Schizophrenia case presentation.

SCHIZOPHRENIA CASE PRESENTATION

1. Case presentation
Dr.Arunitha.R
2
nd
Year PG Scholar
Dept of Kayachikitsa
Govt.AyurvedaCollege,
Thiruvananthapuram

2. PATIENT DATA
Name-Bindhu. Ward-FGW
Age-45 Bed No-42
Sex - Female DOA-22/2/19
MarietalStatus -Married DOD-04/03/19
Religion-Hindu Attending physician-Dr.SubhashBabu
Economic status -middle class Informants-patient,mother
Address kavinpurathuveedu Case taken on-01/03/2019
Taruvamood
Neyyattinkara
Phone No-8129740818(Husband)

3. According to patient,
Two or more persons are dwelling inside and
controlling her-12 years, since 6 month
According to mother,
Self talking
Self laughing 12 years since 6 month
Suspicious
Odd behaviour

4. History of presenting complaints
Accordingtoinformant,
Patientwasapparentlynormalandmentallysoundbefore12
years.
Thecomplaintsstarted12yearsbackwhenpatientwasat
theageof34year.Sheismarriedandhavingtwosons.Her
husbandwasworkingabroadduringthetimewhenher
complaintsstarted.
Duetosomeissuesinthejobsite,herhusbandcouldnot
maintainedanyrelationshipwithher.Shestayedwithher
sonsneartoherownfamily.shewasanxiousandworried
aboutherrelationshipissues.Familyexpenditurewascarried
outbyherfather.
Motherreportedthatsymptomsdevelopedassuddenonset
before12years.Onemorningsheappearedandacted
extremelyfrightened.Herfacialexpressionwasfearful.She
respondedviolentlytowardsalltheattemptmadebyher
mothertoconsoleher.Sheconstantlydidirrelevanttalks
like,someoneistryingtokillherandthepeoplesurrounded
her.

5. Herappearancewaswithstaringwideeyes,flushed
face,clenchedteethandforcefulbreathingwithincreased
sweating.
TheyapproachednearbyGHwhereshewasevaluatedand
treatedwithantipsychoticsmedicines.Inhospitalshewas
veryuncoperativeandaggressive.
Shegotdischargedthenandadvisedtotakemedicinesfor
onemonth.Duringthecourseofmedicationsshefoundto
beextremedrowsy,reluctanttogetoutofbed.sheloss
interestsandpleasureinherusualactivities.sherefusedto
takefoodanddrinks.Butstillshemaintainedgoodpersonal
hygeine.
Patientbecamesociallywithdrawnwithnointerestinher
ownorfamilymatters.Shealsolackemotionsandfailto
sustainrelationship.

6. Patientcontinuedprescribedmedicinesregularlybutdidnot
foundanysignificantimprovement.Fewyearsthereaftershe
resisttocontinuethetreatment,arguingthatthereisnothing
wrongwithherandthosemedicationscancauseharmto
her.
Thereaftershe became increasinglyodd in
behaviour.Accordingtopatienttwoormorepersonsare
dwellinginsideherandshecanhearthevoices.Itiscoming
eitherinsideoroutsideherheadmaybemaleorfemale,and
isnotrecognisedasfamilier.Contentofwhatthevoiceare
usuallyunpleasantandnegative.Sometimesthevoicesare
conversingorcommanding.Thepatienthasbeenunpredictable
andrespondingtointernalstimuliandcursingthem.Shebelieving
thatsheisbeingharrasedorbodilyinjuredbyothersandthey
removedherenergyandbodyparts.
.

