Case Presentation

Group 2Psychiatry RotationBanag-Laum Home

Nov. 28, 2014Case Presentation

PATIENT HISTORY

I. Identifying DataJLM, 36 years old, male, Filipino, married, Roman Catholic, born in San Carlos City, Negros Occidental and presently residing at Apas, Cebu City. The patient was brought in by his brother, cousin and son and was admitted at Banag-Laum Home, for the first time on November 18, 2014.

II. Chief Complaint and Problem Naay gusto mupatay nako! as claimed by the patient.(Somebody wants to kill me!)

III. History of Present Illness:One month prior to admission, patient had onset of delusion of persecution. Few days ago, he claimed to have suicidal ideation associated with insomnia and anorexia for several days. His brother wanted him to be admitted for evaluation and treatment thus admitted.

IV. Past History1. Psychiatric - no previous history of psychiatric illness2. Medical underwent appendectomy at age 13 at San Carlos City3. Alcohol and other substance abuse - the patient is an occasional alcoholic drinker and a smoker; last alcohol intake was few days prior to admission. He has a history of smoking marijuana when he was in high school. Patient also used shabu since college. His last use was one month prior to admission.

V. Personal History1. Prenatal and PerinatalPatient is the fourth child among five siblings. Patient claimed that according to his mother there were no pregnancy problems and that he was delivered via normal spontaneous delivery without complications.2. Early childhood (birth-3 years)Patient is close to his parents and siblings.

3. Middle Childhood (3-11 years)At age 9, both of his parents went to the United States to work. The patient and other siblings were left to the care of his aunt (maternal side) together with four other cousins. According to the patient, his aunt, who was a teacher, was very strict. Although he was close to his siblings and cousins, he longed for the love of his parents. Moreover, he didnt feel any love from his disciplinarian aunt hence the patient grew up to be rebellious.

4. Adolescence(13-17 years old) The patient was very rebellious during his adolescent years. He usually goes home late which gave him more scolding and his aunt would make him do more errands (such as fetching water). He started using marijuana together with his classmates when he was 2nd year high school.

5. AdulthoodA. Occupational HistoryPatient worked for some time but resigned from his job and concentrated on their business in selling veterinary medicines.However the business did not last long thus the patient was jobless, and only waited for his monthly allowance sent by his parents abroad.

B. Marital And Relationship HistoryHe has a child, now 16 years old, from his girlfriend when he was still in college. They were supposed to get married but he refused since the parents of the girl did not want them to stay in one roof after the marriage.He got married after graduation with another woman and they have one son, now 12 years old. However, they are currently not in good terms with his wife who is now working in Australia.

C. Educational HistoryPatient started college at University of San Carlos where he initially took up Electronics and Communications Engineering. But due to the incident when he impregnated his girlfriend he was forced to transfer finishing only just a semester.He finished a two year vocational course in AMA Computer College.

D. ReligionPatient is a Roman Catholic. However, he is not devoted to his religion.

E. Social ActivityMost of his free time, he only sleeps and doesnt do anything. He sometimes hangs out with his friends and take sessions of taking shabu together, and sometimes he does it by himself. There are also times he does it with his younger brother who lives together with him.

G. Legal HistoryThere is no history of any legal issues or imprisonment.

VII. Family HistoryThe patient has an aunt on the maternal side who had schizophrenia.

MENTAL STATUS EXAM

I. General AppearanceThe patient appears to be on his stated age. He was well- shaped, fairly groomed, no unlikely odor and wearing a clean set of clothes which is fit for his age. He has a 2mm scar at the hypothenar eminence of his left hand. He has a tattoo at his left upper back. During the interview, the patient answered the questions without signs of being aggressive however he maintained an indirect brief contact with the examiner. Patient was anxious and tensed which was very apparent. He was shaky and restless. He kept on biting his nails/fingers while he was answering the interviewers questions.

II. Mood and Affect Mood is euthymic and affect is normal.

III. Speech CharacteristicsHis speech was coherent, spontaneous but with low volume and normal rhythm.

IV. PerceptionA. HallucinationsPatient denied experiencing hallucinations of any kind.

V. Thought ContentDelusions of Persecution:Kuyawan ko permi doc. Safe ra ba ko diri? Prior to admission, patient already has delusion of persecution. He kept thinking someone was going to kill him, thus he did not leave the house, and there was sudden behavioural changes noticed by his relatives. Even inside this institution, patient keeps thinking someone from his co-patients might harm him or the people from outside might come and kill him.

