Case Presentation Paranoid Schizophrenia .pptx

This presentation covers a very interesting case of Paranoid Schizophrenia, Based On latest International Classification of diseases and includes History, Examination, Mental Status Examination,investigations, Differentials, Diagnosis and holistic Management.

1. Case Presentation Dr Hamza Farooq( mo psychiatry) Dr zahid mehmood ( pgr neurology) Miss hina Cheema ( psychologist)

2. BIODATA A 23-Year-old male Mr Sadam Hussain s/o Khadim Hussain , unemployed ,unmarried R/o Sadiqabd , Rahim Yar Khan admitted in male psychiatry ward involuntarily through OPD on 08 -04-22 . Information was taken by his father and brother.

3. PRESENTING COMPLAINTS Aggression Self talk and self laugh Suspiciousness Refusal to eat and drink from family members Self neglect Wandering behavior Irrelevant talk Duration : 1 year

4. HISTORY OF PRESENTING COMPLAINTS My patient was in usual state of health 04 years back when he developed above mentioned symptoms. Symptoms started after he quitted job due to his suspiciousness on his boss. after that He developed suspiciousness on his family members He refused to eat and drink from his family, he was convinced that his family is mixing something in his food and water, he started to show less concern in daily activities. He used to get out from home and wander aimlessly on the road.

5. He was not taking care of himself properly He used to get up in the middle of night, crying in loud voice and asked people to stay away from him. He was frightened to go to the wash room alone. Then He refused to go to bath room and change his clothes, if family insisted on it, he used to be aggressive with them, abused them both verbally and physically His family took him to a psychiatrist where he was treated on opd basis, his symptoms improved but he showed poor compliance to medicines.

6. After that he took multiple consultation from psychiatrists and faith healers but he refused to take medicines on daily basis. Last year he was admitted in psychiatry ward, improved significantly then he stopped all his medicines and symptoms reappeared and aggravated with the passage of time. For last two months he s topped taking part in any activity and remains silent all the time and became aggressive if any family member tried to involve him in any activity. His family brought him to psychiatry opd for admission on 08-04-2022 Patient was assessed and admitted

7. SAFETY AND RISK ASSESSMENT YES NO Have you considered harming yourself in past? No Are you taking care of yourself properly? No Have you considered harming someone in past? Yes Is there any other situation where you feel uncomfortable or think you may be at risk? Y es Do you have a forensic history? No

8. RISK ASSESSMENT On Sad Person Scale Score was 05 On Sainsbury risk assessment scale risk was high on self neglect. There was no suicidal intent, planning or any attempt in the past

9. FORENSIC HISTORY No History of any civil or criminal offense.

10. Varieties Used & Routes of administration Quantity & Frequency (Past) Quantity & Frequency (Present) Alcohol Nil Nil Nil Drugs Nil Nil Nil Others (Benzodiazepines, cough syrups, analgesics etc) Nil Nil Nil Tobacco, Paan, Beeri, Gutka etc Nil Nil Nil SUBSTANCE ABUSE:

11. PAST PSYCHIATRIC HISTORY He has history of psychiatric illness and similar sort of symptoms for last 4 years but record is not available as patient torn all his files and burnt them One previous admission in male psychiatry ward last year No history of ECT’s , depot’s , clozapine and lithium

12. PAST MEDICAL AND SURGICAL HISTORY No history of diabetes ,IHD, HTN,TB,Asthma No significant past surgical history .

13. FAMILY HISTORY His paternal uncle has similar psychiatric issue but no psychiatric consultation taken. No History of Mental Retardation in family. No history of epilepsy, or suicide

14. SOCIAL HISTORY He belongs to lower class family. He is financially dependent. He lives with his parents and siblings in well-ventilated single-story house with1 kitchen 2 rooms and attached washrooms. Have basic facilities. Lives in a joint family system. Home environment is Un-Pleasant , Frequent family conflicts

15. PERSONAL HISTORY Born by SVD at home. He was breast fed. Achieved developmental milestones at normal age Started going to school at age of 5 years . Attained education till 9 th grade Multiple jobs

16. CHILDHOOD No history of any neurotic traits( nail bitting , pica,thumb sucking, sleep walking, bed wetting) No history of Autism spectrum disorder No history of childhood sexual or physical abuse Toilet training.

17. EDUCATION Started going to school at the age of 5 years He was an average student Left school after 9 th grade due to two failed attempts in !0 th grade

18. MARITAL HISTORY Patient is unmarried.

19. Sexual history Normal puberty and sexual orientation . Normal libido History of porn watching and masturbation

20. PREMORBID PERSONALITY

21. Relationships Good relationship with parents and relatives Good friend circle and good relationship with them He was an obedient child.

22. attitudes Flexible attitude Not very religious Never steal any thing Takes care of health properly

23. Prevailing mood No inappropriate anger Stable mood

24. Character traits Optimistic Flexible Sociable

25. Leisure and interest He spends free time with friends and cousins . He used to play cricket and football He used to watch urdu serials

26. PHYSICAL EXAMINATION Date of examination: 23 -04-22 Time: 12: 30 P.M Hearing : normal Eyesight: normal ? Mobility: gait is normal No Anemia , jaundice, clubbing, cyanosis, edema. Lymph Nodes not palpable, JVP not raised . Squinting of left eye

27. Respiratory system: normal vesicular breathing Cardiovascular system: S1+S2+0 Alimentary system: no viscera palpable, bowel sounds audible, abdomen is soft.

