l.m.p., a 35 year-old married born again christian who lives in bacoor, cavite

L.M.P., a 35 year-old married Born Again Christian

who lives in Bacoor, Cavite

CHIEF COMPLAINT

(Patient): “Hindi ako nakakatulog, hindi ako nakakakain at huminto kasi akong uminom ng gamot.”

(Sister-in-Law): “Nagsasalita ng kung anu-ano.”

PERSONALITY PROFILE

Premorbid Personality:

“masinop, masayahin, sensitive”

Morbid Personality:

“tahimik, kung ano-anong sinasabi”

SOURCE AND RELIABILITY

Patient: 75%

Sister-in-Law: 85%

December 2004 increased preoccupation with religion

January 2005 more intense preoccupation with religion

quiet and overtly sensitive

believed that members of her church group were against her

HISTORY OF PRESENT ILLNESS

February 2005 God’s voice was “telling” her to do something

lost appetite

reduced amount of sleep

1st week of March 2005 blank stares

anxiety

God “communicated” with her

3rd week of March 2005 unusually quiet

barely did household chores

4th week of March 2005 felt something bad will happen to family

shouted at church members

asked forgiveness

commented on bystanders

something was “plotting” against them

speaking in tongues

hyperventilating

1st week of April 2005 continued to be suspicious of her surroundings

told her relatives not to worship idols

2nd week of April 2005 saw “strange people”

would not come out of van

irritable and shouted at relatives

10-day stay at USTH-CC

“maldita” and “matigas ang ulo”

Tx: Quetiapine 100 mg AM, 200 mg PM

Clonazepam, ¼ tab

3rd week of May 2005 Quetiapine 100 mg AM was discontinued

Patient refused to take medication

June 2005 resistive, hyper, violent

Given diphenhydramine 25 mg IM

and Haloperidol 5 mg IM

ADMISSION

REVIEW OF SYSTEMS

• No headache, loss of consciousness or convulsions

• No fever• (+) anorexia and weight loss• No cough or colds, no dyspnea• No chest pain, no easy fatigability• No change in bowel or bladder habits• No bleeding tendencies

PAST MEDICAL HISTORY

• Not known hypertensive, diabetic or epileptic

• No previous hospitalization or operation

FAMILY HISTORY

• (+ dependence) HPN – mother• (+) stroke – mother• (+) heart disease, PUD – father• (+) alcohol dependence – father• (?) nervous breakdown – great

grandmother

PERSONAL HISTORY

• She is a non-smoker and non-alcoholic beverage drinker

• She denies use of any prohibited substance

ANAMNESIS

PRENATAL AND PERINATAL HISTORY

• NSD at home with• Neurodevelopmental milestones were at

par with age.

EARLY-MIDDLE CHILDHOOD

Lived with parents and three siblings 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

EARLY-MIDDLE CHILDHOOD

• Mother strict and disciplinary• Mother and father occasionally fight• Grew up closer to her father

MIDDLE CHILDHOOD

• Primary education at Malubog-lubog Elementary School in Capiz

• Average student and had very few friends• 6th grade - father died which caused

extreme sadness• Left in the care of the eldest sibling

ADOLESCENCE

• Family Relationship– after father’s death, mother married a

policeman– Siblings were against the marriage– had a harmonious relationship with stepfather

and stepsiblings– Stepfather was kind and approachable but was

not able to fill the void left by her father

ADOLESCENCE

• Social Relationships– Had a number of friends– stayed at home on weekends

• School History– Wanted to take up AB Philosophy – forced by mother to take up BS Nursing– Graduated on time

ADOLESCENCE

• Academic Achievement– failed Nursing Board Exams – failure due to “poor preparation”– had guilt feelings

YOUNG ADULTHOOD

• 1993 - nurse in Capiz and resigned after 6 months– Patient was pious and hardworking– Gave portion of salary to patients

• Also worked in a government hospital in Capiz and resigned as to the request of elder sister

