psyche case presentation

1. Case Presentation
Group 3
Psychiatry Rotation
Banag-Laum Home
January 29, 2015

2. PATIENT HISTORY
I. IDENTIFYING DATA
JG, 29 years old, male, Filipino, married,
Roman Catholic, presently residing at Pit-os,
Cebu City. The patient was brought in by his
mother, wife, sister and mother-in-law. He was
admitted at Banag-Laum Home, for the first
time on January 15, 2015.

3. II. Chief Complaint and Problem
• “Naa ko diri para matarung ako pang huna-huna
og ma contrl nako ako emotion.”
• Visual Hallucination and Delusion

4. III. History of Present Illness:
• A year prior to admission, patient experienced
increase pressure due to a new project at work.
The wife of the patient noted changes in
behavior such as depression, increase the use
of English language, visual hallucination, and
delusions after the patient lived together with a
colleague in his house.

5. IV. Past History
• 1. Psychiatric - no previous history of psychiatric
illness
• 2. Medical – admitted when he was 2 yrs. old
due to dengue
• 3. Alcohol and other substance abuse - the
patient is an occasional alcoholic drinker and a
smoker; last alcohol intake was few days prior to
admission. Patient also used shabu since 2008
and became frequent since 2013. His last use
was few days prior to admission.

6. V. Personal History
1. PRENATAL AND PERINATAL
• Patient is the 3rd child among 3 siblings.
• He was delivered via normal vaginal
spontaneous delivery. Patient has no idea if
there’s any problem or complication during his
mother’s pregnancy and delivery.

7. V. Personal History
2. EARLY CHILDHOOD (BIRTH-3 YEARS)
• Patient was taken care by a yaya.
• Patient had no idea or certain memories during
these years since they are not close with his
mother nor father. They are not always spending
time together since his parents are busy with
their businesses.

8. V. Personal History
3. MIDDLE CHILDHOOD (3-12 YEARS)
• The patient and other siblings were left to the
care of yaya. As he grew, he was never been
close to his siblings and parents.
• He claimed to be a good student from pre-
school to elementary and he had good grades.

9. V. Personal History
4. ADOLESCENCE(13-17 YEARS OLD)
• The patient had no interest in school during his
adolescent years. He cut classes to play PS
games and usually goes home late. He started
smoking cigarette, drinking beer and liquor, and
using shabu together with his peers after
graduating high school.
• He did not go to college for one year due to lack
of interest, but because of family pressure he
went to college.
• He is frequently using shabu while studying in
college.

10. V. Personal History
5. ADULTHOOD
A.Occupational History
Patient worked for one month in an
Architectural Firm. He resigned from his job
because he was recruited to work as a
Draftsman in a souvenir shop. He worked there
for 8 months.
He resigned in that shop to establish his own
business. He asked a friend to be his assistant.
They worked at his home so he can personally
take care his daughter at the same time.

11. V. Personal History
B. Marital And Relationship History
He got married when he was in first year
college and they have one daughter, now 7
years old. They are currently in good terms
with his wife who is now working as a nurse.
His family is staying together in one roof with
his mother and his friend.
He is not close with his mother and they
always argue due to his friend.

12. V. Personal History
C. Educational History
He started college at University of Southern
Philippines where he finished Bachelor of
Science in Architectural Design.
D. Religion
• He is a Roman Catholic.

13. V. Personal History
E. Social Activity
• He has no social activities in the community as
he is busy with his work and taking care of his
daughter. But sometimes, when there is free
time, he take sessions of taking shabu together
with his friend/assistant .
• There are also times he does it with his older
brother who lives next to their house.
F. Legal History
There is no history of any legal issues or
imprisonment.

14. VII. Family History
• Father side - drug induced psychosis
• Hypertension and D.M. on both mother and
father side
• Thyroid disease – mother

15. MENTAL STATUS EXAM
I. GENERAL APPEARANCE
• The patient is a muscular young man, appearing
to be on his stated age, wearing shorts, shirt and
slippers. He was well groomed, and no unlikely
odour. He has a 2mm scars at the anterior side
of his right lower leg from dogbite.

16. I. GENERAL APPEARANCE
• During the interview, the patient answered the
questions calmly with maintained good eye
contact with the examiner. He listens attentively
and answers the questions clearly.

17. II. Mood and Affect
Mood is euthymic and affect is normal.
III. Speech Characteristics
His speech was spontaneous and with
normal volume and normal rhythm and
understandable.

