Transcript Case 1 Week 21 Schizophrenia

PC
-Maria, 20 yo female
- Presents with low mood
HPC
-Low mood for past 3 weeks
- no energy, profound and pervasive anhedonia
- slow thinking
- missed appointment with customers  received warning at work
- overwhelming sense that something bad is about to happen but
can’t identify
- lost 4 kg unintentionally
-Lying awake at night  thinking how pointless her life is
-Has suicidal ideation but no plan (thought would hurt her family
too much)
-Feels dead inside, but not actually believe this
Past Medical Hx & Surgical Hx
-Nil sometimes presented with multiple physical complaints but
always been fit and healthy
-Past Psychiatric Hx
-Anxiety & difficulties coping with work and relationships
-Alcohol abuse in the past
- Eating disorder (binging and purging)
-Received in the past supportive counselling due to childhood
sexual abuse
Medication
Nil
Allergies
Nil
Substance Abuse
-EtOH abuse in the past
- Smoking?
-Illicit drugs?
Personal and social Hx
-Occ: Sales rep
- Living at home with parents
-Abused sexually when 12 yrs old at her friend’s house during sleep
over
Family Hx of Med and Psych
Nil
Questions:
Q 1. What is your provisional diagnosis and differential
diagnosis? Justify the reasons for your answer.
Q 2. What further information would you seek to clarify your
diagnosis and management - justify each of your answers?
Q 3. What physical investigations would you request - justify each
of your answers?
Q 4. Would you raise the issue of Maria's childhood trauma at this
point in the consultation? Why or why not?
Trigger 2:
-Dx with Major Depression  treated with Fluvoxamine 100 mg
and to return in 3 days
- When returned: MSE – ASEPTIC
Appearance
Exhausted
Speech
Slow
Emotion (Mood & affect)
Low  feels better dead
Perception
Nil hallucination and illusion
Thought content & process
? Is spacing out a form of thought disorder??
Insight & Judgement
Won’t kill herself but can’t articulate why
Cognition
Trigger 2...:
Other
-Not eating anything
- Refusing to go to hospital but agree to see private psychiatrist
Questions
Q 5. What treatment options are available at this time?
Q 6. Give the reasons for and against the use of involuntary
treatment for hospitalisation?
Q 7. What things might you do to reduce the risk of harm
befalling Maria?
Trigger 2...:
Maria returned the next day
Appearance & Behaviour
Nil eye contact
Speech
Emotion
Perception
-Complains of repugnant smell coming from her body and believes
her organs are rotting
Thought
-believes she is already dead
-Believes world would be better without her as she is so evil
Insight & Judgment
Cognition
Other
Family Hx: Mother actually had these episodes many yrs ago  ECT
Not eating and drinking  mildly dehydrated
Q 8. What is the likely diagnosis and what symptoms have made
this diagnosis more probable?
Q 9. How are you going to manage this situation in your general
practice?
Trigger 3
-BIBA to hospital
-Continues to express that she is dead and rotting inside
-Refuses to eat, drink, wash or bathe
-Treated as involuntary pt under MHA
-Plan: ECT  father angry as mother was never the same after
receiving ECT and mother had bruising from being held
Q 10. What information can you provide to the father about
ECT?
Q 11. How has the treatment changed from 40 years ago?
Trigger 3...
-Returned 1 month later to see you
-Dx with MDD with Psychotic Features
-Medication: Venlafaxine XR 225 mg Mane and Risperidone 2 mg
Nocte
-Euthymic & little recollection of events prior to hospitalisation
Q 12.What advice will you give Maria regarding side effects of
the antidepressant and the atypical antipsychotics such as
risperidone?
Q 13. What physical examination and investigations will you do
at base line and follow up for a patient on atypical
antipsychotics?
Q 14. How long will Maria need to stay on these medications?
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?
Would you raise the issue of Maria's childhood
trauma at this point in the consultation? Why
or
why
not?
 There’s conflicting advice amongst the literature as to when it’s
best to address the issue of sexual assault.
 Whilst some say that it is necessary to address the issue of sexual
assault regardless of whether it’s the underlying cause of
emotional distress, others suggest a more tactful approach –
addressing the issue initially only if it is the underlying cause of
the emotional distress but the practitioner may wish to address
the issue at a later time point once the patient is less distressed.
 Personally, I feel that the second approach would possibly be
better in this scenario.
 However, if Maria brought up the issue, then I think it should be
addressed
 Alternatively, however, it’s perhaps possible to address the issue
with Maria by asking whether she’s still partaking in supportive
counselling of any form.
What treatment options are available at this
time?
 Antidepressants are more effective for moderate to severe depression,
although concurrent psychological therapies may often be helpful.
 About 50% of patients with major depression respond to treatment with
an initial antidepressant.
 Pharmacological treatment:


Evidence-based medicine reviews indicate that all antidepressants are of
similar efficacy in the treatment of major depression.
Individual drugs differ in their adverse effect profiles, their potential for drug
interactions and their safety.

E.g. sertraline (initial dose: 25-50mg/day; maintenance: 50-100mg/day)
 Non-pharmacological treatment

CBT






Behavioural therapy (including graded task assignment)
Homework
Cognitive therapy/cognitive restructuring
Skill building
IPT
ECT
Give the reasons for and against the use of
involuntary treatment for hospitalisation?
FOR:
 A lack of insight into their conditions may act
as a barrier to necessary treatment
 A majority of persons suffering from severe
mental illness show limited insight into their
illness.
 Schizophrenic patients, in particular, may show
no recognition that they have a mental illness
or need treatment.
 Depressed patients who are unable to envision
hope or recall a better time may be suicidal and
unwilling to seek treatment.
 Manic individuals who have become markedly
grandiose and deny that they have any kind of
problem or illness that needs treatment may
display behaviors that put themselves or others
in danger.
 Other patients may recognize their symptoms
as part of an illness, but disagree with and
refuse recommended treatment.