YOUNG ADULTHOOD• Meaningful Long term relationship

- did not have serious relationships

- 1994 - met Norman and married him after two years

- Stayed with husband’s family

- Got pregnant and went back to Capiz

- 1997 – CSD with her 1st child

• 1998 – went to Abu Dhabi with husband and had no difficulty in adjusting

• 1999 – decided to return to Manila due to 2nd pregnancy

• 2000 – gave birth to second child• Stayed with her mother, who sometimes

helped out with her grandchildren• Longed for her husband

YOUNG ADULTHOOD

• 2001 – returned to UAE because of argument with mother

• Was baptized to a Born-Again Christian group

• Got pregnant with her 3rd child

YOUNG ADULTHOOD

• Work Experience- 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

WORK EXPERIENCE

• 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

FAMILY PROFILE

Leicel35

Norman38

Julius33

Paul Christopher

Patricia Louis

TimAlbert

Cesar45 Ricardo

Gina38

Minerva58

LEGENDHeart attack

Stroke

PHYSICAL EXAMINATION• General Survey

- Conscious, coherent, not in cardio-respiratory distress, ambulatory

• Vital SignsBP: 115/80PR/CR: 90/min regularRR: 18 cpm Temp: 37.1°C

• Skin- Warm, moist skin, no active dermatoses

PHYSICAL EXAMINATION• EENT

- Pink palpebral conjunctivae, anicteric sclerae- No naso-aural discharge, nasal septum midline- Moist buccal mucosa, non-hyperemic posterior pharyngeal wall, tonsils not enlarged

• Neck-supple neck, no palpable cervical lymph nodes, no anterior neck mass

PHYSICAL EXAMINATION• Respiratory

- Symmetrical chest expansion, no retractions, clear breath sounds

• Cardiovascular- Adynamic precordium, AB 5th LICS, MCL, no

murmurs• Gastrointestinal

- Flat abdomen with NABS, soft, non tender, no organomegaly- Warm, moist skin, no active dermatoses

PHYSICAL EXAMINATION• Extremities

- No cyanosis, no clubbing, no edema• Peripheral Vascular

- Pulses are full and equal

NEUROLOGICAL EXAMINATION• Conscious, coherent, oriented to time, place and

person• Intact remote, recent and immediate memory• Cranial Nerves:

- Pupils 2-3mm ERTL, (+) direct and consensual light reflex- Fundoscopy: (+) ROR, clear media, distinct disc margins, C/D ratio 0.3, AV ratio 2:3

NEUROLOGICAL EXAMINATION• Cranial Nerves:

- No visual field cuts- EOMs full and equal- Can clench teeth, no facial sensory deficit- No facial asymmetry, can raise both eyebrows, can smile, can purse lips- (+) gag reflex, uvula midline on phonation- Can shrug shoulders against resistance- Tongue midline on protrusion

NEUROLOGICAL EXAMINATION• MMT no atrophy, no fasciculations, normal

muscle tone• 5/5 in all extremities• Can do APST and FTNT with ease• DTR: ++ in all extremities• (-) Babinski reflex, no frontal release signs• No sensory deficits• No nuchal rigidity

Mental Status Examination on Admission

• Awake but agitated• Well kempt wearing T-shirt and pants• Speech was modulated but repetitive words were spoken• Good eye contact but inattentive when interviewed• Had preoccupation in getting out the Community Center• Oriented to time, place and person• Affect: appropriate• Anxious and uncooperative• Other examinations not performed – Px uncooperative

SALIENT FEATURES• 35 y/o / Female• Born again Christian• Unemployed• preoccupation with at

least 2 delusions (Jan-Apr 2005)

• Bizaare aggressive/agitated behavior (Apr & June 2005)

• Avolition-apathy (3rd wk & 27 Mar)

MSE:• Awake and agitated• Modulated speech

with verbigeration• Inattentiveness• Oriented to time,

place and person• Appropriate affect• Anxious and

uncooperative

DSM-IV TR Criteria for Schizophrenia

A. Characteristic Symptoms– 2 or more of the ff during a 1-month period.1. Delusions2. Hallucinations3. disorganized speech4. grossly disorganized or catatonic behavior5. Negative symptoms (affective flattening, alogia or

avolition)Note: Only one symptom is required if delusion is bizarre or hallucinations

consist of a voice keeping up a running commentary on the persons behavior or thoughts, or 2 or more voices conversing with each other.

