Psychiatry
Case Conference 1
III-B
Buyucan, Kathleen – Diaz, Mark Fernan
General Data
L.M.P
35 y/o
married
Born Again Christian
2nd in a brood of 3
BS Nursing Graduate
unemployed
born & raised in Capiz
admitted 1st time on April 4, 2005
Infomants: Patient: 75%
Husband: 85%
Sister: 85%
Chief Complaint: insomnia, delusion of reference
 According to patient: “ Pinaghihiwalay ang family namin
ng ministry.”
According to husband: “ Hindi makatulog, minsan nagbabasa
ng bible mag-isa”
“ Feeling nya pinagtutulungan siya ng
ministry”
Personality Profile:
Pre-morbid personality: “masinop, masayahin, sensitive”
Morbid personality: “tahimik, kung anu anong sinasabi”
 History of Present Illness
2001
* very active, sings in the choir
2004
* negative feelings towards members and ministry
December
2005
January
2005
February
2005
1st wk March
* persistent negative feelings towards members and
ministry, delusion of reference
* auditory hallucination, loss of appetite, reduced
sleep, negative feeling towards her husband
* auditory hallucination, odd behavior, blank stares
anxious
 History of Present Illness
2005
* quiet, unresponsive
3rd wk March
2005
* verbal aggression, delusion of reference
March 25
2005
March 26
2005
March 27
2005
March 31
* felt guilty of what she said to the members,
delusion of persecution
* neglected her chores and children, delusion
of persecution/anxiety
* singing songs, speaking incomprehensible words
 History of Present Illness
2005
April 1
* suspicious w/her surroundings
* brought to Las Pinas Doctors Hospital
* injected w/unrecalled medication
* admitted @ USTH while sedated
Review of Systems
(-) Headache, loss of consciousness, convulsions
(-) fever
(+) anorexia , weight loss
 (+) HPN – mother
 (+) stroke – mother
 (+) heart disease, PUD – father
 (+) alcohol dependence – father
 (?) nervous breakdown – great grandmother
 Non-smoker
 Non-alcoholic beverage drinker
 Denies use of any prohibited drugs
 Born to 23 y/o G2P1 (1001); NSD at home
 By traditional birth attendant
 No prenatal or postnatal complications
 Neuro-developmental milestones at par with age

Lived with parents and three siblings

Family owns a small grocery store

Left in the care of the father, an alcoholic

Father had occasional fights with his wife

Patient admits his father had his “weaknesses” but was
very affectionate and loving

Patient grew-up closer to her father and siblings
 Primary education at Malubog-lubog Elementary
School in Capiz
 Average student and had very few friends
 6th grade - father died which caused extreme sadness
and felt that a big part of her was lost with the passing
 Left in the care of the eldest sibling (Gina)
 Gina confided of being overprotective of her younger
siblings
 Family Relationship
 after father’s death, mother married a policeman
 Siblings were against the marriage at first
 Patient felt that the mother betrayed her father
 According to the patient, she had a harmonious
relationship with stepfather and stepsiblings
 Stepfather did not impose himself on the stepchildren
 was kind and approachable and was readily approachable
when they need him
 Social Relationships
 Claimed to have a number of friends
 stayed at home on weekends because mother would not allow
her to go out with friends
 School History
 Attended high school in FLAIMER Christian Institute in
Capiz
 Wanted to take up AB Philosophy
 forced by mother to take up BS Nursing
 Graduated on time
 Academic Achievement
 failed Nursing Board Exams (1990)
 failure due to “poor preparation”
 Worked as an assistant nurse in a small clinic
while waiting for the next board exams
 took the boards in Manila and passed with high marks
(1992)
 Did not work at once because she was waiting for her
petition from her maternal aunt to work in Germany
 After some time worked as a ticketing supervisor at Ever
Gotesco Cinema
 Resigned after 2 months, thinking she was not ready to
work yet
 Learned that her petition was declined
 1993 - nurse in Capiz and resigned after 6 months
 Felt bad in an incident when a patient deteriorated
infront of her
 According to sister:
 Patient was pious and hardworking
 Gave portion of salary to patients
 1994- went back to Manila and stayed with sister
 Meaningful Long-term Relationship
 met Norman and married him after two years (1996)
- Stayed with husband’s family (Cavite)
 After a few months, husband flew to Abu Dhabi
 Patient got pregnant and went back to Capiz

