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Case Presentation

Group 2
Psychiatry Rotation
Banag-Laum Home
Nov. 28, 2014

PATIENT HISTORY
I. Identifying Data
JLM, 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 History


1. Psychiatric - no previous history of psychiatric
illness
2. Medical underwent appendectomy at age 13
at San Carlos City
3. 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 History
1. Prenatal and Perinatal
Patient 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. Adulthood
A. Occupational History
Patient 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 History


He 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 History
Patient 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. Religion
Patient is a Roman Catholic. However, he is not

devoted to his religion.

E. Social Activity
Most 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 History
There is no history of any legal issues or

imprisonment.

VII. Family History


The patient has an aunt on the maternal
side who had schizophrenia.

MENTAL STATUS EXAM


I. General Appearance
The 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 Characteristics

His speech was coherent, spontaneous


but with low volume and normal rhythm.
IV. Perception
A. Hallucinations
Patient denied experiencing hallucinations
of any kind.

V. Thought Content
Delusions 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 Process

The patients thoughts are coherent,


linear, logical, and goal directed. There is
no flight of ideas or loose associations.

VII. Sensorium and Cognition

A. Orientation and Memory


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

Recent Past Memory


Question: 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,
Orange
Question: 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 Attention


Abstract Thought:
Question: Unsay may pareha sa Apple og
Orange? What is the similarity of Apple
and Orange?
Answer: Pareha sila Prutas
Question: 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 Insight


The 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. Reliability

Overall the patient appeared forthright


and reliable.

Differential Diagnoses
Delusional Disorder
Paranoid Schizophrenia
Substance-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 type

A 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 SubstanceInduced 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 Diagnosis
Amphetamine-Induced Psychotic Disorder

Amphetamines
Amphetamines 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

Discussion
Amphetamine-Induced Psychotic Disorder
The 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 amphetamineinduced 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

Treatment and Rehabilitation


Management 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/detoxification
1. benzodiazepine to decrease agitation
2. antipsychotics to treat psychotic
symptoms
3. medical and psychological support
B. Extended management/maintenance
1. education for initiation and maintenance
of abstinence

o The treatment of amphetamine (or amphetamine-like)-related

o
o

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 Treatment


Risperidone (Sizodon)
Biperiden (Akidin)
Rivotril (Clonazepam)

Thank You!