• B. Social/Occupational Dysfunction– in 1 or more areas of functioning– work– interpersonal relationship– self-care

• C. Duration– continous signs for atleast 6 months that must include:

• 1 month of active symptoms (or < if succesfully treated)• ± periods of prodromal or residual symptoms

– only negative symptoms– 2 or more Criteria A symptoms in attenuated form (eg. Odd beliefs,

unusual perceptual experience

• D. Schizoaffective and mood disorder exclusion:1. No major depressive, manic, or mixed episodes

concurrently during active symptoms.2. If mood episodes have occurred during active-

phase symptoms:• duration of : mood disorders < active and

(brief) residual periods

• E. Substance/ General medical condition exclusion– disturbance NOT due to:

• a substance ( illicit drug , medication)• general medical condition

• F. Relationship to a pervasive developmental disorder:– w/ Hx of autistic disorder, pervasive developmental

disorder• additional dx of schizophrenia be made only if prominent

delusions or hallucinations are present for atleast 1 month.(or < if successfully treated)

• Classification of Longitudinal Course– can be applied ONLY AFTER at least 1 year since the

initial onset of active-phase symptoms.

PARANOID TYPE•Preoccupation with one or more delusions or frequent auditory hallucinations•No prominent s/s of disorganized type

DISORGANIZED TYPEProminent:1. Disorganized Speech2. Disorganized Behavior3. Flat / Inappropriate Affect

DSM-IV-TR DIAGNOSTIC CRITERIA FOR SCHIZOPHRENIA SUBTYPES

CATATONIC TYPEAt least two of the following:1. Motoric Immobility - Catalepsy or Stupor2. Excessive motor activity - purposeless,not influenced by external stimuli3. Extreme Negativism4. Posturing

RESIDUAL TYPE• Absence of prominent delusions, hallucinations, disorganized

speech, and grossly disorganized, or catatonic behavior• Continuing evidence of disturbance

-negative symptoms in attenuated form

UNDIFFERENTIATED TYPEmeet Criteria A but not for the paranoid, disorganized or catatonic type.

DSM - IV Diagnosis

• Axis I: Schizophrenia, paranoid type• Axis II: none• Axis III: none• Axis IV: psychosocial problems• Axis V: GAF: 20 - some danger of hurting

others

ICD-10 Diagnostic Criteria for Schizophrenia

Comments

In evaluating the presence of these abnormal subjective experiences and behavior, special care should be taken to avoid false-positive assessments, especially where culturally or subculturally influenced modes of expression and behavior or a subnormal pattern level of intelligence are involved.

Pattern of courseIn view of the considerable variation of the course of

schizophrenic disorders it may be desirable (especially for research) to specify the pattern of course by using a fifth character. Course should not usually be coded unless there has been a period of observation of at least 1 year.

ContinuousNo remission of psychotic symptoms throughout the period of observation.

Episodic with progressive deficitProgressive development of “negative” symptoms in the intervals between psychotic episodes.

Episodic with stable deficitPersistent but non progressive “negative” symptoms in the intervals between psychotic episodes.

Episodic remittentComplete or virtually complete remissions between psychotic episodes.

Incomplete remission

Complete remission

Course uncertain, period of observation too short

DIFFERENTIAL DIAGNOSIS

Psychiatric disorders

Psychotic disorder Neurotic disorder

Schizophrenia Schizophreniform disorder

Schizoaffective disorder

Delusional disorder

Brief psychotic disorder

Secondary psychotic disorder

anxiety

others

SALIENT FEATURES

SCHIZOPRENIA SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

1. Epidemiology

Prevalence1% 0.2% 0.5% - 0.8% 0.025% -

Gender - female

F=M F=M F>M F>M

Age – 35 y/o 25 – 35 y/o M=18-24; F=24-35

Older age Mean = 40 Range = (18-

90’s)

