Transcript Extra_Case_1_schitzophrenia[2] - Ipswich-Year2-Med-PBL-Gp-2

Extra Case 1
How do you solve a problem like
Maria?
Maria is a 20 year old single woman living at home with her parents who has
attended your practice for several years. She has a history of anxiety and
difficulties coping with work (she works as a sales representative) and with her
relationships. There has been some alcohol abuse in the past and some
episodes of disordered eating (binging and purging). She has often presented
with multiple physical complaints but has always been fit and healthy. She has
received some supportive counselling in the past for distress associated with
sexual abuse that occurred during her childhood. This had occurred in the
context of a friend's father abusing her whilst on sleep-overs at her friend's
house when Maria was 12 years old.
On this occasion, Maria reports that her mood has been very low for the past
three weeks. She has no energy, profound and pervasive anhedonia. She
describes that her thinking is very slow, she has missed appointments with
customers and she has received a warning at work. She also describes an
overwhelming sense that something bad is about to happen but she can't
identify what that might be.
She has lost about four kilograms in weight unintentionally. She describes
lying awake at night and ruminating on how pointless her life is. She has felt
that she would be better dead on occasions but states she would not act on
this thought because it would hurt her family too much. She states she very
much wants to get better. She says she feels like she is dead inside but says she
does not actually believe this.
Q 1. What is your provisional diagnosis and
differential diagnosis? Justify the reasons for
your answer.
Q 1. What is your provisional diagnosis and differential diagnosis? Justify
the reasons for your answer.
Maria’s clinical picture supporting provisional of Major Depressive Episode:
Depressed mood for 3 weeks
Profound and pervasive Anhedonia
Significant impairment in occupational functioning
Unintentional weight loss
No energy – Fatigue
Suicidal ideation
Diminished ability to concentrate - slowed thinking
Maria’s Risk factors for depression:
Childhood sexual abuse
Alcohol abuse
Age
Gender
Ddx for this case:
Dysthymia, Initial Bipolar II Disorder, Post-traumatic Stress Disorder, substance – induced mood disorder
Common Ddx in general:
Dysthymia, Adjustment disorder with depressed mood, Schizoaffective disorder, Bipolar disorder, ADD/ ADHD,
Bereavement, Substance – induced mood disorder, Mood disorder due to general medical condition/ Tx
Q 2. What further information would you seek
to clarify your diagnosis and management justify each of your answers?
Q 2. What further information would you seek to clarify your diagnosis and
management - justify each of your answers?
• Duration of per cent body weight loss?
• Any sleep disturbance?
• Any particular event or stressor which brought
symptoms on?
• How structured are suicidal thoughts ie.
Plans/ means?
• Recent drug use?
• Previous episode of feeling down?
Q 3. What physical investigations would you
request - justify each of your answers?
Q 3. What physical investigations would you request - justify each of your
answers?
• Neuro exam – investigate for brain neoplasms,
stroke etc
• CVS exam – investigate for anaemia, HF etc
Q 4. Would you raise the issue of Maria's
childhood trauma at this point in the
consultation? Why or why not?
Q 4. Would you raise the issue of Maria's childhood trauma at this point in
the consultation? Why or why not?
• Childhood sexual abuse carries with it a high
risk of developing adult depression
• Pt’s may be hesitant to divulge childhood
abuse unless asked about it directly ‘Were you
every physically, emotionally, or sexually
abused?’
• If pt is extremely distressed due to current
psychiatric symptoms, it may be prudent to
temporarily delay asking about abuse Hx to
avoid worsening the distress
Your patient, Maria, is accepting of a provisional diagnosis of Major
Depression and reports that there was no actual event to cause her
depression. She denies a recent increase in alcohol intake. She then
agrees to treatment with Fluvoxamine 100mg and to return in three
days having guaranteed her safety. You provide her with a medical
certificate to allow her sick leave. The physical investigations are all
normal.
