Transcript schizophrenia and other psychotic disorders

SCHIZOPHRENIA AND OTHER
PSYCHOTIC DISORDERS
Presented By
Paula Green
Monica Lindsey-Drayton
James E. Monroe III
Case Presentation
THE LUMBERMAN
A Norwegian lumberman was admitted to the psychiatric ward of a hospital shortly after
starting his required military duty at the age of 20. During the first week after his arrival at
the military base, he thought the other recruits looked at him in a strange way. He watched
the people around him in order to see whether they were out “to get” him. He heard voices
calling his name several times. He became increasingly suspicious and after another week
had to be admitted to the Psychiatric Department at the University of Oslo. There he was
guarded, scowling, skeptical, and depressed. He gave the impression of being very shy and
inhibited. His psychotic symptoms disappeared rapidly when he was treated with an
antipsychotic drug. However, he had difficulties in adjusting to hospital life. Transfer to a
long-term mental hospital was considered; but after 3 months, a decision was made to
discharge him to his home in the forest. He was subsequently judged unfit to return to
military service and was struck from the military lists.
The patient, the eldest of five siblings, was the son of a farm laborer in one of the
valleys of Norway. His father was an intemperate drinker who became angry and brutal when
drunk. The family was very poor, and there were constant quarrels between the parents. As a
child, the patient was inhibited and fearful and often ran into the woods when troubled. He
had academic difficulties and barely passed elementary school.
When the patient became older, he preferred to spend most of his time in the woods,
where he worked as a lumberman from the age of 15. He had his own horse, lived in a log
cabin, and disliked being with people. He sometimes took part in the your dances in the
village. Although never a heavy drinker, he often got into fights in the village when he had a
drink or two. At the age of 16, he began to keep company with a girl1 year his junior who
sometimes kept house for him in the woods. They eventually became engaged.
SEX PROBLEM
Ms. B. is a 43-year-old housewife who entered the hospital in 1968 with a chief
complaining of being concerned about “her “sex problem”; she stated that she need
hypnotism to find out what was wrong with her sexual drive. Her husband supplied
the history: he complained that she had had many extramarital affairs, with many
different men, all through their married life. He insisted that in one 2-week period
she had had as many as a hundred different sexual experiences with men outside the
marriage. The patient herself agreed with this assessment of her behavior, but
would not speak of the experiences, saying that she “blocks” the memories out.
She denied any particular interest in sexuality, but said that apparently she felt a
compulsive drive to go out and seek sexual activity despite her lack of interest.
The patient had been married to her husband for over 20 years. He was
clearly the dominant partner in the marriage. The patient was fearful of his
frequent jealous rages, and apparently it was he who suggested that she
enter the hospital in order to receive hypnosis. The patient maintained that
she could not explain why she sought out other men, that she really did not
want to do this. Her husband stated that on occasion he had tracked her
down, and when he had found her, she acted as if she did not know him.
She confirmed this and believed it was because the episodes of her sexual
promiscuity were blotted out by “amnesia.”
When the physician indicated that he questioned the reality of the
wife’s sexual adventures, the husband became furious and accused the
doctor and a ward attendant of having sexual relations with her.
Neither an amytal interview nor considerable psychotherapy with Ms.
B. was able to clear the “blocked out” memory of periods of sexual
relationships in the past: one 20 years before the time of admission and the
other just a year before admission. She stated that the last one had actually
been planned by her husband and that he was in the same house at the time.
She continued to believe that she had actually had countless extramarital
sexual experiences, though she remembered only two of them.
Please use the Multiaxial
Evaluation Report form to
record your diagnosis.