Had difficult pregnancy
- 1997 – CSD with her 1st child (Paul Christian)
 1998 – went to Abu Dhabi with husband and had no
difficulty in adjusting
 Worked as sales clerk in a pharmacy
 December 1999 – decided to return to Philippines due
to 2nd pregnancy
 2000 – gave birth to second child (Patricia Lois)
 Stayed with her mother, who sometimes helped out
with her grandchildren
 Longed for her husband
 2001 – returned to UAE with her children because of
argument with mother
 Was baptized to a ALL Nations FULL GOSPEL, a
Born Again Christian group
 Planned to work as a nurse however got pregnant with
her 3rd child
 First worked as an assistant nurse
 Very little compensation while waiting for the next board exams
 resigned to take 2nd board exam
 Worked as Ticketing supervisor and resigned after 2 mos
 Petition by her maternal aunt was declined by the German
Embassy
 1998 - sales clerk in a pharmacy in Abu Dhabi
 1999 - resigned because of 2nd pregnancy
 No difficulty adapting to new environment
 No difficulty adjusting to new role as mother
 Cesar- father
 Died of “heart attack” at 45
 An elementary graduate
 Came from a well off family in Capiz
 Alcoholic since 20 y/o

Drank gin (? amount) almost everyday usually alone or with
friends
 Patient regards him as loving and kind father
 Patient claims she got her talent from him