7. Nowadayssheisbecomingaggressivewithout
anysignificantprovocation.Sheisfightingwith
themandsosheisinconstantstress.Shebelieves
thatsheisbeingfollowedbysomebody,so
becomeunreasonablysuspiciousofothers.She
occasionallyagitatedtowardsfamilymembersand
afterthatshedidnotrememberanythingrelatedto
it.Motheralsoreportedselftalking,selflaughing
alongwithoddbehaviour

8. HISTORY OF PAST ILLNESS
Medical history
No significant past illness
Psychiatric history
No history of psychiatric illness.
Past surgical history-nil

9. DRUG HISTORY
Tab. Lanitor100mg. 0-0-1 since 6months.
Tab. Quetiapine25mg. 0-0-1
Tab. Brupronyl150mg. 1-0-0

10. Family History
H/o HTN
DM2,CVA. DLP
Died @68
22 years
Bike accident @21yrs
Family Psychiatric History –Unremarkable.

11. Family problem-relation with husband
unsatisfactory
Nuclear family…
No family breakup…
Death of immediate family members (+)
Son died before 5 years
No suicidal attempt in family.
No H/0 epilepsy/major medical illness.

12. PERSONAL AND SOCIAL HISTORY
Childhood history
DOB-10/1/1974
Uneventful birth history.
Anti-natal/Natal/post-natal-Uneventful
According to mother she doesn’t suffer any
healthproblemin her earlyage.
No history of maternal deprivation
Early emotional stress –emotionally sound
Childhood neurotic syndrome-absent

13. Educational history
Age of schooling -5years
Below average student
No extra curricular activities
Marks scored in sslc–just passed
Maintain good relation ship with peers and teachers.
No history of trouble or difficulty at school.
Qualifications achieved-pre-degree.

14. Occupational History
Worked in computer centre as assistant
for 2 years.
Then discontinued the job
Reason unknown…….

15. Marital history
Arranged marriage with her consent….
Marriage @18 years
Age of spouse-25 years,
Duration of marriage-27years
Relationship with spouse-unsatisfactory

16. Sexual history
No history of sexual abuse.
No history of premarietalor
extramarietalrelationship.
Patient not at all willing to reveal her
sexual history.

17. Menstrual and obstetric history
Menarche-14 years
Regular cycle
Duration -5-6 days
LMP-February 20, 2019
No associated abnormalities
Obstetric history
First delivery @20 years
Second delivery @24 years
Normal delivery.
No history of abortion.

18. DIETRY HABITS
Wake up –Irregular timings
No exercise/routine daily activities
Breakfast-@ irregular time
usually dosha(2)/puttu/idly(3)/chappathi(2)/uppuma/
poratta(2)occasionly
+chutny/sambar/vegetable curry
Lunch–usually @3.00pm
rice+avial/thoran/sambar/moru/parippu/fish/almost
daily non –veg(meat)

19. [email protected] with snacks(biscuit/vada/any
bakery food items)
[email protected] –rice +menu of lunch.
Sleep-no specific time
Daily non-vegdiet
fishfry/pickles/curd/bakery
food items
Taste predominance of
sour,pungent,
Irregular food habits.

20. Appetite Often increases or decreases.
Bowel- once/day(well-formed stool)
Bladder 3/4 times per day
No associated complaints.
Sleep sleeplessness present since 6
month,difficultyin initiation
of sleep
Disturbed sleep(+)
Allergy nil
Addictions nil

21. Premorbidpersonality
Interpersonal relationship keeping good relationship with
family members and friends
Leisure time Household activities
Predominant mood Stable,nomood swings.
Normal way of
expressing anger
Attitude to self and othersThoughtful
of others
Fantasy of life Absent
Religious beliefs Believer

22. GENERAL EXAMINATION
Appearance-Conscious,oriented
Moderatebuilt,moderate
nourished,wellgroomed.
Height-164cm
Weight-75kg
BMI-27.9kg/m

23. Pallor
Icterus
Cyanosis NIL
Oedema
Clubbing
Lymphadenopathy

24. VITALS
Bloodpressure-130/80mmHg
Pulse rate -80/min
Regular ,normal volume
Heart rate -80/min,Regular
Respiratory rate -20/min
Temperature -Afebrile

25. Physical examination
Head and neck
Thorax and abdomen
NAD
Upperlimbs
Lowerlimbs

26. SYSTEM review
Cardiovascular No H/o chestpain/DOE/increased palpitations
Respiratory systemNo cough/respiratory problems
Gastro intestinal system Appetite-irregular,noabdominal pain/heartburn
Nervous system No H/o paresthesia/weakness
IntegumentarysystemNo visible skin lesions
Genitourinary systems NAD
Locomotorysystem-pain(+) all over body .
(Pins and needle sensation)

27. Mental status examination
1-General appearance
45 year old women,appearas her age is.
Well built,moderatelynourished.
Looks normal.
Patient grooming was fair after morning
care.Mostof the time she exhibited
appropriate facial expressions and posture
during interactions ,maintain good eye
contacts.