Multiaxial Evaluation Report Form
AXIS I:
Clinical Disorders
Other Conditions That May Be Focus of Clinical Attention
Diagnostic code
__ __ __.__ __
DSM-IV name
____________________________________
__ __ __.__ __
____________________________________
__ __ __.__ __
____________________________________
AXIS II:
Personality Disorders
Mental Retardation
Diagnostic code
__ __ __.__ __
DSM-IV name
____________________________________
__ __ __.__ __
____________________________________
AXIS III
General Medical Conditions
ICD-9-CM code
ICD-9-CM name
__ __ __.__ __
____________________________________
__ __ __.__ __
____________________________________
__ __ __.__ __
____________________________________
AXIS IV:
Psychosocial and Environmental Problems
Check:
‘Problems with primary support group Specify:___________________________________
‘Problems related to the social environment Specify:______________________________
‘Educational problems Specify:_______________________________________________
‘Occupational problems Specify:______________________________________________
‘Housing problems Specify:__________________________________________________
‘Economic problems Specify:_________________________________________________
‘Problems with access to health care services Specify:_____________________________
‘Problems related to interaction with the legal system/crime Specify:__________________
‘Other psychosocial and environmental problems Specify:__________________________
AXIS V:
Global Assessment of Functioning Scale
Score:____ ____ ____
Time frame:
Multiaxial Evaluation Report Form
Case Study 1
AXIS I:
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Clinical Disorders
Other Conditions That May Be Focus of Clinical Attention
Diagnostic code
2 9 8. 8 0
3 0 5.0 0
__ __ __.__ __
AXIS II:
DSM-IV name
Brief Psychotic Disorder
Alcohol Abuse
____________________________________
Personality Disorders
Mental Retardation
•
Diagnostic code
DSM-IV name
•
__ __ __.__ __
____________________________________
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7 9 9.9 0
AXIS III
General Medical Conditions
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ICD-9-CM code
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•
__ __ __.__ __
information
__ __ __.__ __
____________________________________
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__ __ __.__ __
____________________________________
AXIS IV:
ICD-9-CM name
Diagnosis is deferred, pending the gather- ing of additional
Psychosocial and Environmental Problems
heck:
‘Problems with primary support group Specify:
‘Problems related to the social environment Specify: Dislike being around people
‘Educational problems Specify: Poor grades during school
‘Occupational problems Specify:______________________________________________
‘Housing problems Specify:__________________________________________________
‘Economic problems Specify:_________________________________________________
‘Problems with access to health care services Specify:_____________________________
‘Problems related to interaction with the legal system/crime Specify:__________________
‘Other psychosocial and environmental problems Specify:__________________________
AXIS V:
Score: 64
Time frame:
Diagnosis Deferred on Axis II
Global Assessment of Functioning Scale
Discussion
The Norwegian psychiatrist who provided this case made the
Scandinavian diagnosis of Reactive Psychosis, Paranoid Type. The
patient displays the typical features of the disorder: reaction to
extreme stress that exacerbates underlying psychological conflicts,
in which the prognosis for full recovery is very good. In order to
label a psychosis reactive, the psychic trauma must be considered of
such significance that the psychosis would not have appeared in its
absence. There must be a temporal connection between the
trauma and the onset of the psychosis, and the content of the
psychotic symptoms must reflect traumatic experience. In this case,
for an extremely shy and isolated man, military service was a much
more serious stressor than for an ordinary person of the same age.
According to the DSM-IV-TR, the differential diagnosis would be
between Delusional Disorder and Brief Psychotic Disorder requires a
duration of at least 1 month, and this patient apparently recovered
fro his psychotic symptoms within a few weeks. Therefore, our
diagnosis would be Brief Psychotic Disorder (DSM-IV-TR, p. 332),
since this diagnosis applies to psychotic illnesses of at least 1 day
but not more than 1 month, with eventual full return to premorbid
functioning, as in this case. The importance of the stressor could be
indicated on Axis IV.
