Case Presentation

Dr Aziz MohammadPGT Psychiatry KTH

Demographic Details

Said Mohammad, 18 years old, single, educated upto 6th class, resident of Mula Zai Warsak Peer Bala Peshawar.

Chief Complaints

• Suspicious, Aggressive, Sleepless, Not eating : 3 days:

• Social Withdrawal: 1 month

History of Present illness

• According to the father of the patients, patient has started avoiding mixing with family members for the last one month, and has started expressing that the whole family has been plotting against him and trying to kill him for the last three days.

• He would become aggressive without any significant provocation, and physically attack those who try to confront or take him for any sort of treatment for his abnormal thoughts.

HOPI (cont..)

• He is sleepless and has stopped eating and drinking in home with a belief that his family members may poison him.

• Soon after developing these symptoms his parents and siblings thought he was been possessed by Jinnat, and he was taken to spiritual healer for treatment two times before they decided to bring him to hospital.

HOPI (cont..)• His parents decided to take him to KaKa Saib Zyarat

after no response to the treatment of a local faith healer. While on way near pabbi the patient jumped from the motor cycle on which he was being carried by his father and mother. Luckily they received no major injuries. He started fighting with his parents again with those thoughts of being taken to be killed. He was then taken in a car with a help of his brothers after a non successful attempt by his father in the pabbi bazar where the father reports many people witnessed them pulling each other.

HOPI (cont..)

• After returning from Zyarat the patient showed no improvement in his condition, and he was brought to hospital at 11’o clock on Saturday night against his will restrained by 4 attendants on a stretcher with his hands tied together.

• The brother of the patient reports that they noticed change in the behaviour of the patient over the past one month when the pt became socially withdrawn and aloof with no interest in matters related to him and his family.

HOPI (cont..)• The only recent stressor which could be

identified is the shifting of the family from their native village Jamrud to Mula Zai (Peer Bala warsak road) about two months ago due to personal security reasons. His father is a driver in army and reports his home was easily accessible to terrorists in Jamrud. All the family members are strangers in the new village with no friends and relatives.

HOPI (cont..)

• There is no history of fever, fits or grossly disorganized/confused behaviour.

• No history of any self talking/muttering/smiling was reported .

• There is also no history of any mood symptoms.

Past History• Patient has history of diarrheal illness which remained

for 3 months before it could be successfully treated 4 months ago.

• For his diarrhea He was investigated In Gastroenterology OPD HMC and found to have mesenteric lymphadenopathy on U/S Abd

• Stool R/E was reported normal.• He was treated with inj:Ceftriaxone 2gm OD, for one

wk on outdoor basis, with which he recovered and his diarrhea subsided. (record available)

• There is no past psychiatric or surgical history.

Family History

• Father: Healthy, no formal education, Driver in army for the past 24 years.

• Mother: Healthy, house wife• Sib: 9 brothers and 1 sister. Most of his siblings are not

educated and working as labourers on daily wages basis.

• B/O: 3rd.• Satisfactory interpersonal relationship with the family

members.• No history of any psychiatric illness in first or second

degree relatives.

Personal History• NVD, with No history of prenatal, or post natal complications. • Achieved his DMS at appropriate age. • No history of separation from parents, or any sort of abuse reported

during early and late childhood. • No history of conduct problems or neurotic traits during childhood. • Started going to school at age 5. Left school in 6th class, as he did not

have interest in going to school further.• Never done any job in his life time, apart from being an assistant for

a month with his brother who is a Pick Up Driver. His father reports he would be roaming around aimlessly and would show no interest in doing any work.

• He is Single, and not engaged• There is No history of any drug abuse or encounter with police or

law.

Pre-morbid Personality

• Father and brother described him as sociable, he has quite a few friends in his old village.

• Used to have adequate coping skills under stressful conditions.

• Would give importance to cultural and religious norms.

• Would spend his leisure time with his friends

Physical Examination

• GPE : He was dehydrated, with sunken eyes, dry mouth and reduced skin turgor.

• BP: 110/70 mm Hg, pulse: 94/min, T: 98F• No Jaundice, Oedema, Lymphadenopathy,

Cluddbing, or Aenmia.• CVS: No added heart sounds. • Chest: Clear, VB.• Abd: Soft, Non tender with no visceromegally

CNS Examination

• Patient was uncooperative and resisted to be examined at all.

