PATIENT’S DETAILS
NAME:
Victor Dauramanzi
AGE/SEX:
34 years/ Male
OCCUPATION:
Self-employed
MARITAL STATUS:
Married
ADDRESS :
Chivhu Town
DATE OF ADMISSION:
7 February 2013
INFORMANT:
Patient
REFERAL PATHWAY:
Patient was brought to Annexe Hospital from home accompanied by his elder brother.
PRESENTING COMPLAINTS
1. Aggressiveness-2/7
2. Beating wife -1/7
HISTORY OF PRESENTING COMPLAINTS:
This is a patient who has been mentally unwell since 2008, and has been in and out the
hospital. The patient admits to having marital problems with his wife who he says is being
unfaithful to him as she is having some extra marital affairs and this has happened for about a
month now. Seven days prior admission the patient said he was told by his friends that his wife
was having an affair with a man from the neighborhood though the wife refused the allegations
when he asked her but rather accused him of not reasoning properly since he is a mental
patient. The patient said this stressed him so much that from then he started drinking beer on
a daily basis as well as smoking marijuana at a frequency more than he normally does. Two
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days prior to admission he said when he got home from the bar he got angry when the wife
said she did not cook for him because he was mentally unwell and they had an alteration of
words. The following day he was tipped off by his friend later in the afternoon that his wife was
in the bush with another man to which he followed the lead and found them having a sexual
intercourse. He took his wife home where he beat her up before he was apprehended by his
brother and brought to hospital on the same day.
On the day he said he had drank two (2) tots of viceroy, one (1) bottle of zed, one (1) pint of
lion lager and one (1) twist of marijuana, prior to this he has been drinking at his usual rate and
has not had problems in the mornings if he sleeps drunk. The money to fund for his drinking he
gets it from his tyre fixing business that he has in the Chivhu town.
PAST PSYCHIATRY HISTORY:
Patient was initially admitted in 2008 after he presented with symptoms of hearing people
talking about him, and feeling as if his mind was manipulated to the advantage of other people
whom he said he did not knew as well his mother directing him of what to do. This happened
for about nine (9) months before he came to hospital where he was admitted and responded
well to medications. He was discharged upon recovery and was given some medications to
take home which he said was adhering to.
Since then he has been admitted three times at the Annexe hospital, once in 2010, followed by
an admission in 2011 then this admission was the third admission. Patient admits that these
episodes are usually associated with his beer drinking and the marijuana smoking.
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He is adherent to his medications as they are being kept by his step mother who operates a
restaurant where he eats during the day and it is during this time that he will be given his
medications.
The patient says that in between these periods of the illness he will be functioning normally,
doing his daily activities and relating well to family, relatives, friends and neighbors.
PAST MEDICAL AND SURGICAL HISTORY

He diagnosed of being HIV positive in 2005 after he presented with severe symptoms of
skin rush and diarrhoea and put on prophylaxis medication for opportunistic infections.

Treated of herpes in 2011

In March 2012 he was put on the full antiretroviral treatment when his CD4 was 290

A CD4 count was repeated in October 2012, it was 305

He has no history of other chronic illnesses like diabetes mellitus, epilepsy, asthma,
tuberculosis or hypertension

No previous operations

No history of head trauma
FAMILY HISTORY:
MOTHER: Died in 1997, she was HIV positive. She had neither psychiatric problems nor a
history of chronic medical illnesses. The patient had a good relationship with the mother
FATHER: Died in 2003 due to kidney problem. He had no psychiatric problem, they had a good
relationship.
SIBLINGS: Patient is the third born in a family of five siblings. He is in a good relationship with
all siblings.
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FAMILY PSYCHIATRIC HISTORY:
There is no history of mental illness in the family
PERSONAL HISTORY
The patient said he was told by his mother that:
Pregnancy
- no history of pregnancy induced hypertension or any other illnesses
-
the mother did not take any medication during pregnancy, she didn’t drink
alcohol
birth
- normal delivery at Mbuya Nehanda Hospital. There were no any complications
during or after delivery
- no history of febrile convulsions or neonatal jaundice.
Childhood
- normal development and he reached the developmental milestones at the
expected times
- he was very sociable and would interact with friends
EDUCATION:
The patient said he started school at 6 years of age. He went up to form four and passed four
subjects but could not proceed with education because he did not pass with the required
passes to proceed. He enjoyed school days and says he used to participate in other activities
like sports.
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OCCUPATION:

He was employed as a general hand at National Foods Chivhu branch but stopped in
2008 due to the mental illness

From then he has been operating tyre mending business up to this day.
Patient said he had a good relationship with his coworkers at his previous job
PSYCHOSEXUAL HISTORY:
Patient says he had an innumerable number of girlfriends in his life before he got married. He
was having sexual intercourse with most of them and frequently he used protection albeit
occasionally he would not use protection on those whom he deemed safe from AIDS.
He married one wife in 2003 and has been staying with that wife since then until now but
admits that they have been having marital problems frequently.
CHILDREN:
He has got one child, a girl who is 9 years old, now doing grade 3.
USE AND ABUSE OF ALCOHOL, TOBACCO AND OTHER DRUGS:
Patient says he drinks mainly strong wines, about a tot of viceroy, whenever he goes for a drink
and this happens three to four days in a week then he would drink other brands of beer about
two pints of lager.
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The patient says he has never thought of cutting down his drinking neither does he drinks
continuously, he feels annoyed when people discuss about his drinking. He does not feel guilt
about the drinking and in the morning he does not need an eye opener to start his day, he
usually starts drinking later in the afternoon usually after work.
From this CAGE assessment the patient is not alcohol depend
Patient says he occasionally smokes marijuana about a twist, he mixes it with maddison.
Besides on occasions when he will be smoking marijuana he does not smoke cigarettes
FORENSIC HISTORY:
He was arrested twice by the police for violent behavior, public drinking and marijuana
smoking. He was sent to Chikurubi Special Unit but was realesed14months later on his mental
health grounds. He was sent home upon his release
HOUSING AND SOCIAL HISTORY
Rents two rooms Chivhu town, uses tap water and flush toilet. He lives with the wife and the
daughter. The earns money from his tyre mending business suffice to take care of the family
needs though it is not enough
PREMORBID PERSONALITY:
He said of late he has been he has been having conflicts occasionally with his wife due to
infidelity. He goes along with his child, his neighbors as well as his co-workers and friends.
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MENTAL STATUS EXAMINATION
APPEARANCE AND BEHAVIOUR:
- He was kempt
-He had mild psychomotor agitation as he could frequent stand up
- Rapport was established and there was cooperation
- He maintained good eye contact
SPEECH:
Speech was coherent, with a normal rate, tone and volume. It was not pressured. There were
no neologisms or word salad.
MOOD AND AFFECT:
The patient said he was happy not elated. Affect was congruent with mood
NEURO-VEGETATIVE SYMPTOMS

No diurnal variation of mood

Terminal insomnia, waking up very early and will be energetic

Normal appetite

No weight change

Normal energy

Interest in pleasurable things was still normal

Normal concentration

Feeling guilty that if he was not able to donate a kidney to his father because he is HIV
positive and also that his mother died in his absence.
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
No suicidal ideation

No hopelessness and worthlessness
THOUGHT PROCESS:
THOUGHT FORM:

No thought block; insertion, broadcast or withdrawal

No neologisms

No word salad

No loosening of association

No flight of ideas
THOUGHT CONTENT:

Patient sober minded

No paranoid delusions

No grandiose delusions

No hallucinations
PERCEPTION:

No auditory, visual, olfactory or gustatory hallucinations

No jama vu or deja vu phenomenon

No illusions

No derealisation

No depersonalization
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COGNITIVE STAGE
1. Consciousness- Patient was fully conscious
2. orientation-well oriented in time, place and person
3. Concentration-patient was concentrating; He could give days of the week from backwards
4. memory-normal
-Intermediate recall-patient could repeat four given fruits: mango, orange, apple
and banana.
-Short term-could repeat the four named fruits five minutes.
-Long term-he was able to state the date Zimbabwe got independent
5. judgment-normal
When asked what he would do with an abandoned baby, he said he will take it to the police.
6. Abstract thinking- was present

he could compare and contrast between a car and an airplane

Could give the meaning of a common Shona riddle ‘Kare haagare ari kare’ to which he
answered, “zvinhu zvochinja hatirambi tiri pataiva kare”
7. intelligence-average in comparison to a general population

Patient could name all neighboring countries of Zimbabwe.
8. Insight-accepts that he is sick and is being helped in hospital. He also admits that his beer
drinking and the smoking of marijuana are exacerbating his mental condition hence the
numerous admissions.
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PHYSICAL EXAMINATION:

Patient was sitting comfortably not in any obvious distress.