28. Attitude co-operative
Facies Appropriate ,sometimes
anxious,andshows
irritation.
Gait Normal
Posture Normal
Psychomotor activity Appropriate
Rapport Easily established

29. 2.Speech
She consumes only minimal time and effort in answering
which is fairly clear and understandable,butdifficult to
follow because sequence of thoughts follows a logic to
patient but not to others.
Rate-Rapid
Speech is present which is spontaneuswith normal rate
Volume -Normal volume with normal pitch
No hesistantor no stammering.

30. 3.Mood and Affect
Affect-Appropriate
Mood -Varying moods from being
happy,sad,irritable.

31. 4.Thought
Patient express variety of odd beliefs.
Stream and form-Impaired
Spontainity+
Flight of ideas+
Thought blocking+
Illogical thinking +

32. 5.Perception
Delusion-present
Hallucinations-Auditory
(2
nd
person)
Patient admit to hallucinations or
respond to auditory stimuli.

33. 6.Cognition
a)Attention –normal
b)concentration-slightly impaired
She couldnotfocus and participate well during the
examination as she is easily distracted by almost
everything.
c)Memory
Remote
Recent
Immediate Intact
d)Intelligence-subnormal
e)Abstract Thinking
Patient is not fully capable of performing
abstractions or conclusive evaluating questions.

34. 7.Insight
Impaired
Clinical rating of insight –Grade 3
(Awareness of being sick,butit is
attributed to external or physical factors)

35. 8.Judgment
Basic judgment is normal .

36. Schizophrenia-At a glance
One of the most disabling and emotionally
devastating illnesses known…
Extremely complex mental disorders…….

37. History
First identified in 1887
Term coined in 1911 by EugenBleuler
Schizo+phrenia
(split)+(mind)=fragmented thinking.

38. The schizophrenicdisordersare
characterizedingeneralbyfundamental
andcharacteristicdistortionsofthinking
andperception,andaffectsthattheyare
inappropriateorblunted.
Clearconsciousnessandintellectual
capacityareusuallymaintainedalthough
certaincognitivedeficitsmayevolveinthe
courseoftime

39. Causes
Genetics
Development factors
Substance abuse
Brain chemical imbalance

41. Types
Paranoid type
Hebephrenic
Catatonic type
Undifferentiated type
Residual type
The ICD-10 defines additional subtypes
Post-schizophrenic depression
Simple schizophrenia

42. Symptoms
Positive/hard symptoms
Delusion
Hallucination
Grossly disorganised
thinking,speech,behaviour
Negative/soft symptoms
Flat affect
Lack of volition
Social withdrawal or discomfort

43. Diagnosis
The DSM 5 outlines the following criterion to make a
diagnosis of schizophrenia:
Two or more of the following for at least a one-month (or
longer) period of time, and at least one of 1,2,3.
Delusions
Hallucinations
Disorganized speech
Grossly disorganized or catatonic behavior
Negative symptoms, such as diminished
emotional expression

44. Impairment in one of the major areas of
functioning for a significant period of time
from the onset of the disturbance: Work,
interpersonal relations, or self-care.
Some signs of the disorder must last for a
continuous period of at least 6 months.
Schizoaffective disorder and bipolar or
depressive disorder with psychotic features
have been ruled out:

45. First Rank Symptoms of
schizophrenia(SFRS)
Audible thought +
Voices heard arguing+
voices commenting ones action+
Thought insertion+
Made volition or acts+
Somatic passivity+
Delusional perception+