18. IV. Perception
A. HALLUCINATIONS
• Before admission, he was experiencing visual
hallucinations (seeing shapes of building design,
raining and birds flying) before he was admitted.
His also experiencing formication every time. In
addition, he also experiencing smelling foul
odours like rotting flesh.
• He also noticed writings on his building designs
that he claimed written by other people. And he
thinks that the purpose of those writings is to ruin
his designs.

19. V. Thought Content
• Delusions of Persecution:
• “nag plot sila sa ako og dautan”
• Prior to admission, he kept thinking that his family
is thinking bad about him and plotting something
bad to him, thus he became silent and observant
with the actions of his family.

20. VI. Thought Process
• During the interview, the patient’s thoughts are
coherent, logical, and goal directed. There is no
flight of ideas or loose associations.

21. VII. Sensorium and Cognition
A. ORIENTATION AND MEMORY
Orientation
• Question: Unsa man ang oras karon karon? Unsa
man ning lugara? Kabalo ka kung kinsa ang nurse
supervisor diri?
• Answer: alas 2 sa hapon, Banag Laum , Sir Ranel
Recent Memory
• Question: What did you eat for breakfast
yesterday?
• Answer: Sausage, ham and rice.

22. Recent Past Memory
• Question: What did you do during Christmas?
• Answer: Spend time with family at home.
Remote Memory:
• Question: What is the name of your grade 1
teacher?
• Answer: Maam Famador

23. Immediate Memory
• I am going to ask you to remember three words
and I will ask you to repeat the to me in 5
minutes. Basketball, flower, cat
• 5 minutes is over.
• Can you remember the words that I told you?
• Answer: Basketball, flower, cat

24. B. Concentration and Attention
Abstract Thought:
• Question: What is the similarity of Apple and
Orange?
• Answer: They are sweet.
• Question: What do you mean by the early bird
catches the worm?
• Answer: The bird which oversleep catches the
worm first.
C. INFORMATION AND INTELLIGENCE:
• Question: Who is the current Papal Pope?
• Answer: Pope Francis

25. • Based on vocabulary, grammar and degree of
education, patient’s intellectual capacity is within
normal limits and he is certainly capable of
functioning at the level of his basic knowledge.
• The patient has no noticeable memory
impairment or gaps. He was able to effectively
recall his recent and past memory without any
difficulty. There were no reported Confabulation,
Deja vu and Jamais vu.

26. VIII. Impulsivity
• The patient has no apparent problems on his
temper. There were no reported sexual
aggressiveness and impulses. He did not show
any tendencies to hurt someone instead he was
always thinking to control his emotion.

27. IX. Judgement and Insight
• The patient’s current judgment is good. His
responses to questions pertaining to social
judgment were positive and well-developed. His
insight and judgment were good. The patient is
able to control his temper at present time. The
patient is medication compliant.

28. • The patient is very open to whatever suggestion
may given by the physician and the nurses on the
ward. But he has no idea of the nature of his
illness and the factors affecting the course of his
illness at the time of the interview. Nonetheless
he seems quite willing to make any effort in order
to improve the prognosis of his condition.
X. Reliability
• Overall the patient appeared reliable.

29. Differential Diagnoses
• Delusional Disorder
• Paranoid Schizophrenia
• Substance-Induced Psychotic Disorder

30. 1. DSM-IV-TR Diagnostic Criteria for
Delusional Disorder
A. Nonbizarre delusions (i.e., involving situations
that occur in real life, such as being followed,
poisoned, infected, loved at a distance, or
deceived by spouse or lover, or having a
disease) of at least 1 month's duration.
B. Criterion A for schizophrenia has never been
met. Note: Tactile and olfactory hallucinations
may be present in delusional disorder if they
are related to the delusional theme.

31. Characteristic symptoms: Two (or more) of the
following, each present for a significant portion
of time during a 1-month period (or less if
successfully treated):
delusions
hallucinations
disorganized speech (e.g., frequent derailment
or incoherence)
grossly disorganized or catatonic behavior
negative symptoms, i.e., affective flattening,
alogia, or avolition

32. C. Apart from the impact of the delusion(s) or its
ramifications, functioning is not markedly
impaired and behavior is not obviously odd or
bizarre.
D. If mood episodes have occurred concurrently
with delusions, their total duration has been brief
relative to the duration of the delusional periods.
E. The disturbance is not due to the direct
physiological effects of a substance (e.g., a drug
of abuse, a medication) or a general medical
condition.

33. 2. Diagnostic Criteria for
Schizophrenia Subtypes
• Paranoid type
A type of schizophrenia in which the following
criteria are met: Preoccupation with one or
more delusions or frequent auditory
hallucinations.
• None of the following are present: disorganized
speech, disorganized or catatonic behavior, or
flat or inappropriate affect.

