Case presentation of Psychotic Episode in a substance abuser


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Medical student assignment. Case presentation of a substance abuser with acute psychosis, from Malaysia. Note that names have been changed to preserve patient's confidentiality

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Case presentation of Psychotic Episode in a substance abuser

  1. 1. Case Presentation of Patient Yusnizam Ismail By Nabilah Amani
  2. 2. Introduction• Name: Yusnizam Ismail• Age: 31 years old• Race: Malay• Sex: Male• Marital Status: Single• Occupation: Unemployed• Information: Incomplete and partly unreliable• Informants: Patient and case file• Rapport was established during the second interview BY NABILAH AMANI TOBENG
  3. 3. Chief Complaint• Patient was brought to hospital for aggressive behavior and assaultHistory:- On 18th September 2012, caretaker of the nursing home noted that patient started having trouble sleeping, where he often wakes up and shout incoherently about 5- 6 times per night.- Most of the contents were abusive language and it was unknown to whom it was directed to- Caretaker suspected patient to have defaulted medication and returned to abusing substances such as cannabis and ecstasy for the past few days BY NABILAH AMANI TOBENG
  4. 4. - On the evening of 19th September 2012, patient’s behavior became more violent and he was set on assaulting others in the nursing home and surrounding community- It was also reported in a police report attached to his case file that he carried a steel rod but no one was harmed by it as police arrived in time- Then he was brought to the hospital by police and was admitted- Upon questioning of the nursing home workers, his aggression was not provoked by anyone prior to his amok but he was glaring at many people as if he would attack them- No other symptoms were noted BY NABILAH AMANI TOBENG
  5. 5. • On third interview with the patient;- Patient admits to have defaulted his medication for 2 weeks prior to the psychotic episode because the side effect was disturbing him- Details of the side effects were not clear- Claims to have met up with friends and his brother who brought the cannabis and ecstasy for him during his stay in the nursing home. He says he hid them from everyone else.- He remembers that he smoked a large dose of cannabis to finish them when he felt that the people in the nursing home were getting suspicious on the 18th of September, hence leading to his earlier symptoms BY NABILAH AMANI TOBENG
  6. 6. Past History• December 2002- First episode of drug-induced psychosis where patient was admitted in old hospital- Patient was taking cannabis supplied by his younger brother and friends since the age of 18 (year 1998)- He describes at the time he smoked the cannabis, he was using a kind of wrapped leaf- Progressively, ecstasy was also included and his cannabis dosage increased, probably being the cause for his first episode of psychosis- In addition, his case file mentioned that he was also developed schizophrenia secondary to the substance abuse BY NABILAH AMANI TOBENG
  7. 7. • June 2003- Admitted into ward for relapsed schizophrenia• Patient was repeatedly admitted for either aggressive behavior, defaulted medication, acute psychosis, relapse or mixed episodes on the following dates:- October 2004- August 2005- June, October, and December 2006- February, June, and December 2007- November 2008- January, July and October 2010- February 2012 BY NABILAH AMANI TOBENG
  8. 8. • Patient had been sent for drug rehabilitation multiple times• Therapy failed to stop his addiction• Patient claims it was difficult to stop because all his friends would often persuade him to take up cannabis again BY NABILAH AMANI TOBENG
  9. 9. Past Medical and Surgical History• Had a moderate velocity MVA in 2001 where patient was thrown off his motorcycle after avoiding a lorry which made a sudden turn• Patient was admitted into Emergency department• Injuries in his lower limbs required surgical intervention due to open fracture on his left shin.*Unable to elicit full history on this as patient doesnot remember much of the details- Apart from that, there are no other medical history BY NABILAH AMANI TOBENG
  10. 10. Family History BY NABILAH AMANI TOBENG
  11. 11. • Biological mother passed away in 2000 due to cardiac disease; patient was very attached to his mother. He was dysthymic but he denies any suicidal thoughts or feelings of worthlessness or hopelessness• Younger brother is also a substance abuser, currently in a rehabilitation center. He has criminal records for robbery and assault• Eldest sister and second sister live with their respective husbands in Perak• Youngest sister (16 years old) lives with father• Family is described as disengaged, having contact with him periodically• Unable to inquire about father as patient becomes agitated and aggressive upon asking, probably due to unresolved childhood conflict BY NABILAH AMANI TOBENG
  12. 12. Personal History• Date of Birth: 17th August 1981- Claims to have been born and raised in Pahang for 6 years before family moved to Kedah when his father was transferred.• Education: Until Form 1 (incomplete education)• Patient had poor performance in school• Marital Status: Single• Occupation: Previously was a factory worker- Has good relationship with employer whom was understanding of his situation- Colleagues mostly avoided him and he claims they often sneer at him for his drug abusing behavior BY NABILAH AMANI TOBENG
