The document presents a detailed case study of a 23-year-old male, Mr. Sadam Hussain, who has been admitted for psychiatric evaluation and treatment due to symptoms of paranoid schizophrenia, including aggression, self-neglect, and delusions. His psychiatric history includes previous treatments with limited compliance, resulting in a recurrence of symptoms. The management plan includes hospitalization, medications, and family therapy, with a mixed prognosis influenced by family support and individual circumstances.

1. Case Presentation
DR HAMZA FAROOQ( MO PSYCHIATRY)
DR ZAHID MEHMOOD( PGR NEUROLOGY)
MISS HINA CHEEMA ( PSYCHOLOGIST)

3. BIODATA
 A 23-Year-old male Mr Sadam Hussain s/o
Khadim Hussain , unemployed ,unmarried R/o
Sadiqabd, Rahim Yar Khan admitted in male
psychiatry ward involuntarily through OPD on 08-
04-22. Information was taken by his father and
brother.

4. PRESENTING COMPLAINTS
 Aggression
 Self talk and self laugh
 Suspiciousness
 Refusal to eat and drink from family members
 Self neglect
 Wandering behavior
 Irrelevant talk
 Duration : 1 year

5. HISTORY OF PRESENTING
COMPLAINTS
 My patient was in usual state of health 04 years back when he developed above
mentioned symptoms. Symptoms started after he quitted job due to his suspiciousness
on his boss.
 after that He developed suspiciousness on his family members
 He refused to eat and drink from his family, he was convinced that his family is mixing
something in his food and water, he started to show less concern in daily activities. He
used to get out from home and wander aimlessly on the road.

6.  He was not taking care of himself properly
 He used to get up in the middle of night, crying in loud voice and
asked people to stay away from him. He was frightened to go to
the wash room alone.
 Then He refused to go to bath room and change his clothes, if
family insisted on it, he used to be aggressive with them, abused
them both verbally and physically
 His family took him to a psychiatrist where he was treated on opd
basis, his symptoms improved but he showed poor compliance to
medicines.

7.  After that he took multiple consultation from psychiatrists and faith
healers but he refused to take medicines on daily basis.
 Last year he was admitted in psychiatry ward, improved significantly
then he stopped all his medicines and symptoms reappeared and
aggravated with the passage of time.
 For last two months he stopped taking part in any activity and
remains silent all the time and became aggressive if any family
member tried to involve him in any activity.
 His family brought him to psychiatry opd for admission on 08-04-2022
 Patient was assessed and admitted

8. SAFETY AND RISK ASSESSMENT
YES NO
Have you considered harming yourself in past? No
Are you taking care of yourself properly? No
Have you considered harming someone in past? Yes
Is there any other situation where you feel uncomfortable or think you may be at
risk?
Yes
Do you have a forensic history? No

9. RISK ASSESSMENT
On Sad Person Scale Score was 05
On Sainsbury risk assessment scale risk was high
on self neglect.
There was no suicidal intent, planning or any
attempt in the past

10. FORENSIC HISTORY
No History of any civil or criminal offense.

11. Varieties Used & Routes of
administration
Quantity & Frequency (Past) Quantity
&
Frequenc
y
(Present)
Alcohol Nil Nil Nil
Drugs
Nil Nil Nil
Others
(Benzodiazepin
es, cough
syrups,
analgesics etc)
Nil Nil Nil
Tobacco,
Paan, Beeri,
Gutka etc
Nil Nil Nil
SUBSTANCE ABUSE:

12. PAST PSYCHIATRIC HISTORY
 He has history of psychiatric illness and similar sort of symptoms for
last 4 years but record is not available as patient torn all his files and
burnt them
 One previous admission in male psychiatry ward last year
 No history of ECT’s , depot’s , clozapine and lithium

13. PAST MEDICAL AND SURGICAL HISTORY
 No history of diabetes ,IHD, HTN,TB,Asthma
 No significant past surgical history.

14. FAMILY HISTORY
 His paternal uncle has similar psychiatric issue but no psychiatric
consultation taken.
 No History of Mental Retardation in family.
 No history of epilepsy, or suicide