VI. Thought ProcessThe patients thoughts are coherent, linear, logical, and goal directed. There is no flight of ideas or loose associations.

VII. Sensorium and CognitionA. Orientation and Memory OrientationQuestion: Unsa man oras karon? Unsa man ning lugara?-What time is it now? What place is this? Answer: Alas 7:00 sa buntag, Banag Laum

Recent MemoryQuestion: Unsa man imo gisud-an gahapon sa pamahaw?-What did you have for breakfast yesterday?Answer: Itlog. -Eggs

Recent Past MemoryQuestion: Unsa man imo gibuhat pag Pasko og pag New Year? What did you do during Christmas and New Year?Answer: Pabuto-pabuto, kaon og Apple, OrangeQuestion: Pag birthday nimo, nag unsa man ka?- What did you do on your Birthday?Answer: Kaon-kaon, nag hikay

Remote Memory:Question: Asa man ka nahuman og college? Unsa tuig ka nahuman? Where did you finish college? What year?Answer: 2001, AMA Computer College diha sa Jones sauna.

B. Concentration and AttentionAbstract Thought:Question: Unsay may pareha sa Apple og Orange? What is the similarity of Apple and Orange?Answer: Pareha sila PrutasQuestion: Unsa man imo pagsabot anang walay asong makumkum? Answer:Walay sekretong Matago

Information and Intelligence:Question: Kinsa man ang Presidente karon? Who is the current President of the country?Answer: Noynoy Aquino

Based on vocabulary, grammar and degree of education, patients intellectual capacity is within normal limits and he is certainly capable of functioning at the level of his basic endowment. The patient was educated and finished a two-year vocational course. The patient has no noticeable memory impairment or gaps. He was able to effectively recall his recent and past memory without any difficulty. There were no reported Confabulation, Deja vu and Jamais vu.

VIII. Impulsivity The patient has no apparent problems on his temper. There were no reported sexual aggressiveness and impulses. He did not show any tendencies to hurt someone instead he was always fearful that the people around him might hurt him or even kill him.

IX. Judgement and InsightThe patients current judgment is good. His responses to questions pertaining to social judgment were positive and well-developed. His insight and judgment were good. The patient is able to control his temper at present time. The patient is medication compliant. The patient is very open to suggestion by the therapists and the physicians on the ward. He is just beginning to understand the nature of his illness and the factors affecting the course of his illness. Nonetheless he seems quite willing to make any effort in order to improve the prognosis of his condition.

X. ReliabilityOverall the patient appeared forthright and reliable.

Differential DiagnosesDelusional DisorderParanoid SchizophreniaSubstance-Induced Psychotic Disorder

1. DSM-IV-TR Diagnostic Criteria for Delusional Disorder

A. Nonbizarre delusions (i.e., involving situations that occur in real life, such as being followed, poisoned, infected, loved at a distance, or deceived by spouse or lover, or having a disease) of at least 1 month's duration. B. Criterion A for schizophrenia has never been met. Note: Tactile and olfactory hallucinations may be present in delusional disorder if they are related to the delusional theme. Characteristic symptoms: Two (or more) of the following, each present for a significant portion of time during a 1-month period (or less if successfully treated): delusions hallucinations disorganized speech (e.g., frequent derailment or incoherence) grossly disorganized or catatonic behavior negative symptoms, i.e., affective flattening, alogia, or avolition

C. Apart from the impact of the delusion(s) or its ramifications, functioning is not markedly impaired and behavior is not obviously odd or bizarre. D. If mood episodes have occurred concurrently with delusions, their total duration has been brief relative to the duration of the delusional periods. E. The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition.

2. Diagnostic Criteria for Schizophrenia Subtypes

Paranoid typeA type of schizophrenia in which the following criteria are met: Preoccupation with one or more delusions or frequent auditory hallucinations. None of the following is prominent: disorganized speech, disorganized or catatonic behavior, or flat or inappropriate affect.