He usually sang with her
 Minerva- mother
 58 y/o, elementary graduate
 Strict disciplinarian in the family
 Managed mini-grocery store with Cesar
 Patient would have arguments with her
 Ricardo Delfin – stepfather
 60 y/o, retired policeman
 Treated his stepchildren as his own
 Takes care of Minerva very well
 Gina – sister
 38 y/o, BS Music undergraduate
 Married, currently unemployed
 Previously worked as a singer in Japan
 Currently lives with husband and 5 children in Caloocan
 Very close to the patient; patient’s confidant
 Julius- brother
 33 y/o, college undergraduate
 Married with 2 children
 Previously worked as a seafarer
 Stays at Panitan, Capiz with their mother
 Suffered stroke
 Small business – selling prepaid cards
 Norman- husband
 38 y/o, aeronautics graduate
 Trainer at Estilat Telecom Co. in UAE
 Member of ALL Nations FULL GOSPEL for 10 years
 Very loving and supportive husband and father
 Paul Christian – son
 8 y/o, Grade 2 student
 Good relationship with parents and siblings
 Has problems in school
 Hyperactive and lazy to copy notes
 Patricia Lois – daughter
 5 y/o, Kinder II student
 Very bright daughter
 Consistent honor student
 Has good relationship with parents and siblings
 Tim Albert- son
 2 y/o
Cesar
45
Ricardo
Delfin
60
Minerva
58
4
199
6
Gina
38
L
35
Norman
38
Julius
33
2
5
LEGEN
D Heart attack
Stroke
Paul
Patricia
Christian Lois
8
5
Tim Albert
2
PUD
HPN
SALIENT FEATURES
 35 y/o
 Female
 Born again Christian
 Unemployed
 Preoccupation with at least 2 delusions (JanMarch2005)
 Auditory hallucination
 Aggressive/agitated behavior (March 2005)
 Avolition-apathy (3rd wk & 27 Mar)
SALIENT FEATURES
 Incomprehensible speech
 Impaired social functioning
 Physiologic disturbance: anorexia and insomnia
 Family history: great grandmother had nervous
breakdown
 Non-smoker, non-alcoholic, denies use of prohibited
drugs
 Poor relation with mother
Diagnosis and Discussion
Schizophrenia
• chronic psychotic disorder with onset typically occurring in adolescence or
young adulthood
• results in fluctuating, gradually deteriorating, or relatively stable
disturbances in thinking, behavior, and perception
• severity can range from mild and subtle with very good adaptation to
everyday life, to severely disabling requiring constant supervision in a
restricted environment.
Classification of Longitudinal
Course
Episodic with inter-episode residual symptoms (episodes are defined
by the reemergence of prominent psychotic symptoms)
• also specify if: with prominent negative symptoms
Episodic with no inter-episode residual symptoms
Continuous (prominent psychotic symptoms are present throughout
the period of observation)
• also specify if: with prominent negative symptoms
Single episode in partial remission
• also specify if: with prominent negative symptoms
Single episode in full remission
Other or unspecified pattern
Epidemiology
 US lifetime prevalence: 1%
 DSM-IV-TR: annual incidence 0.5-5.0 per 10,000
 Equally prevalent in men and women.
 Earlier onset in men (10-25 yrs old), women (25-35)
 Men are more likely to be impaired with negative
symptoms
 Women have better social functioning prior to disease
onset
Infection and season birth
• Season specific risk factor such as
a virus or season change in diet
Geographic Distribution
• Greater in the northeastern and
Western US than in any other
areas.
Reproductive Factors
• The fertility rate of schizophrenia
patients is close to the general
population
Medical illness
• Higher mortality rate from
accidents and natural causes than
the general population
Suicide Risk
• Suicide-leading cause of mortality
(15%)
Substance abuse
• Cigarette smoking
• Alcohol
• Cannabis and cocaine
Population factors
• Prevalence is correlated with local population
density
• Social stressors in the urban setting affest the
development of schizophrenia in persons at risk
Socioeconomic & Cultural Factors
•
•
•
•
Low socioeconomic group
Downward drift hypothesis
Social causation hypothesis
Stress of Immigration
ETIOLOGY
Pathophysiology
Dopamine Hypothesis
Hypodopaminergic activity in
mesocortical system
Hyperdopaminergic activity
in mesolimbic system
NEGATIVE
SYMPTOMS
POSITIVE
SYMPTOMS
Examples of Positive and Negative
Symptoms in Schizophrenia
Positive
symptoms
• delusions
• hallucinations
• disorganized
speech and
behavior
Negative
symptoms
• poverty of
speech
• flattened affect
• social
withdrawal
• avolition
Genetic Factors
Population
Prevalence (%)
General population
1
 Increased rate among the