He has no jaundice, no pallor, no finger clubbing, no cyanosis, no oedema
and lymphadenopathy

He had no neulogical symptoms

Other systems were essentially normal
FORMULATION:
STATEMENT OF THE PROBLEM:
A 34 year old married male patient currently on psychiatric medication who presented with a
two day history of aggressiveness and a day’s history of beating his wife.
DIFFERENTIAL DIAGNOSIS:
1. Substance Induced Psychosis
2. Schizophrenia
3. Organic induced psychosis due to HIV
SUBSTANCE INDUCED PSYCHOSIS
Pros
 Male patient aged 36 years
 A weeks history of excessive drinking
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 Availability of funds for the drinking activity
 Smoking of marijuana
 Marital problems at home
 Forensic history associated with drinking
Cons

Patient says he frequently drinks with no such problems

Evidence of the cheating wife
SCHZOPHRENIA
Pros
 Association of symptoms with marijuana smoking
 Disorganized behaviour
 Previous history of: -Thought insertion
-Passivity phenomenon
-Third person hallucinations
Cons

No positive family history of mental illness

No history of wandering away from home

Premorbid personality of being a sociable person
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ORGANIC PSYCHOSIS SECONDARY TO HIV INFECTION
Pros
 Tested HIV positive
 Chronicity of the HIV in the patient
Cons

Symptoms mainly associated with beer drinking and marijuana smoking

The CD4 of the patient relatively high
WORKING DIAGNOSIS
Schizophrenia with co-morbid substance induced psychosis
AETIOLOGY:
Predisposing factors -genetic factors
Precipitating factors
-excessive beer drinking
-smoking of marijuana
-cheating wife
Perpetuating factor
-continuous taking of alcohol
-smoking of marijuana
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INVESTIGATIONS
1. SOCIAL
To obtain collateral history from the brother and the wife so as to clarify whether the patient’s
personality before the incident as well as the issue of the infidelity.
2. PHYSICAL
i.
Repeat a CD4 count to check for the immune status of the patient
ii.
Urine toxicology-to check for drugs
iii.
Liver function test-increased liver enzymes in alcohol hepatitis, specifically gamma
glutaryl transferase (GGT)
iv.
Thyroid function tests-rule out any form of hypothyroidism or hyperthyroidism as
thyrotoxicosis can present in a mania like manner
v.
FBC- to rule out any form of infection hence looking specifically at the white cell count
vi.
Renal function test to check for renal functioning since he is a known HIV positive
patient who is on a full regiment of antiretroviral therapy
TREATMENT:
PHARMACOLOGICAL
Due to the fact that the presenting complaint is aggressiveness I will initially manage him by:

Haloperidol I.M to sedate him
Then voluntarily admit the patient

Haloperidol 1.25mg b.d because it has got antipsychotic properties, less likely to cause
extra pyramidal side effects

Vitamin B supplement because of chronic alcohol intake
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Will keep an eye on the side effects of the drug on the patient, in the event they do occur will
put him on:

Benzhexol 5mg p.o B.D-it counteracts the extra-pyramidal actions of haloperidol
Ideally would have wanted to use Olanzapine since is an antipsychotic drug with less extrapyramidal effects, but however it is expensive and not easily available in Zimbabwe
PSYCHOEDUCATION:
Education to the family and patient about the illness is very important so that the family can
give the patient full support. Also provision of education on how to take medication and its
potential side effect is important.
REHABILITATION:
Encompass the services of a clinical psychologist to explain to the patient the need to reduce
and finally stopping his drinking and smoking as they have a bad prognostic factor on his
psychiatric condition of schizophrenia.
PROGNOSIS:
GOOD PROGNOSTIC FEATURES:

