Transcript Case history

Farhan is a young boy of 23 years of age, single
,unmarried, educated upto Fsc. He is resident of
district Chakwal and was referred to me by one of
my senior colleague from Rawalpindi , in OPD on
26.9.2006. This is his first admission in PIMH .
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Presenting Complains
Aggressive abusive and irritable
Suspicious to his family members,
Self talking , self laughing along with odd behaviour.
Disturbed sleep
 Family
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History
No family history of any Psychiatric illness.
 Personal
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History
Poor performance in school
Asocial
Down ward drift
 Premorbid
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Schizoid
History
 Drug
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History
During his stay with us
Following drugs has been given
SEP to NOV 2006
Risperidone upto 6mg /day
but with poor response
DEC to 15JAN 2007
olanzapine 20mg/day but
with poor response
15JAN to MARCH 2007 Zeldox400mg/day but with
poor response
Currently he is on Clozapine 400mg/day and gradually
increasing the dose (100mg/week)
Mental State
Examination
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Appearance and Behavior
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Young thin boy .wearing hospital uniform,
sitting comfortably in chair ,cooperative ,
making and maintaining eye contact adequately
showing self smiling during interview.
MOOD Subjectively I am happy
MOOD Objectively Euthymic
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Talk
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Verbatum of the Patient
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Verbatum is in urdu, It is translated in English for your
convenience.
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I have been selected for president
First of all iwas Major General but iwas not promoted to
Brigadier
I have the power of four knowledge's
Religion Knowledge
Black knowledge (Magic)
Sky Knowledge
Knowledge .which I developed myself.
There are army control room
They control my whole village.Also in my home and control
me.
Army people have taken out my brain.
Now aday Iam General “Ghain” this name has been given
to me by GHQ Rawalpindi
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In Navy Iam “QUTTAR KANDUCTOR”(invented
word with no meaning)
In air force Iam “DEAL LAKORA”(invented word with
no meaning in urdu)
Iam the GUL of whole world.
Iam under women like magic they want to convert me in
a girl.
Ihave the knowledge of ideas that is very powerful.I
come to know each and every thing through this
This is not for only muslims but also people belonging
to other religions.
People living in my village also have this knowledge.
Thatpush different thoughts into my mind,rather they
push my thought into the mind other peoples
While describing all this talk, there was no pressure of
speech,no elation rather he was quite cold and devoid of
any emotion
 Auditory
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Hallucination
Not found
 Thoughts
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disorder
Thought insertion
Broadcasting
Withdrawl
Delusion of grandeur / paranoid
Passivity - positive
 Orientation
and
Concentration
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He is well oriented in time and space.
 Insight
According to patient, he is not suffering from any
psychiatric illness and needs no medication.
 D/D
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In my opinion The most likely diagnosis is
SCHIZOPHRENIA
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SCHIZOAFFECTIVE DISORDER
BAD
CHRONIC MANIA
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in favour of first
diagnosis
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Continuous pattern of illness without seasonal
variation .
Premorbid personality
Delusion of control and thoughts disorder .
Absence of pressure of speech ,poor emotional
response while talking
Neologism
 Precipitating
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Factors
The poor performance in Fsc result in the initiation of
the illness.
 Maintaining
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Premorbid personality
Poor drug compliance
HEE
Factors
 MANAGEMENT
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I would like to manage this case on following aspect
Pharmacological
Psychological
Social
Along with pharmacological treatment, psychosocial
education of the family is being carried out.
 SCHIZOPHRENIA
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Schizophrenia is one of the group of psychiatric disorders
traditionally called the functional psychoses.
 SCHIZOPHRENIA
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NEGATIVE SYMPTOMS
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POSITIVE SYMPTOMS
 DIAGNOSIS
DSM-TR
ICD-10
PARANOID
PARANOID
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DIORGANISED
HEBEPHERNIC
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CATATONIC
CATATONIC
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UNDIFFERENTIATED UNDIFFERENTIATE
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RESIDUAL
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SIMPLE
 EPIDEMIOLOGY
INCIDENCE
.1%
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PREVALENCE
Life time risk is 7-13% per 1000 population.
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MORTALITY
Suicide is the most common cause of early death in schizophrenia (713%).
 AETIOLOGY
BIOLOGICAL FACTORS
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BIRTH COMPLICATIONS
NEURODEVELOPEMENTAL
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POST NATAL INFECTIONS (VIRAL)
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EXPOSURE TO DRUGS
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CONTINUE…….
ENVIROMENTAL FACTORS
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HOME ATMOSPHERE
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ROLL OF CAREGIVERS
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MIGRATION
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EARLY DEATHS OF PARENTS
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UNUSUAL STRESS
 CONTINUE…..
GENETIC FACTORS
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IDENTICAL TWINS
NON IDENTICAL TWIN
REAL SIBLINGS
BOTH PARENTS
ONE PARENT
GENERAL POPULATION
RISK
46%
12-15%
08%
40%
12-15%
1%
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JUEL K(1993) MORTALITY AND CAUSES OF DEATH
IN FIRST ADMITTED SCHIZOPHERNIC PATIENTS
BJP 163
 NEUROPSYCHOLOGICAL
FINDINGS
NEUROIMAGINING
CT-SCAN/MRI
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VENTRICULAR ENLARGEMENT
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AMYGDLA THICKENING
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CEREBELLAR ATROPHY
 CONTINUED…..
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PET SCAN
REDUCED CEREBERAL BLOOD FLOW
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AN APPROACH TO TREATMENT
RESISTANT SCEHIZOPHRENIA
DEFINITION
FAILURE TO RESPOND TO 2 OR MORE ANTIPSYCHOTIC
MEDICATION GIVEN IN THERAPEUTIC DOSAGE FOR SIX
WEEKS.
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PREVALENCE
APPROX 30%
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AETIOLOGY
NEURODEVELOPEMENT FACTORS,COGNITIVE
IMPAIRMENT,DRUG NON COMPLIANCE.
 CONTINUE…
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MANAGEMENT
CLARIFY DIAGNOSIS,ADRESS COMORBIDITY AND NON
COMPLIANCE
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PHARMACOLOGICAL INTERVENTION
ONLY CLOZAPINE IS APPROVED FOR TRS.
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REHABILITATION
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EFFECTS OF
CONVENTIONAL
ANTIPSYCHOTICS
ACUTE
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ANTICHOLINERGIC SIDE EFFECTS,NMS,EPS
SUB ACUTE
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PIGMENTATION,WEIGHT GAIN,LFT,
CHRONIC
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TARDIVE DYSKINESIA
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SIDE EFFECT PROFILE OF ATYPICAL
ANTIPSYCHOTICS(RISPERIDONE,OLANZAPIN
E,
QUETIAPINE,ZYPRESSIDONE,CLOZAPINE)
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SEDATION
CHOLINERGIC VS ANTICHOLENERGIC
WEIGHT GAIN
METABOLIC SYNDROME
BLOOD DYSCRASIA
ECG CHANGES
SEIZURES
EPS
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 APPROVED
INDICATIONS FOR
CLOZARIL
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TREATMENT RESISTANT SCHIZOPHRENIA
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REDUCING THE RISK OF RECURRENT SUICIDAL
BEHAVIOUR
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PSYCHOSIS DURING THE COURSE OF PARKINSONS DISEASE
 OTHER
INDICATIONS OF
CLOZAPINE
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SCHIZOAFFECTIVE DISORDERS?
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BIPOLAR DISORDERS?
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POST TRAUMATIC STRESS DISORDERS?
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THE END