28. Nervous system Motor system: all superficial and deep reflexes are intact. No muscle twitches or fasciculation observed. Planters B/L dorsiflexed.

29. Motor System: Rt. Upper limb Lt. Upper limb Rt. Lower limb Lt. Lower limb Bulk Normal Normal Normal Normal Tone Normal Normal Normal Normal Power 5/5 5/5 5/5 5/5 Reflexes Normal Normal Normal Normal

30. Sensory systems: intact Cerebellar function: intact Cranial nerves intact Gait: normal gait. Meningeal signs: absent

31. Frontal assessment Battery Primitive reflexes absent Similarities  Lexical Fluency Luria’s Test Conflicting instruction Go-No-Go Prehension Behaviour Patient Score : 15/18

32. MENTAL STATE EXAMINATION A young male of average built, and height and weight entered into room with his father with normal gait , wheatish complexion , freckles on face, untrimmed beard and mustache, small hair, wearing dirty shalwar and qameez with opened buttons of his Qameez , odour from the clothes and body, nails were long and dirty, continuously scratching his head, poor or dental hygiene ,ulcers on the tongue, maintaining eye contact, seems cooperative ,sitting uncomfortably on the chair, placing both hands on the chest, seems frightened and negative attitude towards the doctor Significant signs of self neglect noted He was continuously trying to get away from the room Repeatedly standing and walking towards the door Rapport was difficult to built No abnormal movements seen

33. SPEECH poverty of speech , low in volume , mumbled and incoherent .

34. MOOD AND AFFECT MOOD: Subjectively Mood is sad Objectively Mood is euthymic Mood is incongruent AFFECT: Affect is Inappropriate . No suicidal ideation, hopelessness and passive death wish.

35. THOUGHTS Poverty of thoughts Loosening of association Delusional mood Delusional memory Delusion of persecutory Erotomania /De Clerambault’s No disorder of thought possession

36. PERCEPTION Hallucinations might be present Illusions are absent No depersonalization and derealization

37. COGNITION Oriented in time, place and person Attention and concentration were intact He was able to recall and register major life events Abstract thoughts and judgments were good Insight level 1

38. PSYCHODYNAMIC FORMULATION Defenses present in this patient Denial Projection Rationalization Isolation of affect

39. Psychometeric test Positive and negative syndrome scale

40. SUMMARY Differential diagnosis Multiaxial diagnosis Etiological formulation Risk and protective factors Prognosis

41. ETIOLOGY Biological Social Psychological Predisposing factor Family history Age Gender Precipitating factor Poor Compliance Family conflicts High expressed emotions Tragic incident Low socioeconomic status Psychosexual Stressor Maintaining Factor Poor compliance High expressed emotions Unemployment Low socioeconomic status No insight

42. Protective Factors: Supportive Family Education

43. DIFFERENTIAL DIAGNOSIS Schizophrenia Organic S chizotypal Disorder Schizoaffective Disorder

44. Points in Favor Of Schizophrenia Age Delusions Hallucinations Self Neglect Disorganized behavior Duration more than 6 months

45. Points in Favor of Organicity Age Rapid onset of symptoms

46. Points against Organicity CT scan brain plain normal Thyroid profile normal All the baselines and lipid profile is within normal limits No history of any trauma

47. Points in Favor of Substance induced Psychotic disorder Male Age Easily Availability of drugs

48. Points against Substance Induced Psychotic Disorder No History of substance abuse No Withdrawal symptoms Urine for drug analysis is negative

49. Points in favor of Schizotypal Odd Behavior Odd thinking & Speech Paranoid ideation Disturbed Affect

50. Points Against Sociable person No social anxiety Good friend circle Good relationships Taking part in extra-curricular activities

51. Points in Favor of Schizoaffective Disorder Delusions Hallucinations Duration more than 2 weeks Mood symptoms (Aggression)

52. Points Against Schizoaffective Criteria for Schizoaffective not met No major Mood(Depressive/Maniac) episode reported

53. PROVISIONAL DIAGNOSIS AXIS I : Paranoid schizophrenia (6A40) AXIS II: Nil AXIS III: Nil AXIS IV: Unemployment, unmarried, AXIS V: GAF (41-50 ) ? serious impairment in social, occupational, or school functioning (e.g., no friends, unable to keep a job).

54. investigations All base line investigations are normal. X-ray is normal Lipid profile normal ECG is normal Urine complete examination normal CT scan normal

55. MANAGEMENT: Management of Risk Management of Disorder Prevention of relapse Strong follow-up

56. Management Of Risk Admitted the patient in Psychiatry ward Offered oral treatment Tab Olanzapine 10mg P/O BD Tab Valium 10mg BD Started sessions of ECT’s Informational Care to the attendants regarding the nature and course of illness

57. Management of Disorder Antipsychotics Sedatives Sessions of ECT’s

58. Prevention of Relapse Shifting to Long acting Injectables Work on high expressed emotions Informational Care to the attendants Occupational therapy Work on the development of insight Work on the stressors Family therapy Strong Follow-up

59. PROGNOSIS Good prognostic factors : family is supportive, educated Bad prognostic factors : unemployed , single, high expressed emotions, no insight

60. Thank YOu