Classically, the paranoid type of schizophrenia is characterized mainly by the presence of delusions of persecution or grandeur Patients with the paranoid type of schizophrenia show less regression of their mental faculties, emotional responses, and behavior than do patients with other types of schizophrenia.

Patients with paranoid schizophrenia are typically tense, suspicious, guarded, reserved, and sometimes hostile or aggressive, but they can occasionally conduct themselves adequately in social situations.

Their intelligence in areas not invaded by their psychosis tends to remain intact.

3. DSM-IV-TR Diagnostic Criteria for Substance-Induced Psychotic Disorder

A. Prominent hallucinations or delusions. B. There is evidence from the history, physical examination, or laboratory findings of either (1) or (2): the symptoms in Criterion A developed during, or within a month of, substance intoxication or withdrawal medication use is etiologically related to the disturbance C. The disturbance is not better accounted for by a psychotic disorder that is not substance induced. D. The disturbance does not occur exclusively during the course of a delirium.

Final DiagnosisAmphetamine-Induced Psychotic Disorder

AmphetaminesAmphetamines are used clinically and also are drugs of abuse.They are medically indicated in the management of attention deficit/hyperactivity disorder(ADHD) and narcolepsy. They are sometimes used to treat depression in the elderly and terminally ill, and depression and obesity in patients who do not respond to other treatments. The most common clinically used amphetamines are dextroamphetamine (Dexedrine), methamphetamine (Desoxyn), and a related compound, methylphenidate (Ritalin). Speed, ice (methamphetamine), and ecstasy (methylenedioxymethamphetamine(MDMA) are street names for amphetamine compounds.

Neurotransmitter associations

Stimulant drugs work primarily by increasing the availability of dopamine (DA).Amphetamine use causes the release of DA. Cocaine primarily blocks the reuptake of DA.Both the release of DA and the block of DA reuptake result in increased availability of this neurotransmitter in the synapse.Increased availability of DA in the synapse is apparently involved in the euphoric effects of stimulants and opioids (the reward system of the brain). As in schizophrenia, increased DA availability may also result in psychotic symptoms.

Effects of Use and Withdrawal of Stimulants

DiscussionAmphetamine-Induced Psychotic DisorderThe hallmark of amphetamine-induced psychotic disorder is the presence of paranoia. Amphetamine-induced psychotic disorder can be distinguished from paranoid schizophrenia by several differentiating characteristics associated with the former, including a predominance of visual hallucinations, generally appropriate affects, hyperactivity, hypersexuality, confusion and incoherence, and little evidence of disordered thinking (e.g., looseness of associations)

In several studies, investigators also noted that, although the positive symptoms of amphetamine-induced psychotic disorder and schizophrenia are similar, amphetamine-induced psychotic disorder generally lacks the affective flattening and alogia of schizophrenia. Clinically, however, acute amphetamine-induced psychotic disorder can be completely indistinguishable from schizophrenia, and only the resolution of the symptoms in a few days or a positive finding in a urine drug screen test eventually reveals the correct diagnosis.

Treatment and RehabilitationManagement of substance abuse ranges from abstinence and peer support groups to drugs that block physical and psychological withdrawal symptoms.

Management of withdrawal symptoms includes immediate treatment or detoxification (detox) and extended management aimed at preventing relapse (maintenance).

A. Immediate management/detoxification1. benzodiazepine to decrease agitation2. antipsychotics to treat psychotic symptoms3. medical and psychological support

B. Extended management/maintenance1. education for initiation and maintenance of abstinence

The treatment of amphetamine (or amphetamine-like)-related disorders shares with cocaine-related disorders the difficulty of helping patients remain abstinent from the drug, which is powerfully reinforcing and induces craving. An inpatient setting and the use of multiple therapeutic methods (individual, family, and group psychotherapy) are usually necessary to achieve lasting abstinence. The treatment of specific amphetamine-induced disorders (e.g., amphetamine-induced psychotic disorder and amphetamine-induced anxiety disorder) with specific drugs (e.g., antipsychotic and anxiolytics) may be necessary on a short-term basis. Antipsychotics may be prescribed for the first few days. In the absence of psychosis, diazepam (Valium) is useful to treat patients' agitation and hyperactivity.

Actual Patient TreatmentRisperidone (Sizodon)Biperiden (Akidin)Rivotril (Clonazepam)

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