34. • Classically, the paranoid type of schizophrenia is
characterized mainly by the presence of
delusions of persecution or grandeur
• Patients with the paranoid type of schizophrenia
show less regression of their mental faculties,
emotional responses, and behavior than do
patients with other types of schizophrenia.

35. • Patients with paranoid schizophrenia are
typically tense, suspicious, guarded,
reserved, and sometimes hostile or
aggressive, but they can occasionally
conduct themselves adequately in social
situations.
• Their intelligence in areas not invaded by
their psychosis tends to remain intact.

36. 3. DSM-IV-TR Diagnostic Criteria
for Substance-Induced Psychotic
Disorder
A. Prominent hallucinations or delusions.
B. There is evidence from the history, physical
examination, or laboratory findings of either (1)
or (2):
– the symptoms in Criterion A developed
during, or within a month of, substance
intoxication or withdrawal
– medication use is etiologically related to the
disturbance

37. C. The disturbance is not better accounted for by a
psychotic disorder that is not substance induced.
D. The disturbance does not occur exclusively
during the course of a delirium.

38. Final Diagnosis
Substance-Induced Psychotic Disorder :
Methamphetamine

39. Methamphetamine
• is a potent central
nervoussystem (CNS)stimulant of
the phenethylamine and amphetamine classes
that is used as a recreational drug and, rarely, to
treat attention deficit hyperactivity
disorder (ADHD) and obesity.
• also known as "meth," "crystal meth," "ice," and
"glass

40. Methamphetamine
• Methamphetamine is a white, odorless, bitter-
tasting crystalline powder that easily dissolves in
water or alcohol.
• Methamphetamine can be taken orally, by
intravenous injection, by smoking, or by snorting.
• It is often used recreationally for its effects as a
potent euphoriant and stimulant as well
as aphrodisiac qualities.

41. Methamphetamine
• The United States government
reported in 2008 that
approximately 13 million people
over the age of 12 have used
methamphetamine—and 529,000
of those are regular users.
• In 2009, crystalline
methamphetamine users
accounted for 62 percent of all
drug users in the Philippines.
(Manila Bulletin, Sept. 16, 2011 )

42. Short-term effects :
• Increased attention and decreased fatigue
• Increased activity and wakefulness
• Decreased appetite
• Euphoria and rush
• Increased respiration
• Rapid/irregular heartbeat
• Hyperthermia

43. Long-term effects:
• Addiction
• Psychosis, including:
– paranoia
– hallucinations
– repetitive motor
activity
• Changes in brain
structure and function
• Deficits in thinking
and motor skills

44. Long-term effects:
• Increased
distractibility
• Memory loss
• Aggressive or violent
behavior
• Mood disturbances
• Severe dental
problems
• Weight loss

45. Methamphetamine Induced
Psychotic Disorder

46. Methamphetamine Induced
Psychotic Disorder
• Methamphetamine increases synaptic levels of
the neurotransmitters dopamine, serotonin (5-
HT) and norepinephrine
• Norepinephrine is responsible for
methamphetamine’s alerting, anorectic,
locomotor and sympathomimetic effects.
• Dopamine stimulates locomotor effects,
psychosis, and perception disturbances.
• 5HT is responsible for delusions and psychosis.

47. Methamphetamine Induced
Psychotic Disorder
• Methamphetamine has been suggested to
induce psychosis through inhibiting the
dopamine transporter, with a resultant increase
in dopamine in the synaptic cleft.
• Methamphetamine psychosis is characterised by
persecutory delusions, auditory or visual
hallucinations, strange or unusual beliefs,
thought reading, ideas of reference and
delusions of reference and thought insertion..

48. Methamphetamine Induced
Psychotic Disorder
• The patient may lack insight and high levels of
fear may lead to aggressive behaviour,
particularly where persecutory beliefs are held
• Sleep deprivation is also believed to exacerbate
psychotic symptoms
• The positive symptoms of methamphetamine
psychosis is consisting mainly of delusions
(particularly of persecution, but also ideas of
reference) and hallucinations

49. • Auditory hallucinations are reported by some
research to be more prevalent in this disorder
than visual and tactile hallucinations.
• The absence of thought disorder in many
published reports of methamphetamine
psychosis was thought to be a major
distinguishing feature of methamphetamine
psychosis

50. Treatment : Acute Intoxication
and Withdrawal

53. Actual patient treatment
• Sizodon 2 mg 1 tab. BID
• Akidin 2 mg 1 tab. BID

54. Thank you!