Multiaxial Evaluation Report Form
Case Study 2
AXIS I:
Clinical Disorders
Other Conditions That May Be Focus of Clinical Attention
–
Diagnostic code
2 9 7.3 0
__ __.__ __
__ __ __.__ __
AXIS II:
DSM-IV name
Shared Psychotic Disorder (Folie a Deux)
____________________________________
____________________________________
Personality Disorders
Mental Retardation
Diagnostic code
7 9 9.9 0
__ __ __.__ __
–
AXIS III
•
AXIS IV:
DSM-IV name
Diagnosis Deferred on Axis II
____________________________________
General Medical Conditions
ICD-9-CM code
ICD-9-CM name
__ __ __.__ __
information
__ __ __.__ __
____________________________________
__ __ __.__ __
____________________________________
Diagnosis is deferred, pending the gather- ing of additional
Psychosocial and Environmental Problems
Check:
‘Problems with primary support group Specify:
Marital problems with husband
‘Problems related to the social environment Specify:______________________________
‘Educational problems Specify:_______________________________________________
‘Occupational problems Specify:______________________________________________
‘Housing problems Specify:__________________________________________________
‘Economic problems Specify:_________________________________________________
‘Problems with access to health care services Specify:_____________________________
‘Problems related to interaction with the legal system/crime Specify:__________________
‘Other psychosocial and environmental problems Specify:__________________________
AXIS V:
Score: 58
Time frame:
Global Assessment of Functioning Scale
Discussion
One’s first impression is that an amnesic syndrome should be
considered, either dissociative or resulting from a general medical
condition or substance use. However, the plot thickens as evidence
accumulates that the husband, the chief informant, has delusional
jealousy, believing that his wife is repeatedly unfaithful to him.
Apparently under his influence, his wife has accepted this delusional
belief, explaining her lack of memory of the events by believing that
she has “amnesia.” It would seem that she has adopted his
delusional system and does not really have any kind of “amnesia.”
Before the onset of the delusions, there was no indication of any
prodromal symptoms of Schizophrenia. Because her delusional
system developed as a result of a close relationship with another
person who had an already established delusion (i.e., her husband)
And because her delusions are similar in content to his delusions, the
diagnosis is Shared Psychotic Disorder (DSM-IV-TR, p. 334),
traditionally known as folie a deux. An interesting twist to this case
is that it is the patient who, by virtue of her alleged extramarital
activity, is the source of the husband’s distress. It is more common
in a Shared Psychotic Disorder for the person who has adopted the
other’s delusional system to believe that he or she is also being
harmed.
Please go to the treatment plan.
You have 5 minutes to develop a
plan for Case Study 1
Treatment Plan
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CLIENT NAME:_______________________________________________________________________
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SITE/PROGRAM________________________________________DATE OF PLAN:_______________
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Issues for consideration are family, legal, health (mental or physical), attitude, appearance, substance abuse. housing, education, employment. Treatment plan must be
developed with the client and fully explained to them.
CLINICAL ISSUE#1:
Identified by:__________________
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Extent of issue:
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Goals/Objectives and projected dates of accomplishment:
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Interventions:
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Referrals/Linkages made to address issue: (Give specific names &dates)
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CLINICAL ISSUE#2:
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Extent of issue:
•
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Goals/Objectives and projected dates of accomplishment:
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Interventions:
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Referrals/Linkages made to address issue: (Give specific names &dates)
REVIEW:______________
DATE OF NEXT
Identified by:_________________
–
CLINICAL ISSUE#3:
by:__________________
Identified
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Extent of issue:
•
Goals/Objectives and projected dates of accomplishment:
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Interventions:
•
Referrals/Linkages made to address issue: (Give specific names &dates)
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CLINICAL ISSUE#4:
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Extent of issue:
•
Goals/Objectives and projected dates of accomplishment:
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Interventions:
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Referrals/Linkages made to address issue: (Give specific names &dates)
Identified by:__________________
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As a resident participating in this program you are required to meet with your primary case manager at least ______per week to review your progress
in reaching the goals you have established in this treatment plan.