46. Suggested investigations
Thyroid function test
Brain CT,MRI.

47. PROVISIONAL DIAGNOSIS
SCHIZOPHRENIA

48. Differential diagnosis
Schizoaffective disorder
Delusional disorders.
Mood disorders.

49. DIAGNOSIS
SCHIZOPHRENIA

50. Modern management
Pharmacological management
Psycologicalmanagement
Rehabilitation
Family work
Other physical management

51. AYURVEDIC CLINICAL ASSESsMENT
A)Rogipareeksha
Dasavidhapareeksha
Assesmentof Dooshya
1)Dosha
Saririkadosha vata(bhaya,soka,chinta)
pitta(krodha,alpanidrata)
Manasikadosha rajas ,tamas
2)Dhatu rasa

53. Rogabala(pravara)
Assessment of Bala
Rogibala(avara)

54. Assessment of Kala
ksanadi Greeshma
vyadhyavasta purana

55. Assessment of anala vishama
Assessementof prakrithi
Saririkaprakruthikapha,vata
Manasaprakruthitamopradhanam
Assessmentof vayamadhyamam
Assessment of satmyamadhyamam

56. Assessment of Aharasakti
Jaranasakti madhyamam
Abhyavaharanasakthiavaram

57. Assessment of manovahasrotas
1.Manas
Indriyabhigrahagrossly impaired
Manonigraham impaired
Ooham normal
Vichara normal

58. 2.Budhi impaired
3.Samnjananam
orientation to place,date
person-intact
Attention ,concentration –slightly impaired
4.Smrithi intact

59. 5.Bhakti (desire)
Ahara normal
Vyavaya
Vesa
ranjanam

60. 6.Seela
Diet-occasional dislike towards food.
Sleep-disturbed
No addictions/drug abuse
Daily routine activities impaired..
7.Chesta
General motor activities
Speech
Facial expression normal
posture

61. 8.Achara
Personal standards impaired
social standards impaired
No obsessions in work
Habit of cleanliness (+)

62. Rogapareeksha
Nidana
Ahara
Teekshnahara(pickles),
katuamlarasapradhana,gurvahara(curd,meat)
Snidhaahara(bakery foods,friedfood)
Vishamaaharavidhi-
pramithabhojana,adhysana
Vihara–nisajagarana

63. Manasika bhaya,soka,chinta

64. Roopam- ekatrahasati
ekatrarodati
alpahara
anidra
anannabhilasha
atichesta

65. Samprapthi
Due to nidanasareerika
doshas(vata,kapha)vitiated
Trigunasof manasgot dearranged(avarasatva)
satwa rajas tamas affect
manovahasrotas
manovikaras

66. Sapeksharoganirnayamvatikaunmada/
Vyavachedakaroganirnayam
pittaja,sannipathikaunmadam
Atatvabhinivesam
Apasmaram

67. ROGA NIRNAYAM
VATIKA UNMADAM

68. Chikitsa
Yuktivyapasrayachikitsa
Sattvajayachikitsa
Daivavyapasrayachikitsa

69. Chikitsasutra
Virechanam
Deepanam
snehapanam
Sirodhara
Nasya

70. Virechanamwith avipathichoornam-40gm morning
withmadhu
Deepanawith
Aswagandharishtam+panchakolachooram(5g)for 3 days
Snehapanamwith mahakalyanakaghritastarting with
50ml uptomaximum dose.
Abhyngam+usmaswedam for threedayswith sarsapa
tailam

71. Sirodharawith chandanaditailamfor 7 days
Nasyam+thalamfor 3 days
Nasyawith anutailam
Thalamwith ksheerabala+panchagandhachooram
As rasayana
Aswagandhachoornamwith milk bedtime

72. Kasayayogas
Drakshadikasayam
Brahmeedrakshadi
Kalyanakakashayam
Choornas
Sankupushpichoornam
Aswagandhachoornam
Jadamamsichoornam
Yastichoornam

73. Gulika
Manasamitravatakam
Ghritam
Brahmighrtam
Mahakalyanakaghrtam
Kayanakaghrtam
Paisachikaghrtam