Maria returns for review accompanied by her mother. Maria reports
that nothing has changed. She continues to feel depressed. You
observe that she appears exhausted and her speech is slow. She
reports that she goes to sleep feeling very tired but awakes around
midnight and cannot return to sleep. She continues to report that she
would be better dead but guarantees that she won't kill herself. She
can't articulate what is keeping her going. Her mother says she
appears "spaced out all the time" and has wondered if she is using
drugs (Maria denies this). Her mother also reports that she is not
eating anything. Maria says she is not hungry. You are left feeling very
worried about her but she is refusing to go to the hospital for further
assessment. She agrees to see a private psychiatrist however it will be
ten days before she can get her initial appointment.
Q 5. What treatment options are available at
this time?
Q 5. What treatment options are available at this time?
Biological treatments:
• Antidepressant medication – TCA’s better for depression with melancholic
features and SSRI’s and MAOI’s better for depression with atypical features
• Electroconvulsive Therapy (ECT) – One of the most rapidly effective treatments for
depression, esp for those cases complicated by psychotic or catatonic features,
suicidal ideation, and recurrent episodes or intolerable SE’s from antidepressants.
There are no absolute contraindications to ECT
• Alternative therapies – The best studied is St. John’s wort, which has been shown
effective in the treatment of mild-to-moderate depression
Psychosocial interventions:
• Cognitive behavioural therapy (CBT) – specific styles of habits of thinking and
behaving are identified and systemically challenged using a variety of techniques
• Interpersonal psychotherapy (IPT) – Like CBT but focussed on interpersonal
problems and challenges in the patient’s life
Q 6. Give the reasons for and against the use of
involuntary treatment for hospitalisation?
Q 6. Give the reasons for and against the use of involuntary treatment for
hospitalisation?
• Maria has a mental illness
• Maria’s illness requires immediate treatment
• Maria’s proposed treatment is available at an authorised mental health service
• because of Maria’s illness:
- there is an imminent risk that the person may cause harm to herself or someone else, or
- Maria is likely to suffer serious mental or physical Deterioration there is no less restrictive way of
ensuring she receives appropriate treatment for the illness, and
• Maria:
- lacks the capacity to consent to be treated for the illness, and
- has unreasonably refused proposed treatment for the illness.
Maria meets all the requirements of the Mental Health Act 2000 stipulated to deem a patient
appropriate to be subject to an involuntary treatment order, although she has consented to visit a
private psychiatrist in 10 days. I would feel that 10 days is a long time to wait without extra specialist
support and treatment. It is too risky to take the chance with taking the promise of someone who is
not competent to make good decisions by themselves to present for help in 10 days. If her Mum
promises to support her and regularly check on her you might consent to let her be managed at
home with daily presentations to GP clinic while waiting for psychiatrist review.
Q 7. What things might you do to reduce the
risk of harm befalling Maria?
Q 7. What things might you do to reduce the risk of harm befalling Maria?
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Involve a family member or person close to the patient, if allowed.
– Work with these people also to make sure they are aware of the risk of self harm and suicide
and are willing to stay with Maria at all times
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Ask about the availability of lethal means (eg, firearms, medications) and make
them inaccessible to the patient.
Increase the frequency of contact with the patient; communicate a commitment
to help.
Begin aggressive treatment of psychiatric disorders or substance abuse.
Treatment options may include hospitalization, medication, more frequent
psychological intervention, mobilizing supports, access to crisis intervention
services, and no-suicide contracts.
The level of intervention depends upon the level of suicide risk, available support,
and the ability of the child or adolescent to join with those who seek to keep him
or her safe.
Immediate psychiatric evaluation (through the emergency department or
psychiatry crisis clinic) and/or hospitalization is indicated when there is an
imminent risk of suicide (eg, an active plan or intent without solid support or
psychiatric or psychological intervention already in place to maintain safety)
Referral to a mental health professional is warranted if the risk is not imminent.
However, consideration of the availability of the mental health professional is
important, so as to avoid delays in needed treatment.
You get Maria to come back the next day and she attends
with her mother. You are struck by how depressed Maria
appears. She makes no eye contact. She states that the
world would be better without her because she is so evil.