15. SOCIAL HISTORY
He belongs to lower class family.
He is financially dependent.
He lives with his parents and siblings in well-ventilated single-story
house with1 kitchen 2 rooms and attached washrooms. Have
basic facilities.
Lives in a joint family system.
Home environment is Un-Pleasant, Frequent family conflicts

16. PERSONAL HISTORY
 Born by SVD at home.
 He was breast fed.
 Achieved developmental milestones at normal age
 Started going to school at age of 5 years.
 Attained education till 9th
grade
 Multiple jobs

17. CHILDHOOD
 No history of any neurotic traits( nail bitting, pica,thumb sucking,
sleep walking, bed wetting)
 No history of Autism spectrum disorder
 No history of childhood sexual or physical abuse
 Toilet training.

18. EDUCATION
 Started going to school at the age of 5 years
 He was an average student
 Left school after 9th
grade due to two failed attempts in !0th
grade

19. MARITAL HISTORY
Patient is unmarried.

20. Sexual history
 Normal puberty and sexual orientation.
 Normal libido
 History of porn watching and masturbation

21. PREMORBID
PERSONALITY

22. Relationships
 Good relationship with parents and relatives
 Good friend circle and good relationship with them
 He was an obedient child.

23. attitudes
 Flexible attitude
 Not very religious
 Never steal any thing
 Takes care of health properly

24. Prevailing mood
 No inappropriate anger
 Stable mood

25. Character traits
 Optimistic
 Flexible
 Sociable

26. Leisure and interest
 He spends free time with friends and cousins.
 He used to play cricket and football
 He used to watch urdu serials

27. PHYSICAL EXAMINATION
Date of examination: 23-04-22
Time: 12: 30 P.M
Hearing : normal
Eyesight: normal ?
Mobility: gait is normal
 No Anemia, jaundice, clubbing, cyanosis, edema.
Lymph Nodes not palpable, JVP not raised.
Squinting of left eye

28. Respiratory system: normal vesicular breathing
Cardiovascular system: S1+S2+0
Alimentary system: no viscera palpable, bowel sounds audible, abdomen
is soft.

29. Nervous system
Motor system: all superficial and deep reflexes are intact. No muscle
twitches or fasciculation observed.
Planters B/L dorsiflexed.

30. Motor System:
Rt. Upper
limb
Lt. Upper
limb
Rt. Lower
limb
Lt. Lower limb
Bulk Normal Normal Normal Normal
Tone Normal Normal Normal Normal
Power 5/5 5/5 5/5 5/5
Reflexes Normal Normal Normal Normal

31. Sensory systems: intact
Cerebellar function: intact
Cranial nerves intact
Gait: normal gait.
Meningeal signs: absent

32. Frontal assessment Battery
 Primitive reflexes absent
 Similarities 
 Lexical Fluency
 Luria’s Test
 Conflicting instruction
 Go-No-Go
 Prehension Behaviour
 Patient Score : 15/18

33. MENTAL STATE EXAMINATION
 A young male of average built, and height and weight entered into room with his father with
normal gait ,wheatish complexion, freckles on face, untrimmed beard and mustache, small hair,
wearing dirty shalwar and qameez with opened buttons of his Qameez, odour from the clothes
and body, nails were long and dirty, continuously scratching his head, poor or dental
hygiene ,ulcers on the tongue, maintaining eye contact, seems cooperative ,sitting
uncomfortably on the chair, placing both hands on the chest, seems frightened and negative
attitude towards the doctor
 Significant signs of self neglect noted
 He was continuously trying to get away from the room
 Repeatedly standing and walking towards the door
 Rapport was difficult to built
 No abnormal movements seen

34. SPEECH
 poverty of speech , low in volume , mumbled and incoherent.

35. MOOD AND AFFECT
MOOD: Subjectively Mood is sad
Objectively Mood is euthymic
Mood is incongruent
AFFECT: Affect is Inappropriate.
No suicidal ideation, hopelessness and passive death wish.