Family Hx ?grandmother

(+) stressor

Genetic predisposition / stressor

Social Hx stressor stressor stressor stressor

SALIENT FEATURES

SCHIZO-PRENIA

SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

2. Consciousness – oriented to PPT

Usually oriented Usually oriented Usually oriented

Usually oriented

3. Emotion a. affect:

appropriate

b. mood: irritable

c. others: anxiety, agitation

d. physiologic disturbance: anorexia, insomnia

Appropriate/ restricted/ flat/

blunt (accdg. To subtype)

Appropriate/ restricted/ flat/

blunt (accdg. To subtype)

Appropriate/ inappropriate

Appropriate

emotional

responsiveness or overly active and inappropriate emotion

emotional

responsiveness or overly active and inappropriate emotion

Depressed or elevated move

Mood congruent or incongruent

+/- +/- - +/-

SALIENT FEATURES

SCHIZOPRENIA SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

4. Motor

Normal to aggressive

Normal to disorganized or catatonic

Intermittent but frequent forms of catatonic behavior, posturing, waxy flexibility

5. Speech

Normal Normal to disorganized

Normal to disorganized/

confused alogia

Normal to grossly irrelevant or incoherent speech - pressure speech

Normal

SALIENT FEATURES

SCHIZO-PRENIA

SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

6. Thinking

a. process of thinking: psychosis

b. form of thought

- Glossolalia

- Verbigeration

c. content of thought

Delusion Noesis

psychosis

Neologism,verbigeration,word salad- looseness of assoc.- derailment, incoherence- echolalia, mutism- tangientiality, circumstantiality

Delusion

psychosis

Delusion

psychosis

Delusion

psychosis

Depends on delusion

Non-bizarre delusion

SALIENT FEATURES

SCHIZO-PRENIA

SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

7. Perception a. distribution:visualauditory hallucination

b. Assoc with cognitive disorder:Anosognosia

All types of hallucination

No hallucinations but may be present of

consistent w/ delusion

8. Memory: normal intact intact intact intact

9. Insight and judgement: impaired

impaired impaired impaired normal / impaired

SALIENT FEATURES

SCHIZO-PRENIA

SCHIZO-PHRENIFORM

SCHIZO-AFFECTIVE

DELUSIONAL DISORDER

10. Social functioning:

impaired

impaired impaired impaired normal

11. Grooming: poor

poor poor well to overly groomed

12. Time period of patient: 6mos

6months; 1 month

symptomatic 1-6 months

Mood Sx: substantial portions of total duration of patients illness Psychotic Sx: at least 2 weeks without the prominent mood symptom

At least 1 month

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.

TARGETS OF TREATMENT

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

PHARMACOLOGIC INTERVENTION

• Non- emergency situation– Partial Compliant patient

• Liquid ( eg. Risperidone, Haloperidol)• Quick- dissolving ( eg. Olanzapine, Risperidone)• Short acting Intramuscular ( eg. Haloperidol)

– Non- compliant• Long- acting Injectable

• Initiate rapid emergency treatments when an acutely psychotic patient is exhibiting aggressive behaviors toward self or others.

• Short-acting parenteral formulations of 1st- or 2nd- generation antipsychotic agents w/ or w/o parenteral benzodiazepines.

• Oral Quick Dissolving 2nd- generation agents (Olanzapine , Risperidone)

FIRST GENERATION ANTIPSYCHOTICS:DOPAMINE RECEPTOR ANTAGONISTS

• immediate blockade of dopamine D2 receptors • ↓ release of dopamine from presynaptic terminals• Two-year studies:

• relapse during tx: 30% only vs. 80% w/o tx

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

In comparison with conventional antipsychotics, atypical antipsychotics show at least an equal

efficacy against positive symptoms

- hold true for first- episodes as well as chronic multi-episode patients

- when used as long term maintenance, atypicals demonstrate a positive effect on relapse prevention in controlled trials

Bridler, Rene, Daniel Umbricht. 2003. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly. 133: 53-76.

