Transcript Psychiatry Case Conference 1

Psychiatry
Case Conference 1
III-B
Cueto, Mary Anne – Diaz, Mark Fernan
General Data
L.M.P
35 y/o
married
Born Again Christian
2nd in a brood of 3
BS Nursing Graduate
unemployed
born & raised in Capiz
admitted 1st time on April 4, 2005
Infomants: Patient: 75%
Husband: 85%
Sister: 85%
Chief Complaint: insomnia, delusion of reference
 According to patient: “ Pinaghihiwalay ang family namin
ng ministry.”
According to husband: “ Hindi makatulog, minsan nagbabasa
ng bible mag-isa”
“ Feeling nya pinagtutulungan siya ng
ministry”
Personality Profile:
Pre-morbid personality: “masinop, masayahin, sensitive”
Morbid personality: “tahimik, kung anu anong sinasabi”
 History of Present Illness
2001
* very active, sings in the choir
2004
* negative feelings towards members and ministry
December
2005
January
2005
February
2005
1st wk March
* persistent negative feelings towards members and
ministry, delusion of reference
* auditory hallucination, loss of appetite, reduced
sleep, negative feeling towards her husband
* auditory hallucination, odd behavior, blank stares
anxious
 History of Present Illness
2005
* quiet, unresponsive
3rd wk March
2005
* verbal aggression, delusion of reference
March 25
2005
March 26
2005
March 27
2005
March 31
* felt guilty of what she said to the members,
delusion of persecution
* neglected her chores and children, delusion
of persecution/anxiety
* singing songs, speaking incomprehensible words
 History of Present Illness
2005
April 1
* suspicious w/her surroundings
* brought to Las Pinas Doctors Hospital
* injected w/unrecalled medication
* admitted @ USTH while sedated
Review of Systems
(-) Headache, loss of consciousness, convulsions
(-) fever
(+) anorexia , weight loss
 (+) HPN – mother
 (+) stroke – mother
 (+) heart disease, PUD – father
 (+) alcohol dependence – father
 (?) nervous breakdown – great grandmother
 Non-smoker
 Non-alcoholic beverage drinker
 Denies use of any prohibited drugs
 Born to 23 y/o G2P1 (1001); NSD at home
 By traditional birth attendant
 No prenatal or postnatal complications
 Neuro-developmental milestones at par with age

Lived with parents and three siblings

Family owns a small grocery store

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

Patient grew-up closer to her father and siblings
 Primary education at Malubog-lubog Elementary
School in Capiz
 Average student and had very few friends
 6th grade - father died which caused extreme sadness
and felt that a big part of her was lost with the passing
 Left in the care of the eldest sibling (Gina)
 Gina confided of being overprotective of her younger
siblings
 Family Relationship
 after father’s death, mother married a policeman
 Siblings were against the marriage at first
 Patient felt that the mother betrayed her father
 According to the patient, she had a harmonious
relationship with stepfather and stepsiblings
 Stepfather did not impose himself on the stepchildren
 was kind and approachable and was readily approachable
when they need him
 Social Relationships
 Claimed to have a number of friends
 stayed at home on weekends because mother would not allow
her to go out with friends
 School History
 Attended high school in FLAIMER Christian Institute in
Capiz
 Wanted to take up AB Philosophy
 forced by mother to take up BS Nursing
 Graduated on time
 Academic Achievement
 failed Nursing Board Exams (1990)
 failure due to “poor preparation”
 Worked as an assistant nurse in a small clinic
while waiting for the next board exams
 took the boards in Manila and passed with high marks
(1992)
 Did not work at once because she was waiting for her
petition from her maternal aunt to work in Germany
 After some time worked as a ticketing supervisor at Ever
Gotesco Cinema
 Resigned after 2 months, thinking she was not ready to
work yet
 Learned that her petition was declined
 1993 - nurse in Capiz and resigned after 6 months
 Felt bad in an incident when a patient deteriorated
infront of her
 According to sister:
 Patient was pious and hardworking
 Gave portion of salary to patients
 1994- went back to Manila and stayed with sister
 Meaningful Long-term Relationship
 met Norman and married him after two years (1996)
- Stayed with husband’s family (Cavite)
 After a few months, husband flew to Abu Dhabi
 Patient got pregnant and went back to Capiz