36. THOUGHTS
Poverty of thoughts
Loosening of association
Delusional mood
Delusional memory
Delusion of persecutory
Erotomania/De Clerambault’s
No disorder of thought possession

37. PERCEPTION
Hallucinations might be present
Illusions are absent
No depersonalization and derealization

38. COGNITION
Oriented in time, place and person
Attention and concentration were intact
He was able to recall and register major life events
Abstract thoughts and judgments were good
 Insight level 1

39. PSYCHODYNAMIC FORMULATION
Defenses present in this patient
 Denial
 Projection
 Rationalization
 Isolation of affect

40. Psychometeric test
 Positive and negative syndrome scale

41. SUMMARY
Differential diagnosis
Multiaxial diagnosis
Etiological formulation
Risk and protective factors
Prognosis

42. ETIOLOGY
Biological Social Psychological
Predisposing factor Family history
Age
Gender
Precipitating factor Poor Compliance Family conflicts
High expressed
emotions
Tragic incident
Low
socioeconomic
status
Psychosexual
Stressor
Maintaining Factor Poor compliance High expressed
emotions
Unemployment
Low
socioeconomic
status
No insight

43. Protective Factors:
Supportive Family
Education

44. DIFFERENTIAL DIAGNOSIS
 Schizophrenia
 Organic
 Schizotypal Disorder
 Schizoaffective Disorder

45. Points in Favor Of Schizophrenia
 Age
 Delusions
 Hallucinations
 Self Neglect
 Disorganized behavior
 Duration more than 6 months

46. Points in Favor of Organicity
 Age
 Rapid onset of symptoms

47. Points against Organicity
 CT scan brain plain normal
 Thyroid profile normal
 All the baselines and lipid profile is within normal limits
 No history of any trauma

48. Points in Favor of Substance
induced Psychotic disorder
 Male
 Age
 Easily Availability of drugs

49. Points against Substance Induced
Psychotic Disorder
 No History of substance abuse
 No Withdrawal symptoms
 Urine for drug analysis is negative

50. Points in favor of Schizotypal
 Odd Behavior
 Odd thinking & Speech
 Paranoid ideation
 Disturbed Affect

51. Points Against
 Sociable person
 No social anxiety
 Good friend circle
 Good relationships
 Taking part in extra-curricular activities

52. Points in Favor of Schizoaffective
Disorder
 Delusions
 Hallucinations
 Duration more than 2 weeks
 Mood symptoms (Aggression)

53. Points Against Schizoaffective
 Criteria for Schizoaffective not met
 No major Mood(Depressive/Maniac) episode reported

54. PROVISIONAL DIAGNOSIS
AXIS I : Paranoid schizophrenia (6A40)
AXIS II: Nil
AXIS III: Nil
AXIS IV: Unemployment, unmarried,
AXIS V: GAF (41-50) ? serious impairment in social, occupational, or
school functioning (e.g., no friends, unable to keep a job).

55. investigations
All base line investigations are normal.
X-ray is normal
Lipid profile normal
ECG is normal
Urine complete examination normal
CT scan normal

56. MANAGEMENT:
Management of Risk
Management of Disorder
Prevention of relapse
Strong follow-up

57. Management Of Risk
 Admitted the patient in Psychiatry ward
 Offered oral treatment
 Tab Olanzapine 10mg P/O BD
 Tab Valium 10mg BD
 Started sessions of ECT’s
 Informational Care to the attendants regarding the nature and
course of illness

58. Management of Disorder
 Antipsychotics
 Sedatives
 Sessions of ECT’s

59. Prevention of Relapse
 Shifting to Long acting Injectables
 Work on high expressed emotions
 Informational Care to the attendants
 Occupational therapy
 Work on the development of insight
 Work on the stressors
 Family therapy
 Strong Follow-up

60. PROGNOSIS
 Good prognostic factors : family is supportive, educated
 Bad prognostic factors : unemployed, single, high expressed emotions, no
insight

61. Thank YOu