Psychiatry Case Conference 1

III-B

Cueto, Mary Anne – Diaz, Mark Fernan

General Data L.M.P35 y/omarriedBorn Again Christian2nd in a brood of 3BS Nursing Graduateunemployedborn & raised in Capizadmitted 1st time on April 4, 2005

Infomants: Patient: 75%Husband: 85%Sister: 85%

History of Present Illness

2001 * very active, sings in the choir

2004 * negative feelings towards members and ministry

December

2005 * persistent negative feelings towards members and

January ministry, delusion of reference

2005 * auditory hallucination, loss of appetite, reduced

February sleep, negative feeling towards her husband

2005 * auditory hallucination, odd behavior, blank stares

1st wk March anxious

History of Present Illness

2005 * quiet, unresponsive

3rd wk March

2005 * verbal aggression, delusion of reference

March 25

2005 * felt guilty of what she said to the members,

March 26 delusion of persecution

2005 * neglected her chores and children, delusion

March 27 of persecution/anxiety

2005 * singing songs, speaking incomprehensible words

March 31

History of Present Illness

2005 * suspicious w/her surroundings

April 1 * brought to Las Pinas Doctors Hospital

* injected w/unrecalled medication

* admitted @ USTH while sedated

Review of Systems

(-) Headache, loss of consciousness, convulsions

(-) fever

(+) anorexia , weight loss

(+) HPN – mother

(+) stroke – mother

(+) heart disease, PUD – father

(+) alcohol dependence – father

(?) nervous breakdown – great grandmother

Non-smoker

Non-alcoholic beverage drinker

Denies use of any prohibited drugs

Born to 23 y/o G2P1 (1001); NSD at home

By traditional birth attendant

No prenatal or postnatal complications

Neuro-developmental milestones at par with age

Lived with parents and three siblings

Family owns a small grocery store

Left in the care of the father, an alcoholic

Father had occasional fights with his wife

Patient admits his father had his “weaknesses” but was very affectionate and loving

Patient grew-up closer to her father and siblings

Primary education at Malubog-lubog Elementary School in Capiz

Average student and had very few friends

6th grade - father died which caused extreme sadness and felt that a big part of her was lost with the passing

Left in the care of the eldest sibling (Gina)

Gina confided of being overprotective of her younger siblings

Family Relationship

after father’s death, mother married a policeman

Siblings were against the marriage at first

Patient felt that the mother betrayed her father

According to the patient, she had a harmonious relationship with stepfather and stepsiblings

Stepfather did not impose himself on the stepchildren was kind and approachable and was readily

approachable when they need him

Social Relationships

Claimed to have a number of friends stayed at home on weekends because mother

would not allow her to go out with friends

School History

Attended high school in FLAIMER Christian Institute in Capiz

Wanted to take up AB Philosophy forced by mother to take up BS Nursing Graduated on time

Academic Achievement

failed Nursing Board Exams (1990)

failure due to “poor preparation”

Worked as an assistant nurse in a small clinic while waiting for the next board exams

took the boards in Manila and passed with high marks (1992)

Did not work at once because she was waiting for her petition from her maternal aunt to work in Germany

After some time worked as a ticketing supervisor at Ever Gotesco Cinema

Resigned after 2 months, thinking she was not ready to work yet

Learned that her petition was declined

1993 - nurse in Capiz and resigned after 6 months

Felt bad in an incident when a patient deteriorated infront of her

According to sister: Patient was pious and hardworking

Gave portion of salary to patients

1994- went back to Manila and stayed with sister

Meaningful Long-term Relationship

met Norman and married him after two years (1996)

- Stayed with husband’s family (Cavite)

After a few months, husband flew to Abu Dhabi

Patient got pregnant and went back to Capiz

Had difficult pregnancy

- 1997 – CSD with her 1st child (Paul Christian)

1998 – went to Abu Dhabi with husband and had no difficulty in adjusting

Worked as sales clerk in a pharmacy

December 1999 – decided to return to Philippines due to 2nd pregnancy

2000 – gave birth to second child (Patricia Lois)

Stayed with her mother, who sometimes helped out with her grandchildren

Longed for her husband

2001 – returned to UAE with her children because of argument with mother

Was baptized to a ALL Nations FULL GOSPEL, a Born Again Christian group

Planned to work as a nurse however got pregnant with her 3rd child

First worked as an assistant nurse

Very little compensation while waiting for the next board exams

resigned to take 2nd board exam

Worked as Ticketing supervisor and resigned after 2 mos

Petition by her maternal aunt was declined by the German Embassy

1998 - sales clerk in a pharmacy in Abu Dhabi

1999 - resigned because of 2nd pregnancy

No difficulty adapting to new environment

No difficulty adjusting to new role as mother

8

Cesar

Gina

Paul Christian

12

Patricia Lois

9

L35

Norman

1996

Minerva58

4

LEGEND Heart

attackStroke

PUD

HPN

Cesar- father

Died of “heart attack” at 45 An elementary graduate Came from a well off family in Capiz Alcoholic since 20 y/o