  13. 13. • Social relationships:- Most of his friends consisted of substance abusers, hence contributes to his difficulty in stopping the habit- He used to meet up with them on a weekly basis to smoke cannabis and ecstasy- Has poor family support and negligent father (as claimed by patient)• Hobbies and Interests:- Singing- Reciting poetry- Reading newspaper• Unable to elicit Psychosexual and Pre-Morbid Histories BY NABILAH AMANI TOBENG
  14. 14. • Current circumstances:- Patient is being cared for in a nursing home- He also undergoes occupational therapy while in the hospital and he claims that once he is allowed to return to the nursing home, he will go back to the factory he was previously working in- He has no significant other to care for nor any financial responsibilities- He only has qualms about working in the same department in the factory as he does not like his co-workers, especially those who openly mock him. BY NABILAH AMANI TOBENG
  15. 15. Mental State Examination• Appearance:- Normal body build and height of about 170cm- Well kempt in hospital attire- Good hygiene• Facial Expression:- Alert and responsive- Patient retains stern- looking expression• Motoric behavior:- Rigid but coordinated- Assumes “military posture” at times BY NABILAH AMANI TOBENG
  16. 16. • Mood:Subjective;- Bold, Confident, often assumes military-like formalityObjective;- Mood congruent and euthymic• Affect: Appropriate• Speech:- Pressured; loud and difficult to interrupt- Spontaneous and Talkative- Normal reaction time- Partially irrelevant- Formal mannerism BY NABILAH AMANI TOBENG
  17. 17. Thought• Stream:- Flight of ideas and grandiosity- Quote:“Aku seorang askar, mampu berlawan dengantangan tanpa senjata dan boleh membunuh hantu,jin, iblis dan jembalang. Kalau kau berani mengakukau hantu, aku akan bunuh kau. Baik kau jangancakap kau hantu….”“Mak aku mati sebelum pembedahan jantung.Doktor tak mampu buat apa-apa. Kau yang bunuhmak aku, baik mengaku!” (Points at interviewer) BY NABILAH AMANI TOBENG
  18. 18. Translation;“I’m a soldier, with the ability to fight withoutweapons and kill ghosts, jinn, demons andmonsters. If you dare admit that you’re a ghost, Iwill kill you. Better not say you’re a ghost!”“My mother died before her heart surgery. Thedoctor could not do anything. You killed mymother, admit it!”• Possession:- There was no thought alienation, withdrawal, insertion or broadcast- No obsession or pre-occupation BY NABILAH AMANI TOBENG
  19. 19. • Content:- Erotomanic delusions of being married to Siti Nur Haliza (a popular Malaysian singer) since the age of 3 years.- Consistently insists that he is married to her, even during the second interview- Even claims that they were childhood friends when he was living in Pahang• Perception:- Patient has no problems with perception- He denies hearing any voices talking to him, about him or comment on his actions.- He denies having any visual hallucinations BY NABILAH AMANI TOBENG
  20. 20. • Cognition• Orientation:- Patient is orientated to time, place and person• Memory:- Immediate, short and long-term memories are intact• Unable to assess attention and concentration as he is difficult to interrupt or persuade• Unable to assess visuo-spatial organization, calculation, abstraction or executive functioning• Unable to assess intelligence BY NABILAH AMANI TOBENG
  21. 21. • Insight:- During first interview, patient has very poor insight (may be due to psychosis)- Insight improved on second and third interview which had a gap of 2 days each- On third interview, patient is aware of his illness, understands that the cause is due to his poor compliance to medication and returning habit of substance abuse, and understands the impact it has to his life and his surroundings. He even says he will try to stop meeting his friends and brother in effort to break the habit. BY NABILAH AMANI TOBENG
  22. 22. Physical Examination*Unable to execute a full examination as it wasprohibited by staff due to his unpredictablebehavior and recent report of molesting a studentnurseInspection:- Alert and conscious- No attachments to his limbs such as cannula, IV drips, etc- Multiple linear scars on his face- Patient claims scars were from previous brawls Patient’s vital signs were stable and within normal limits, the rest of the physical examination was unremarkable BY NABILAH AMANI TOBENG
  23. 23. Differential Diagnosis• F20.0 – SchizophreniaDiagnosis :F12.50 – Psychotic disorder, Schizophrenia- likewith use of cannabinoids BY NABILAH AMANI TOBENG
  24. 24. Management PlanPharmacotherapy:• If I were the attending doctor, I would administer either Haloperidol or Diazepam IV/ IM• Once the patient is more calm, can continue with; Oral benzodiazepines, e.g. Diazepam, for anxiety and agitation Antipsychotic medication, e.g. risperidone, or olanzapine, or quetiapine or amisulpride SSRI or SNRI antidepressants BY NABILAH AMANI TOBENG
  25. 25. • Psychotherapy;• Cognitive Behavioral Therapy• Occupational Therapy BY NABILAH AMANI TOBENG
  26. 26. Summary• Mr. Yusnizam Ismail, a 31 year old Malay man, was admitted in Hospital Sultan Abdul Halim for aggressive behavior, substance abuse and poor compliance. He is a known case of cannabis abuser with underlying schizophrenia since December 2002. After administration of medications, he is now in a stable phase of illness. BY NABILAH AMANI TOBENG