• He would make his body stiff whenever some one would touch him and would not let the hand of examiner go beneath his head by extending his neck, pressing his head against the pillow, so neck stiffness could not be elicited. His deep tendon reflexes were brisk in all 4 limbs.

• His motor/sensory systems and gait could not be formally assessed, but there were no evidence of any focal motor deficits, as his would contract any part of his body when touched for examination.

Investigations

• FBC: TLC 7800, N:60, L:30, ESR :10• CXR: Clear Lungs fields, No Hilar pathalogy• LFT: AST:30, • Urea:60, creat: 0.7• HbsAg/Anti HCV: non-reactive• S. Electrolytes: Na: 145, K:3.5, Cl:105• RBS: 78• MRI Brain: Normal

MSE• A/B: A boy of apparantly 18-20 years, lying in bed,

with a torn qamees, and bruises on his left side of forehead and left hand, not responding to questions or commands, resisting to be examined. No rapport or eye contact could be established or maintained.

• Mood: Obj: Flat• Speech: Mute• T/P: hallucinations and delusions could not be

formally elicited, the pt exhibited paranoid behaviour, • Cognition could not be tested.• Insight: Absent

Differential Dx

On the basis of history and MSE, 1st preferable diagnosis according to ICD-10 on Axis 1.• (F23): Acute and Transient Psyhotic Disorder with its

sub category (F23.3): Acute Predominantly Delusional Psychotic

DisorderDDs include: (F06.2) Organic delusional [schiphrenia like] Psychosis (F10-19): Mental and Behavioural disorder due to

psychoactive substance abuse (F1x.0) Acute Intoxication.

DDs (Cont..)

• On Axis ll (disabilities).. Score 1-5• Personal Care: 5• Occupation: 5• Family and House Hold: 5• Broader Social Context: 5• On Axis lll (contexual factors)• Recent migration of the family

Management

• Immediate:• Patient was admitted in psychiatry ward• He was rapidly tranquillized due to his mental

state at the time of his arrival.• Short Term:• He was assessed in detail in the morning on

Sunday, with his full physical examination. His father and brother were interviewed about the onset, course and nature of his symptoms.

• His routine investigations were sent.

Management (cont..)

• Short Term (cont..):• He was given Inf: Dextrose W 5% 1L iv stat and• Inj: Haloperidol 5mg x2 amp IM BD • Inj: Diazepam 10 mg IV BD.• His father and brothe were provided with

informational care, about the nature of the illness and its management.

Management(cont..)• Medium Term:• 4 hourly Monitoring of the patients BP, temperature, intake

and output record was maintained.• Was found to have no urine output for 2 days before

admission with inadequate oral intake, he was given inf; R/Lactate 1L i.v stat and then OD, soon after receiving the infusion the pt passed urine.

• He was non communicative, uncooperative, and detail CNS examination could not be done in detail even on 3rd day of admission.

• Liaison was made with medical ward to rule out the possibility of organic cause for his current condition.

Management(cont..)• Medium Term (cont..)• Patient was started on • Inj: Aclova (Acyclovir) 500 mg iv TDS• Inj: Gen-M (Artemisunate) 2gm iv OD.• Tab: Olanzapine 10 mg OD (nocte) • The investigations advised along with MRI

brain was done, which came out to be normal.

Management(cont..)

• Medium Term (cont..)• Serial MSE• PANSS scale was applied with scores of (P:35,

N:24 and G:40, total: 99)• 1st episode Psychosis proforma attached and

filled. • Temp/BP monitoring 6 hourly• Monitoring for any afverse effects of

medication

Medium Term (cont..)

• Medium Term (cont..)• Patient has shown improvement, and has

started taking food and fliud orally, with marked reduction in his paranoa, although prefers to talk very less his speech is relevent. His sleep is normal. Has not developed any EPS.

Prognosis

• Short Term: acute onset, short duration, positive symptoms and good early response to antipsychotics are all in favour of good short term outcome.

• Long Term: Due to male gender, young age, poor educational background and premorbid dependent nature of patient the long term prognosis will depend on adherence with treatment and his social support and is guarded at the moment.