Non-twin sibling of
biological relatives of
patients with schizophrenia a schizophrenia
8
patient
 Correlated with the
Child with one
closeness of the relationship parent with
to an affected relative
schizophrenia
Dizygotic twin of a
schizophrenia
patient
12
12
Child of two parents 40
with schizophrenia
Monozygotic twin
of a schizophrenia
patient
47
Neuropathology
 Loss of brain volume results from reduced density of the
axons, dendrites and synapses that mediate associative
functions of the brain.
Central Ventricles
• CT scans consistently shown lateral
and third ventricle enlargement and
some reduction in cortical volume.
Reduced Symmetry
• Temporal, frontal, occipital lobes.
• Originate during fetal life
Limbic System
• Decrease in the size of the region
including the amygdala, the hippocampus
and the parahippocampal gyrus.
• Hippocampus- functionally abnormal as
indicated by distrubances in glutamate
transmission.
Thalamus
• Volume shrinkage or neuronal loss.
Basal Ganglia and Cerebellum
• Increase in the number of D2
receptors in the caudate, putamen,
and the nucleus accumbens.
Eye Movement Dysfunction
• Inability to follow moving visual
target accurately  defining basis
for the disorders of smooth visual
pursuit and disinhibition of saccadic
eye movements.
• Trait marker for schizophrenia
• Independent of drug treatment and
clinical state
CLINICAL FEATURES
 No clinical sign or symptom is pathognomonic for
schizophrenia
 Patient’s symptoms change with time
 Clinicians must take into account the patient’s
educational level, intellectual ability and cultural and
subcultural membership.
Premorbid Signs and
Symptoms
 Appear before the prodromal phase of the illness
 Patients had schizoid or schizotypal personalities.
 Quiet, passive, and introverted
 As children, they had few friends
 Signs may have started with complaints about somatic
symptoms
 Headache, back and muscle pain, weakness and digestive
problems
 Family and friends may notice that the patient has
changed and no longer functioning well in occupational,
social, and personal activities.
 May begin to develop an interest in abstract ideas,
philosophy and the occult or religious questions
 Include markedly peculiar behavior, abnormal affect,
unusual speech, bizarre ideas and strange perceptual
experiences.
Psychiatric
Diagnostic Exams
MENTAL STATUS
EXAM
 important part of the clinical assessment process in
psychiatric practice.
 structured way of observing and describing a patient's
current state of mind, under the domains of appearance,
attitude, behavior, mood and affect, speech, thought process,
thought content, perception, cognition, insight and judgment
Trzepacz, PT; Baker RW (1993). The Psychiatric
Mental Status Examination. Oxford, U.K.: Oxford
University Press. p. 202.
Mental Status Exam
Appearance
Attitude
Behavior
Mood and affect
Speech
Thought and Process
Thought content
Perceptions
Cognition
Insight
Judgment
MENTAL STATUS EXAM
DOMAIN
APPEARANCE
ATTITUDE
BEHAVIOR
In The Patient
Awake, but agitated
With appropriate manner
of dressing and grooming
Uncooperative
No noted abnormal
movements but (+)
hallucinations; good eye
contact but inattentive
when interviewed
MENTAL STATUS EXAM
DOMAIN
In The Patient
MOOD AND AFFECT
Affect appropriate but
mood was anxious
“speaking in tongues”,
incomprehensible
spontaneous speech;
Logically incoherent
SPEECH
THOUGHT PROCESS
MENTAL STATUS EXAM
DOMAIN
THOUGHT CONTENT
PERCEPTIONS
COGNITION
In The Patient
Delusions that “someone”
is plotting against her and
her family; Preoccupation
against her Christian
Community
Positive auditory
hallucinations and
illusions
Oriented to time, place
and person; alert
MENTAL STATUS
EXAM
DOMAIN
In the Patient..
INSIGHT
Seems to be unaware of
her mental illness
JUDGMENT
Paranoid and suspicious
of her surroundings
Perceptual Disturbances
Diagnostic Tests
HALLUCINATIONS
 Any of the five senses may be affected
 Auditory  most common hallucinations
 Patient
 She felts that God’s voice was telling her to do something
about the church
 God communicated with her through “discerning spirit”
 Visual hallucinations
Illusions
 They are distortions of real images or sensations
 active phases, prodromal phases and during periods of
remission
 substance-related cause for the symptoms
Thought :
 Thought Content
 Patient's ideas, beliefs, and interpretations of stimuli
 Delusions
 Patient
 “ Pinaghihiwalay ang family namin ng
ministry”
 “Huhulihin ka nyan, magtago na tayo”
Thought
 Form of Thought

