation + ( while presenting to the OPD, patient was concerned about the neighbour’s relatives getting into his house and even believed that they might have followed him up to here at the hospital). Systematization – Mood congruent. 28

29. Mood: Fearful Affect: Appears anxious; appropriate to mood. Congruent to thought process. Intensity of emotional expression- High. Range of affective responses- full. Mobility and Reactivity to environmental factors present. No lability of affect and mood. 29

30. Perception: MODALITY- Auditory hallucinations. Characteristics of auditory hallucinations: Verbal Continuous (No diurnal variation). Multiple voices ( two males specifically) Familiar voices Unpleasant – threatening type (2 nd person type). Running commentary type amongst themselves (3 rd person type). Mood congruent. Reaction to hallucinations: Talking to self/ muttering to self present. No hallucinations of other modalities like visual, olfactory, gustatory and tactile. 30

31. Higher mental functions: Oriented to time/person/place Attention Intact; checked with Digit span test. Concentration Intact; Tested by SST. INFERENCE: Attention aroused and concentration sustained. Memory: Immediate memory intact, checked by 5 object repetition test. Recent memory intact (checked by 24hrs recall passed) and Remote memory intact (dob, date of independence, name and no. of family members.) Responses given by the patient cross checked from the informant. 31

32. Intelligence : GENERAL INFORMATION: able to tell the name of seasons, crops and fruits grown in particular seasons. INTELLIGENCE: Able to tell the prizes of food grains or food items. Able to tell the prized of land. COMPREHENSION: ( The ability to understand questions asked during an interview ) answering appropriately to the question asked. ( eg. What will you do if it starts ton rain when you start for work?) ARITHMETIC: I borrowed 6 rupees from a friend and returned 2 rupees, how much do I still owe to him? (Answered within 15 seconds) How many pencils do you buy for 2 rupees if one pencil costs 25ps. (answered within 30 seconds). INFERENCE: Intelligence app. To educational cultural background. 32

33. Judgement : Personal Judgement: Impaired (unable to tell about future plans and goals). Social Judgement: Impaired (inappropriate behaviour in social situations as observed and acc. To the informant). Test Judgement: Impaired. Abstract thinking: Differences : mentioned 3 differences between stone and potato. Similarities : mentioned 2 similarities between orange and banana. Proverb test: Unable to give a proverb. But, Able to interpret the given proverb. (all that glitters is not gold). INFERENCE: Abstract thinking up to the level of semi-abstract. Abstract thinking appropriate to the level of educational and cultural background. Insight: Grade 2/6. 33

34. Summary A 46Y/O married male patient, illiterate, who is an agricultural labourer by occupation belonging to low SES, Telugu speaking background, belonging to Hindu religion, from rural area, was brought to the psychiatry OPD in a clear sensorium, by his wife with the c/o Hearing of voices, Suspiciousness from 4 years with Decreased work function, and Sleep disturbances from 3 months which are continuous and progressive in nature with previous psychiatric consultation due to similar complaints 2 years back followed by poor treatment adherence to the medication. MSE Findings s/o Hesitant facial expressions, increased psychomotor activity, increased tone of speech with fearful mood and affect appearing to be anxious, with auditory hallucinations, verbal, continuous, multiple, familiar, 2 nd person (threatening) and 3 rd person (running commentary) voices and delusions of persecution and reference, with affective response, non bizarre, convicted, extended, pressured, and deviant with impaired judgement and absence of insight. 34

35. Diagnostic formulation A middle aged married male patient with no formal education belonging to rural area was brought to the psychiatry OPD in a clear sensorium with the following: Hallucinatory voices giving a running commentary discussing the patient among themselves and threatening him . Persistent hallucinations accompanied by delusions of persecution and reference. Mood disturbances s/o fearfulness and affect appropriate to mood and congruent to situation. Impaired Judgement and personality with declined work function. According to ICD-10 matching the criteria of c,d and i of block F20, all for a period of 1 month or more. (4 years in this case) 35

36. Impaired personal, social, occupational functions with no h/o substance abuse and other medical comorbidities. So the probable diagnosis is Paranoid schizophrenia (F20.0) 36

37. Differential diagnosis Delusional Disorder (F22) Substance induced psychotic disorder. (F10.5) Schizoaffective disorder (F25.0) (Within the same episode, at least 2 typically schizophrenic symptoms must be present along with prominent mood symptoms for at least a duration from 2 weeks) Mania with psychosis. (F30.2) Paranoid personality disorder. (F60.0) 37

38. Management Admit the patient in Male psychiatry ward; Carry out investigations: CBP, LFT, RFT, RBS, ECG and CT or MRI brain according to the requirement of the patient. 1. Pharmacological management (acute/long term) 2. non pharmacological management 38

39. MANAGEMENT ACUTE MANAGEMENT: RAPID TRANQUILIZATION IF PATIENT IS IRRITABLE INPATIENT TREATMENT: Using 2 nd generation, atypical SDA Antipsychotics T. RISPERIDONE 2MG OD. INJ.HALOPERDIDOL 5MG/SOS INJ.PHENERGAN 25MG/SOS PSYCHOMETRIC ASSESSMENT SCALES APPLIED: PANSS: Positive and negative symptoms scale BPRS (Brief psychotic rating scale) ENSURE COMPLIANCE/ADHERENCE WATCH FOR ADVERSE DRUG REACTIONS (DAILY MONITORING) PSYCHOEDUCATION REGARDING THE ILLNESS TO PATIENT AND ATTENDEES INFORMATION REGARDING TREATMENT MODALITIES/SERVICES LONG TERM MANAGEMENT: AT TIME OF DISCHARGE ENSURE COMPLIANCE/ADHERENCE TO TREATMENT SELF CARE MONITORING PSYCHOEDUCATION 39

40. THANK YOU… 40