PHARMACOLOGIC INTERVENTIONS

2nd – Generation - Atypical Antipsychotics

> 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.

2nd – GENERATION - ATYPICAL ANTIPSYCHOTICS:

On Negative Symptoms

true ameliorative effect shown by substituted benzamide amilsupride:

50 – 300 mg/d demonstrated a significantly greater decrease of negative symptoms

after 6- 26 weeks of Tx

Bridler, Rene, Daniel Umbricht. Atypical antipsychotics in the Treatment of Schizophrenia, Swiss Med Weekly 2003 133: 53-76.

In a 1-yr controlled trial in pxs with chronic stable schizophrenia with only moderate levels of

positive symptoms but high levels of negative symptoms, ziprasidone was associated with a

small, but statistically significant improvement in negative symptoms compared to placebo

In a 38 week comparison of ziprasidone and haloperidol in stable schizophrenic outpatients,

significantly more patients treated with ziprasidone demonstrated a reduction of negative symptoms of 20 % or more than

patients treated with haloperidol.

On Treatment - Refractory Cases

Treatment-refractory patients – fail to adequately respond, ie, show reduction of symptoms to at least two antipsychotics belonging to a different class given in sufficiently high doses of 6-8 weeks

The superiority of clozapine over conventional antipsychotics in the treatment of refractory patients with schizophrenia is well established

A double blind, random assignment, prospective study that assessed the effects of clozapine and

olanzapine on suicidality and suicide risk over two years showed a significantly reduced suicidality and suicide risk with clozapine than olanzapine.

On Affective Symptoms And Suicidality

Therefore, the overall risk benefit ratio is more favorable for the atypicals,

making them the preferred treatment for most patients.

Atypical antipsychotics are recommended as first line treatment.

SIDE EFFECTS OF ATYPICAL ANTIPSYCHOTICS

2nd - GEN. ANTIPSYCHOTIC + ADJUNCTIVE MEDICATION

• Study: Effect of Divalproex Combination with Olanzapine or Risperidone on the Acute Phase of Paranoid Schizophrenia

• earlier improvement of symptoms rather than monotherapy• Divalproex: form of valproic acid that is slowly absorbed

– increases GABA, modulating activity of dopaminergic and other NT activity within cortico-striatal-thalamic pathway.

Casey, D.E., et al. 2003. Effect of Divalproex Combination with Olanzapine or Risperidone in Patents with an Acute Exacerbation of Schizophrenia. Neuropsychoparmacology. 28: 182-192.

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

Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins: USA.

“Lack of improvement in the first 1-4 weeks should prompt an increase in the dose, followed by a change to another drug after an additional four to six weeks, if the response remains inadequate.”

PSYCHIATRIC MANAGEMENT

• Structured and predictable environment• Low performance requirement• Tolerant, non demanding, supportive

relationships• Promoting relaxation and reduced arousal

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

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

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

PSYCHOSOCIAL THERAPIES

Saddock BJ and Sadock VA. 2003. Kaplan & Sadock’s Synopsis of Psychiatry: Behavioral Sciences / Clinical Psychiatry. 9th ed. Lippincott Williams & Wilkins: USA.

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

• improve cognitive distortions• reduce distractibility• correct errors in judgment

COGNITIVE BEHAVIORALTHERAPY

INDIVIDUAL PSYCHOTHERAPY

• therapist’s reliability, emotional distance & genuineness

• long term• good outcomes at 2-year follow-up evaluations

• personal therapy

TREATMENT OPTIONS

2nd – Generation Antipsychotic

DrugEfficacy Safety Suitability Affordability Total

Risperidone +++ + ++ ++ 8

Olanzapine +++ + ++ + 7

Quetiapine +++ ++ ++ + 8

Ziprasidone +++ +++ + 0 7

l.m.p., a 35 year-old married born again christian who lives in bacoor, cavite

tab3rd week

friends6th grade father

household chores4th

hindi ako nakakakain

hindi ako nakakatulog

sensitive morbid personality

earlymiddle childhoodlived

nagsasalita ng kung

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