patients' spoken and
written language

looseness of
associations

derailment

incoherence

tangentiality

circumstantiality

neologisms

echolalia

verbigeration

word salad

mutism
 Patient

“speaking in tongues”
Thought
 Thought Process
 way ideas and languages are formulated
 observe the patients behavior, especially in carrying out discrete
tasks
 flight of ideas
 thought blocking
 impaired attention
 poverty of thought content
 poor abstraction abilities
 perseveration
 idiosyncratic associations
 over inclusion
 circumstantiality
Impulsiveness, Violence,
Suicide and Homicide
 IMSULSIVENESS

Agitated, little impulse
control

Decreased social sensitivity

Suicide and homicide
attempts in response to
hallucinations
Impulsiveness, Violence,
Suicide and Homicide
 VIOLENCE.

Excluding homicide

Risk factors:

Delusions of
persecutory behavior

Previous episodes of
violence

Neurologic deficits
 SUICIDE
 50% of all schizophrenia patients attempt suicide (1015% die by suicide)
 Precipitants of suicide:
 Misdiagnosed depression
 Feelings of absolute emptiness
 Need to escape from mental torture
 Auditory hallucinations
Impulsiveness, Violence,
Suicide and Homicide
 SUICIDE

Risk factors:

Awareness of the illness,

Male sex,

College education,

Young age

A change in the course of the disease

Improvement after a relapse

Dependence on the hospital

Overly high ambitions

Previous suicide attempts early in the course of the disease

Living alone
Impulsiveness, Violence,
Suicide and Homicide
 HOMICIDE

Same incidence as in general population

Unpredictable or bizarre reasons based on
hallucinations or delusions

Possible predictors:

History of previous violence

Dangerous behavior while hospitalized

Hallucinations or delusions involving such
violence
Sensorium and Cognition
Diagnostic Tests
Orientation
 Usually oriented to person, time, and place
 Some may give incorrect or bizarre answers
 “I am Christ; this is heaven; and it is AD 35.”
Memory
 Usually intact.
 BUT, there can be minor cognitive deficiencies.
 Also, it may be impossible to have the patient to attend
closely enough to the memory tests for it to be assesed
adequately.
Judgment and Insight
 Classically, schizophrenic patients are described to have:
 (1) poor insight of the nature of their disease.
 (2) poor insight of the severity of their disorder.
 Associated with poor compliance of treatments.
 Clinician must also examine various aspects of insight
(awareness of symptoms, social adeptness and reasons
for problem).
 (a) Treatment of Strategy
 (b) Affected Brain Area (parietal lobes » lack of insight)
Reliability
 Schizophrenic patients are no less reliable than other
psychiatric patients.
 Examiner is required to verify important information
through additional sources -- given the nature of the
disorder.
Neurological Signs
 Nonlocalizing Signs
 Dysdiadochokinesia
 Astereognosis
 Primitive Reflex
 Diminished dexterity
 Abnormal motor tones
 Impaired fine motor skills
 Abnormal movements
Neurological Signs
 Eye Examination
 Disorder of smooth occular pursuit (Blank stares)*
 Elevated Blink rate
 Speech
 Incomprehensible words *
 Aphasia (Disturbances in language output)*
* Seen in patient
Other Physical Findings
 Embryonic and Fetal Growth anomaly
 Genetics
 Complications
 Compulsive water intake (hyponatremia)
TREATMENT
OVER-ALL TREATMENT GOALS
 Reduce or eliminate the symptoms
 Maximize quality of life and adaptive functioning
 Promote and maintain recovery from the delibitating
effects of illness to the maximum extent as possible
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
Phases of Treatment
Acute Phase
Stabilization Phase
Maintenance Phase
TREATMENT:
ACUTE PHASE
ACUTE PHASE TREATMENT
 Goals:
 Prevent harm
 Control disturbed behavior
 Reduce severity of symptoms
 Identify factors that led to recurrence of acute episode
 Effect a rapid return to the best level of functioning
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
FIRST GENERATION ANTIPSYCHOTICS:
DOPAMINE RECEPTOR ANTAGONISTS
• immediate blockade of dopamine D2 receptors
• ↓ release of dopamine from presynaptic
terminals
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349:
18
FIRST GENERATION ANTIPSYCHOTICS:
DOPAMINE RECEPTOR ANTAGONISTS
• Disadvantages
• Positive symptoms only
• Only 20% of patients recover to normal functioning
• Side effects:
• Akathisia, Parkinsonian-like symptoms
• Tardive dyskinesia, Neuroleptic Malignant
syndrome
FIRST GENERATION ANTIPSYCHOTICS:
DOPAMINE RECEPTOR ANTAGONISTS
• Examples
• Chlorpromazine
• Haloperidol
2nd – Generation - Atypical Antipsychotics
Serotonin – Dopamine Antagonist
> exert more beneficial effects in the reduction
of negative symptoms
> greatly reduced occurrence of acute
extrapyramidal side effects & reduced
incidence of tardive dyskenisia
> decrease affective symptoms and suicidality
Bridler, Rene, Daniel Umbricht. 2003. Atypical antipsychotics in the
Treatment of Schizophrenia, Swiss Med Weekly. 133: 53-76.
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349:
18
SIDE EFFECTS OF ATYPICAL ANTIPSYCHOTICS
Freeman R. 2003. Schizophrenia. New England Journal of Medicine. 349:
18
Serotonin – Dopamine antagonist
Examples:
Risperidone
Clozapine
Olanzapine
Sertindole
Quetispine
Ziprasidone
18
ADJUNCTIVE MEDICATION
Benzodiazepines / Lorazepam
 Managing catatonia or to
decrease anxiety and agitation;
sleep disturbances
Anti-depressants
For co-morbid major
depression & OC disorder
Beta-blockers
Decrease severity of
recurrent hostility & aggression
Mood Stabilizers
Lithium
reduce symptoms up to
50%; for mood swings.
Decrease severity of
recurrent hostility &
aggression
Anticonvulsants
(Valproic acid/
carbamazepine)
Reduce episodes of violence
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry:
Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins:
USA.
What should we give to the
patient?
Serotonine – Dopamine antagonist
Risperidone
IM – every 1 to 2 hours
Per orem – every 2 to 3 hours
PSYCHIATRIC MANAGEMENT
 Structured and predictable environment
 Low performance requirement
 Tolerant, non demanding, supportive relationships
 Promoting relaxation and reduced arousal
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
TREATMENT:
STABILIZATION PHASE
STABILIZATION PHASE
 Goals
 Reduce stress on patient & provide support to minimize
likelihood of relapse
 Enhance patient adaptation to life in community
 Facilitate continued reduction in symptoms &
consolidation of remission
 Promote process of recovery
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
PHARMACOLOGICAL
INTERVENTION
 Continue medications for 6 months
 Adjust dose or change drug to minimize side effects
 Prevent premature lowering of dose or discontinuation
 Recurrence of symptoms & possible relapse
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
TREATMENT:
MAINTENANCE PHASE
MAINTENANCE PHASE
 Goals