She states that nothing will help her to get better. She
complains of the repugnant smell coming from her body
and believes her organs are rotting. She also reports
that her father was very upset because his mother had
acted like this periodically and received ECT for these
episodes many years ago. Maria's mother reports that
they had hidden tablets at home because Maria had
started telling them that she was already dead. Maria
has also stopped eating and drinking and clinically she is
mildly dehydrated.
Q 8. What is the likely diagnosis and what
symptoms have made this diagnosis more
probable?
Q 8. What is the likely diagnosis and what symptoms have made this
diagnosis more probable?
Major depression with psychotic features
• Maria exhibits features of Major Depression, as
this was her provisional diagnosis earlier.
• She now also has developed acute psychotic
symptoms as exhibited by her negative and
self-critical thoughts regarding her evil soul and
her body undergoing decomposition and also
experiencing olfactory hallucinations of this
rotting odour.
• These thoughts and hallucinations make a
diagnosis of Major Depression with psychotic
features (Psychotic Depression) more likely.
Q 9. How are you going to manage this
situation in your general practice?
Q 9. How are you going to manage this situation in your general practice?
Maria exhibits features that indicate referral to a mental
health team or psychiatric specialist:
• severe depression that is endangering her life
• psychotic depression
Maria may be treated using psychological and
pharmacological therapies (both antidepressants and
antipsychotics), although in her case ECT should be
seriously considered as a form of treatment as it is shown
to be a highly effective, well tolerated and safe treatment
for depressive disorders where melancholic or somatic
features are present, and/or psychosis is present.
ECT is effective in more than 90% of patients suffering
from severe melancholic depression or psychotic
depression.
After some discussion that goes around in circles, you
decide to call an ambulance and ask Maria's mother and
your receptionist to supervise Maria. She is taken to
hospital where the staff advise you of her progress. She
continues to express the belief that she is dead, rotting
inside. She refuses to eat, drink, wash or bathe. She is
seen by two psychiatrists and she is treated as an
involuntary patient under the mental health act. The plan
is for her to receive ECT. You then are met by Maria's
father who is very angry that you sent her to hospital. He
is very worried Maria will receive ECT and wants to know
more about it. He states her mother was never the same
after receiving ECT and he remembers her often having
bruising from being held during the treatment.
Q 10. What information can you provide to the
father about ECT?
Q 10. What information can you provide to the father about ECT?
Q 11. How has the treatment changed from 40
years ago?
Q 11. How has the treatment changed from 40 years ago?
Maria returns to see you one month later having
been diagnosed with Major Depressive Disorder
with Psychotic Features. Her current medication
is venlafaxine XR 225mg Mane and risperidone
2mg Nocte. She is euthymic and has little
recollection of the events that lead to her
hospitalisation. She wants to know how long she
needs to remain on the medication and the
possible side effects it might cause her.
Q 12.What advice will you give Maria
regarding side effects of the antidepressant
and the atypical antipsychotics such as
risperidone?
Q 12.What advice will you give Maria regarding side effects of the
antidepressant and the atypical antipsychotics such as risperidone?
All medication have side effects, some of the side effects are useful but some can be unpleasant –
but most of the time they are worth putting up with for the benefit they give. Risperidone can be
associated with weight gain, which might be useful in your case, but can be managed with an
exercise and diet program which should be part of your treatment anyway. Risperidone can also
make you drowsy, so taking your dose at night may negate this side effect and allow a better nights
sleep anyway. So you shouldn’t drive while you feel you are under the drowsy effects of the
medication. Side effects like involuntary movements, movement difficulty and increased saliva that
some people experience can be managed by other medications, but most people don’t get them. If
you ever experience muscle spasms and increasing muscle tremors or fever then tell your doctor
immediately.
Venlafaxine also has side effects, including Nausea, insomnia/ drowsiness, dry mouth and
constipation. Regular checkups on your blood pressure will need to be done to make sure it doesn’t
change to much. While the medication is starting to work in your system you may have increased
negative thoughts about your future life – if you do please promise to tell a doctor or psychologist/
mental health worker. If you start having palpitations, profuse sweating with increased nausea,
vomiting or diarrhea… or if you just don’t feel right in yourself for any reason, contact a doctor
immeadiately.