Had difficult pregnancy
- 1997 – CSD with her 1st child (Paul Christian)
 1998 – went to Abu Dhabi with husband and had no
difficulty in adjusting
 Worked as sales clerk in a pharmacy
 December 1999 – decided to return to Philippines due
to 2nd pregnancy
 2000 – gave birth to second child (Patricia Lois)
 Stayed with her mother, who sometimes helped out
with her grandchildren
 Longed for her husband
 2001 – returned to UAE with her children because of
argument with mother
 Was baptized to a ALL Nations FULL GOSPEL, a
Born Again Christian group
 Planned to work as a nurse however got pregnant with
her 3rd child
 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
 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
Cesar
Minerva
58
199
6
Gina
L
35
4
Norman
LEGEN
D Heart attack
Stroke
Paul
Patricia
Christian Lois
12
9
8
PUD
HPN
 Cesar- father
 Died of “heart attack” at 45
 An elementary graduate
 Came from a well off family in Capiz
 Alcoholic since 20 y/o

Drank gin (? amount) almost everyday usually alone or with
friends
 Patient regards him as loving and kind father
 Patient claims she got her talent from him

He usually sang with her
SALIENT FEATURES
 35 y/o
 Female
 Born again Christian
 Unemployed
 Preoccupation with at least 2 delusions (JanMarch2005)
 Auditory hallucination
 Aggressive/agitated behavior (March 2005)
 Avolition-apathy (3rd wk & 27 Mar)
SALIENT FEATURES
 Incomprehensible speech
 Impaired social functioning
 Physiologic disturbance: anorexia and insomnia
 Family history: great grandmother had nervous
breakdown
 Non-smoker, non-alcoholic, denies use of prohibited
drugs
 Poor relation with mother
DIFFERENTIAL
DIAGNOSIS
 Major Depressive Disorder
 Bipolar Disorder
 Schizophrenia
DSM-IV-TR Diagnostic
Criteria for Major
Depressive Episode
A. FIVE (OR MORE) OF THE FOLLOWING SYMPTOMS HAVE BEEN PRESENT DURING THE
SAME 2-WEEK PERIOD AND REPRESENT A CHANGE FROM PREVIOUS FUNCTIONING; AT
LEAST ONE OF THE SYMPTOMS IS EITHER (1) DEPRESSED MOOD OR (2) LOSS OF INTEREST
OR PLEASURE.
NOTE: DO NOT INCLUDE SYMPTOMS THAT ARE CLEARLY DUE TO A GENERAL MEDICAL
CONDITION, OR MOOD-INCONGRUENT DELUSIONS OR HALLUCINATIONS.
1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g.,
feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and
adolescents, can be irritable mood.
2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every
day (as indicated by either subjective account or observation made by others)
3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body
weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider
failure to make expected weight gains.
4. insomnia or hypersomnia nearly every day
5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective
feelings of restlessness or being slowed down)
6. fatigue or loss of energy nearly every day
7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every
day (not merely self-reproach or guilt about being sick)
8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective
account or as observed by others)
9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan,
or a suicide attempt or a specific plan for committing suicide
B. THE SYMPTOMS DO NOT MEET CRITERIA FOR A MIXED EPISODE.
C. THE SYMPTOMS CAUSE CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN SOCIAL,
OCCUPATIONAL, OR OTHER IMPORTANT AREAS OF FUNCTIONING.
D. THE SYMPTOMS ARE NOT DUE TO THE DIRECT PHYSIOLOGICAL EFFECTS OF A
SUBSTANCE (E.G., A DRUG OF ABUSE, A MEDICATION) OR A GENERAL MEDICAL CONDITION
(E.G., HYPOTHYROIDISM).
E. THE SYMPTOMS ARE NOT BETTER ACCOUNTED FOR BY BEREAVEMENT, I.E., AFTER THE
LOSS OF A LOVED ONE, THE SYMPTOMS PERSIST FOR LONGER THAN 2 MONTHS OR ARE
CHARACTERIZED BY MARKED FUNCTIONAL IMPAIRMENT, MORBID PREOCCUPATION WITH
WORTHLESSNESS, SUICIDAL IDEATION, PSYCHOTIC SYMPTOMS, OR PSYCHOMOTOR
RETARDATION.