Patient adhering to his medications

Early age of onset

Acute onset of the schizophrenia symptoms

Quick response to medications

Good premorbid personality
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BAD PROGNOSTIC FEATURES

Beer drinking

Marijuana smoking

Marital problems
HOW TO IMPROVE PROGNOSIS
Psych education to patient to encourage him to reduce and finally stop his drinking of beer as
well as the smoking of marijuana and counseling him together with his wife.
DISCUSSION:
Atypical Antipsychotics in Clinical Practice
A number of new antipsychotic drugs ("atypical antipsychotics") have been introduced since
1990. The first of these, clozapine (Clozaril), has been shown to be more effective than other
antipsychotics, although the possibility of severe side effects - in particular agranulocytosisrequires that patients be monitored with blood tests every one or two weeks. After a year of
stable white blood cell results, blood monitoring can be dropped down to once a month.
Studies show that clozapine may be more effective than other antipsychotics in some perome.
Newer antipsychotic drugs, such as risperidone (Risperdal), quetiapine (Seroquel), olanzapine
(Zyprexa), and Abilify (Aripiprazole) are safer regarding the movement related side effects
(known as tardive dyskinesia) common with first-generation antipsychotics, and they do not
have the same risk of lowering white blood cell counts like Clozaril. Olanzapine (Zyprexa) has
many similarities to Clozaril. It appears to be similar in effectiveness and reveral of negative
symptosm, but free of the risk of agranulocytosis.
The main advantages of choosing atypical antipsychotics can be summarized in four main points
which are:
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1. Atypical antipsychotics undoubtedly cause far fewer extrapyramidal side effects (EPS) than
do conventional antipsychotics and often cause essentially no EPS (they really do perform in
this respect, as predicted pharmacologically and as advertised).
2. Atypical antipsychotics reduce negative symptoms of schizophrenia better than do
conventional antipsychotics. The magnitude of this effect is not as good as the effects on
EPS, and further innovations will be necessary to solve the negative symptom problem in
schizophrenia.
3. Atypical antipsychotics reduce affective symptoms in schizophrenia and related disorders
such as treatment-resistant depression and in bipolar disorder, where treatment effects
appear to be quite favourable.
4. Atypical antipsychotics may possibly reduce cognitive symptoms in schizophrenia and
related disorders such as Alzheimer's disease.
The magnitude of these properties is far from trivial and, in fact, makes the four atypical
antipsychotics risperidone, olanzapine, quetiapine, and ziprasidone easily preferable as
first-line therapies for psychosis, with conventional antipsychotics and clozapine as secondline therapies.
Atypical antipsychotics may not work as fast as conventional antipsychotics for acutely
psychotic, aggressive, agitated patients requiring sedation and onset of action within minutes;
for such patients, conventional antipsychotics or sedating benzodiazepines may be useful as
adjuncts or as substitutes.
On the other hand, these atypical have got there side effects some of which includes weight
gain, type II diabetes mellitus, hyperlipidemia, QTc interval prolongation on the ECG,
myocarditis, sexual side effects, extrapyramidal side effects and cataracts. Some
recommendations about how to prevent and manage these side effects are also provided. It is
concluded that atypical antipsychotics do not represent a homogeneous class, and that
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differences in side effects should be taken into account by clinicians when choosing an
antipsychotic for an individual patient.
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REFERENCES:
1. Current Diagnosis and Treatment in Psychiatry, Michael H Ebert, Peter T Lossen , Barry
Nurcombe (2007)., McGraw Hills Access medicine
2. New Oxford Textbook of Psychiatry, Michael G. Gelder (Editor), Juan J. Lopez-Ibor
(Editor), Nancy Andreasen (Editor), Jaun J. Lopez-Idor
By Oxford University Press, (September 2003)
3. Oxford handbook of clinical specialties, Collier Longmore and Duncan Brown; 5th edition,
Oxford University press, (1999).
4. Psychiatry for students, David Stanford-Clanc; 6th edition, George Allen and Unwin
Publishers, (1983)
5. Comprehensive textbook of Psychiatry, Harold K. Kaplan; 3rd edition, (1998)
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