Q 13. What physical examination and
investigations will you do at base line and
follow up for a patient on atypical
antipsychotics?
Q 13. What physical examination and investigations will you do at base line
and follow up for a patient on atypical antipsychotics?
Before starting any antipsychotic drug ECG and
cardiovascular physical examination should be
undertaken to identify any specific
cardiovascular risk, if the patient has a history of
cardiovascular disease or a family history of long
QT syndrome, especially if antipsychotic is
known to prolong QT. Aggranulocytosis and
heart failure due to cardiomyopathy is also
potential but rare risk with some antipsychotic
use. Concurrent anaemia and immune status
should be identified too.
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ECG  recommended at baseline; also monitor ECG if there are risk factors
– Major risk factors: IHD, LVH, congenital long QTc syndromes, family Hx of early cardiac death, prior QTc
prolongation or Torsades de Pointes
– Always monitor for signs of arrhythmia (SOB, presyncope, LOC, palpitations)
Fasting blood glucose  increased DM in schizophrenia (causality/risk uncertain)
– When changing/starting medication and also every 3-6 months
– If diagnosed with DM: monitor glycosylated Hb every 3-6 mths (glycaemic control)
FBC  monitor for neutropenia
– Every 3-6 mths; stop medication and consult haematologist if < 1.5 x 10^9/L
BP  monitor during dose titration
U&Es  if RF for arrhythmia, monitor 6 monthly
LFTs  if signs/symptoms of hepatic damage and/or Pt has pre-existing conditions
BMI and waist/hip ratio  check at least every 3 months (r/v treatment if BMI>30 or waist/hip ratio is >1.0 in
males or >0.8 in females)
Neuroleptic malignant syndrome  monitor for muscle rigidity, fever, autonomic instability (esp diaphoresis,
unstable BP), cognitive changes, elevated creatine phosphokinase
– Muscular symptoms due to D2-blockage
Amisulpride, olanzapine, risperidone: monitor plasma prolactin level
Quetiapine: thyroid function test (baseline and at one month)
Clozapine: clozapine monitoring system
– Obligatory: FBC
– Additional: ECG and troponin I  small inc risk of myocarditis and cardiomyopathy
Q 14. How long will Maria need to stay on
these medications?
Q 14. How long will Maria need to stay on these medications?
• The NHMRC website has the antipsychotic therapy guidelines
put out by the Western Australia Therapeutics Advisory Group
– “Treatment should be continued for at least 12 months,
then if the disease has remitted fully, may be ceased
gradually over at least 1-2 months.”
• RACGP guidelines on antidepressants: “Antidepressants
should be continued for at least four months beyond initial
recovery or improvement after a single episode of major
depression to prevent a relapse within this period.” “Patients
receiving higher doses, those with a previous history of
discontinuation symptoms and those who develop withdrawal
symptoms and those who develop withdrawal symptoms
when the antidepressant is ceased, may require tapering over
4-7 days, or longer, if discontinuation symptoms are severe.”
Q 15. During one of her appointments, Maria
asks if the abuse she experienced in childhood
is the cause of her psychotic depression? What
is the association between the childhood
trauma that Maria experienced and her
psychotic depression?
Q 15. During one of her appointments, Maria asks if the abuse she
experienced in childhood is the cause of her psychotic depression? What is
the association between the childhood trauma that Maria experienced and
her psychotic depression?
• Childhood trauma = risk factor for adulthood depression, esp
with additional stress
– Childhood trauma  sensitization of the neuroendocrine
stress response, glucocorticoid resistance, increased
central corticotropin-releasing factor (CRF) activity,
immune activation, and reduced hippocampal volume 
close parallel of the neuroendocrine features of
depression
– But not all depression is related to childhood trauma and
there are biologically distinguishable subtypes of
depression due to childhood trauma