enusure symptoms of remission or control is sustained
 Improve or maintain level of functioning or QOL
 Monitor side effects of treament
American Psychiatric Association. 2004. Practice Guideline for the Treatment of
Patients With Schizophrenia, Second Edition.
PSYCHOSOCIAL
THERAPIES
Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry:
Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins:
SOCIAL SKILLS TRAINING
 Also referred to as behavior therapy
 Improve social abilities and interpersonal
communication
 Increase practical skills and self-sufficiency
 Reduce the frequency of maladaptive or deviant
behavior
FAMILY-ORIENTED THERAPY
 Involves preparing the family and the patient going
home
 Includes postdischarge period, the recovery process, its
length and its rate
 Help the family and the patient learn about
schizophrenia and its psychotic episode
 Control emotional intensity of family sessions with the
patient
CASE MANAGEMENT
• to have one person aware of all the forces
(psychiatrists, social workers, occupational
therapists, etc.) acting on the px
• case manager – ensures that their efforts are
coordinated and the px keeps appointments and
complies w/ tx plans
- make home visits and even accompany px to
work
Assertive Community
Treatment (ACT)
 for the delivery of services for persons with chronic
mental illness
 Team has a fixed caseload of pxs and delivers all services
when & where needed by the px, 24/7.
 Adv: decrease the risk of rehospitalization
 Disadv: labor-intensive and expensive
GROUP THERAPY
 focuses on real-life plans, problems, and relationships
 may be behaviorally oriented, psychodynamically or
insight oriented, or supportive
 effective in reducing social isolation, increasing the
sense of cohesiveness, and improving reality testing
COGNITIVE BEHAVIORAL
THERAPY
• improve cognitive distortions
• reduce distractibility
• correct errors in judgment
INDIVIDUAL PSYCHOTHERAPY
• therapist’s reliability, emotional distance &
genuineness
• long term
• good outcomes at 2-year follow-up
evaluations
• personal therapy
Thank You!