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Client Signature______________________________________Date______________________
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Client Signature________________________________Date______________________
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Primary case manager Signature___________________
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A COPY MUST BE MAINTAINED IN THE FILE AND ONE COPY GIVEN TO CLIENT
REVISED 1/01
Date______________________
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Treatment Plan
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CLIENT NAME:
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SITE/PROGRAM________________________________________DATE OF PLAN:_______________
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Issues for consideration are family, legal, health (mental or physical), attitude, appearance, substance abuse. housing, education, employment.
Treatment plan must be developed with the client and fully explained to them.
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Case 1
DATE OF NEXT
REVIEW:______________
CLINICAL ISSUE#1:
Extent of issue:
Bizarre content of thought (delusions persecution)
Identified by:
Jem
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Goals/Objectives and projected dates of accomplishment:
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1. Control or eliminate active psychotic symptoms such that supervised functioning is positive
and medication is taken consistently.
2. Significantly reduced or eliminate hallucinations and/or delusions.
3. Eliminate acute, reactive, psychotic symptoms and return to normal function in affect,
thinking, and relating.
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Objectives:
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1. Describe the type and history of the psychotic symptoms
2. Understand the necessity for taking antipsychotic medications and agree to cooperate with prescribed care.
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Interventions:
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1a.
1b.
1c.
2a.
2b.
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Referrals/Linkages made to address issue: (Give specific names &dates)
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Patient, Counselor, Therapist, Physician
Demonstrate acceptance through calm, nurturing manner, good eye contact, and active listening.
Assess pervasiveness of thought disorder through clinical interview and/or psychological testing.
Determine if psychosis is of a brief reactive nature or long term with progromal and reactive elements.
Arrange for administration of appropriate psychotropic medications through a physician.
Monitor patient for medication compliance and redirect if patient is noncompliant.
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CLINICAL ISSUE#2:
Extent of issue:
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Alcohol Abuse
Continued substance use despite persistent physical, social, or relationship problems that are
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Goals/Objectives and projected dates of accomplishment:
1. Improve quality of life by maintaining abstinence from all mood altering chemicals.
2. Establish and maintain total abstinence while increasing know3ledge of the disease and the
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Objectives:
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1. Cooperate with medical assessment and an evaluation of the necessity for pharmacological intervention.
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2. Attend didactic sessions and read assigned material to increase knowledge of addiction and the process of recovery.
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Interventions:
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1a. Physician will perform a physical exam and write treatment orders, including, if necessary, prescription of medications.
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1b. Physician will monitor the side effects and effectiveness of medication, titrating as necessary.
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2a. Have the patient attend a chemical dependence didactic series to increase knowledge of the patterns and effects of chemical dependence.
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2b. Require the patient to attend all chemical dependence didactic; ask him to identify several key points learned from each didactic, and process these points with the therapist.
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Referrals/Linkages made to address issue: (Give specific names &dates)
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Patient, Counselor, Therapist, Physician
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CLINICAL ISSUE#3:
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Extent of issue:
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Goals/Objectives and projected dates of accomplishment:
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Referrals/Linkages made to address issue: (Give specific names &dates)
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CLINICAL ISSUE#4:
Identified by:
Jem
directly caused by the substance use.
recovery process.
Identified by:__________________
Identified by:__________________
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Extent of issue:
•
Goals/Objectives and projected dates of accomplishment:
•
Referrals/Linkages made to address issue: (Give specific names &dates)
•
•
As a resident participating in this program you are required to meet with your primary case manager at least ______per week to
review your progress in reaching the goals you have established in this treatment plan.
•
Client Signature______________________________________Date______________________
•
Client Signature________________________________Date______________________
•
Primary case manager Signature___________________ Date______________________
•
A COPY MUST BE MAINTAINED IN THE FILE AND ONE COPY GIVEN TO CLIENT
REVISED 1/01
THE BEGINING