DSM-IV-TR Diagnostic
Criteria for Manic Episode
A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at
least 1 week (or any duration if hospitalization is necessary).
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) and have been present to a significant degree:
inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The symptoms do not meet criteria for a Mixed Episode.
D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning
or in usual social activities or relationships with others, or to necessitate hospitalization to prevent
harm to self or others, or there are psychotic features.
E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse,
a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).
DSM-IV-TR Diagnostic
Criteria for Hypomanic
Episode
A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4
days, that is clearly different from the usual nondepressed mood.
B. During the period of mood disturbance, three (or more) of the following symptoms have persisted
(four if the mood is only irritable) and have been present to a significant degree:
1. inflated self-esteem or grandiosity
2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)
3. more talkative than usual or pressure to keep talking
4. flight of ideas or subjective experience that thoughts are racing
5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)
6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor
agitation
7. excessive involvement in pleasurable activities that have a high potential for painful consequences
(e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)
C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the
person when not symptomatic.
D. The disturbance in mood and the change in functioning are observable by others.
E. The episode is not severe enough to cause marked impairment in social or occupational
functioning, or to necessitate hospitalization, and there are no psychotic features.
F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a
medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).
DSM-IV-TR Diagnostic Criteria
for Schizophrenia
A. CHARACTERISTIC SYMPTOMS: TWO OR MORE OF THE FOLLOWING, EACH PRESENT FOR
A SIGNIFICANT PORTION OF TIME DURING A ONE-MONTH PERIOD (OR LESS IF SUCCESFULLY
TREATED)
1. Delusions
2. Hallucinations
3. Disorganized Speech
4. Grossly Disorganized or Catatonic Behavior
5. Negative Symptoms
B. SOCIAL/OCCUPATIONAL DYSFUNCTION
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 DISORDER EXCLUSION
E. SUBSTANCE/ GENERAL MEDICAL CONDITION EXCLUSION
F. RELATIONSHIP TO A PERVASIVE DISORDER
DSM-IV-TR Diagnostic Criteria
for Schizophrenia Subtypes
PARANOID TYPE
A.PREOCCUPATION WITH ONE OR MORE DELUSIONS OR FRQUENT HALLUCINATIONS
B. NO DISORGANIZED SPEECH, DISORGANIZED OR CATATONIC BEHAVIOR, FLAT OR
INAPPROPRIATE AFFECT
DISORGANIZED TYPE
A. ALL OF THE FOLLOWING ARE PROMINENT:
1. Disorganized Speech
2. Disorganized Behavior
3. Flat or Inappropriate Affect
B. THE CRITERIA ARE NOT MET FOR CATATONIC TYPE
CATATONIC TYPE
A type of schizophrenia in which the clinical picture is dominated by at least two of the following:
1. Motoric immobility as evidenced by catalepsy or stupor
2. Excessive motor activity
3. Extreme negativism
4. Peculiarities of voluntary movement as evidenced by posturing, stereotypied movements, prominent
mannerisms, prominent grimacing
5. Echolalia or echopraxia
UNDIFFERENTIATED TYPE
A type of schizophrenia in which symptoms meet Criterion A present, but the criteria are not met for the
paranoid, disorganized, or catatonic type
RESIDUAL TYPE
A.Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized
speech and grossly disorganized, or catatonic behavior
B. There is continuing evidence of the disturbance, as indicated by the presence of negative
symptoms listed in Criterion A for schizophrenia present in attenuated from