Untreated depression, mania, and psychosis can
have devastating effects on both the affected
individual and those around him or her: suicide,
assaults on others, inadvertent tragedies
stemming from delusional thinking, financial
and social ruin, and inability to adequately care
for one’s own needs.
AGAINST:
There is controversy surrounding
involuntary treatment of mental health
patients as many critics argue that it
violates basic human liberty.
Critics argue that patients with cancer are
not forced to have chemotherapy and thus,
this should also apply to mental health
disorders
Self-harm does not justify interference
with an individual’s right of autonomy
(Donnelly, M From autonomy to dignity:
treatment for mental health disorders and
the focus for patient rights)
What physical examination and investigations will you
do at base line and follow up for a patient on
atypical antipsychotics?
Atypical antipsychotic: Clozapine, Risperidone, Olanzapine, Quetiapine,
Ziprasidone, Aripiprazole
 Shared side Effects
1. Neurological
 Acute EPS: pseudoparkinonism, dystonia, akathisia, akinesia
 Chronic EPS: Tardive dyskinesia, tardive dystonia, neuroleptic malignant syndrome
(Tetrad of: fever, rigidity, mental status change, autonomic instability)
2. Sedation
3. Cardiovascular
 Postural hypotension
 Tachycardia
 QT prolongation
4. Anticholinergic and antriadrenergic effects
 Dry mouth, blurred vision, constipation, tachycardia, urinary retention,
thermoregulatory effects
 Central anticholinergic: confusion, delirium, somnolence, hallucinations
5. Weight gain and metabolic abnormalities
 Metabolic abnormalities: diabetes and hyperlipidemia
6. Disturbance in sexual function and Hyperprolactinemia
 Breast tenderness, breast enlargement, lactation, decreased gonadal
hormones (incl. Estrogen and Testosterone), eliminate menstrual cycles,
reduced sexual interest and function
Specific Side Effects
 Clozapine: agranulocytosis, sialorrhea, drooling, myocarditis, seizures,
rare: pancreatitis, DVT, PE, hepatitis, eosinophilia, weight gain
 Risperidone: small increase in risk of stroke in pt with dementia
 Olanzapine: nil specific
 Quetiapine: increased risk of cataracts in beagles (not proven in human)
 Ziprasidone: Insomnia
 Aripiprazole: Insomnia
Monitoring
 For all: Do initial exam and monitor for shared side effects: Cardiovascular
health (Pulse, BP, ECG, electrolytes), Extrapyramidal side effects, sedation,
weight gain, hyperlipidemia, diabetes, hyperprolactinemia (prolactin level)
 Then monitor specific, eg:
 Clozapine: monitor WBC and neutrophils
 Quetiapine: Ophtalmology exam is recommended
Q 14. How long will Maria need to stay on these medications?
From uptodate:
 Duration of treatment depends on diagnosis. Pt with delirium, agitation,
brief psychotic disorders, or impulsivity may require only a few days or
weeks of treatment.
 Schizophrenic patients, in contrast, benefit from continuous treatment and
are at risk for relapse with medication discontinuation or even dose
reduction
 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?
From Uptodate
 Short term sequelae (2 yrs of assault) of sexual abuse in childhood: fear,
disturbances in sleep and eeating, phobias, guilt, shame, anger, depression,
school problems, delinquency, aggression, hostility, antisocial behaviour,
inappropriate sexual behaviour, and running away
 Longer term: depression, sleep problems, eating disorders, obesity,
feelings of isolation, stigmatization, poor self-esteem, problems with
interpersonal relationships, negative effect on sexual function,
revictimization, substance abuse, suicidal behavior, and psychosis
Depends on:
 Severity of the assault eg: penetration, duration, frequency, force,
relationship to abuser, maternal support
 Protective factors: family, teacher caring, other adult caring, school safety
Just for Interest (from Additional resources Blackboard)
• During childhood and teen  brain brings major upgrades to neural networks
that generate powers of judgement, cognition, and behavioural control
• The idea is: schizophrenia arises from miscues or shoddy work in this
complicated and delicate time
• Particular area of interest: DLPFC (Dorsolateral prefrontal cortex)  important to
tying threads of experience, memory, thought and emotion into coherent,
consistent view of the world.
• DLPFC builds its circuitry during childhood and adolescence, responding to both
genes and experience
Just for Interest:
It has mainly 2 types of cells
1. Pyramidal neurons  spans several layers of cortex
• Generate complex electrical signallying in DLPFC and in prefrontal cortex as a
whole
• Adult with schizo  smaller cell bodies and fewer of dendritic spines that receive
input of synapses
• Thought due to abnormal synaptic pruning during adolescence (Pruning is
thought to eliminate weak synapses and leave strong ones). In schizo  thought
that pruning ‘indiscriminately’
• In monkey brain however, found that pyramidal neurons functionally mature
before pruning started. Alternative hypothesis that schizophrenic had weaker
synapses before pruning ever began
2. Chandelier cells  sit near the base of pyramidal cells
• Only connected to pyramical cells
• Take huge hits in schizo  proteins reduced by 40%
• Thought that schizophrenic  chandelier cells fail at its task of cultivating
pyramidal cells during childhood or early adolescence
• Failure of chandelier & pyramidal  do not generate enough neural traffic
required  prefrontal cortex incapable of creating vigorous & coordinated firing
(‘gamma synchrony’) that generates working memory  shattered mind of
schizophrenia