Drank gin (? amount) almost everyday usually alone or with friends

Patient regards him as loving and kind father Patient claims she got her talent from him

He usually sang with her

SALIENT FEATURES 35 y/o

Female

Born again Christian

Unemployed

Preoccupation with at least 2 delusions (Jan-March2005)

Auditory hallucination

Aggressive/agitated behavior (March 2005)

Avolition-apathy (3rd wk & 27 Mar)

SALIENT FEATURES

Incomprehensible speech

Impaired social functioning

Physiologic disturbance: anorexia and insomnia

Family history: great grandmother had nervous breakdown

Non-smoker, non-alcoholic, denies use of prohibited drugs

Poor relation with mother

DIFFERENTIAL DIAGNOSIS

Major Depressive Disorder

Bipolar Disorder

Schizophrenia

DSM-IV-TR Diagnostic Criteria for Major

Depressive Episode

A. FIVE (OR MORE) OF THE FOLLOWING SYMPTOMS HAVE BEEN PRESENT DURING THE SAME 2-WEEK PERIOD AND REPRESENT A CHANGE FROM PREVIOUS FUNCTIONING; AT LEAST ONE OF THE SYMPTOMS IS EITHER (1) DEPRESSED MOOD OR (2) LOSS OF INTEREST OR PLEASURE. NOTE: DO NOT INCLUDE SYMPTOMS THAT ARE CLEARLY DUE TO A GENERAL MEDICAL CONDITION, OR MOOD-INCONGRUENT DELUSIONS OR HALLUCINATIONS.

1. depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by others (e.g. appears tearful). Note: In children and adolescents, can be irritable mood.

2. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others)

3. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month), or decrease or increase in appetite nearly every day. Note: In children, consider failure to make expected weight gains.

4. insomnia or hypersomnia nearly every day

5. psychomotor agitation or retardation nearly every day (observable by others, not merely subjective feelings of restlessness or being slowed down)

6. fatigue or loss of energy nearly every day

7. feelings of worthlessness or excessive or inappropriate guilt (which may be delusional) nearly every day (not merely self-reproach or guilt about being sick)

8. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others)

9. recurrent thoughts of death (not just fear of dying), recurrent suicidal ideation without a specific plan, or a suicide attempt or a specific plan for committing suicide

B. THE SYMPTOMS DO NOT MEET CRITERIA FOR A MIXED EPISODE.

C. THE SYMPTOMS CAUSE CLINICALLY SIGNIFICANT DISTRESS OR IMPAIRMENT IN SOCIAL, OCCUPATIONAL, OR OTHER IMPORTANT AREAS OF FUNCTIONING.

D. THE SYMPTOMS ARE NOT DUE TO THE DIRECT PHYSIOLOGICAL EFFECTS OF A SUBSTANCE (E.G., A DRUG OF ABUSE, A MEDICATION) OR A GENERAL MEDICAL CONDITION (E.G., HYPOTHYROIDISM).

E. THE SYMPTOMS ARE NOT BETTER ACCOUNTED FOR BY BEREAVEMENT, I.E., AFTER THE LOSS OF A LOVED ONE, THE SYMPTOMS PERSIST FOR LONGER THAN 2 MONTHS OR ARE CHARACTERIZED BY MARKED FUNCTIONAL IMPAIRMENT, MORBID PREOCCUPATION WITH WORTHLESSNESS, SUICIDAL IDEATION, PSYCHOTIC SYMPTOMS, OR PSYCHOMOTOR RETARDATION.

DSM-IV-TR Diagnostic Criteria for Manic

Episode

A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood, lasting at least 1 week (or any duration if hospitalization is necessary).

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

inflated self-esteem or grandiosity

2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. more talkative than usual or pressure to keep talking

4. flight of ideas or subjective experience that thoughts are racing

5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The symptoms do not meet criteria for a Mixed Episode.

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features.

E. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatments) or a general medical condition (e.g., hyperthyroidism).

DSM-IV-TR Diagnostic Criteria for Hypomanic

Episode

A. A distinct period of persistently elevated, expansive, or irritable mood, lasting throughout at least 4 days, that is clearly different from the usual nondepressed mood.

B. During the period of mood disturbance, three (or more) of the following symptoms have persisted (four if the mood is only irritable) and have been present to a significant degree:

1. inflated self-esteem or grandiosity

2. decreased need for sleep (e.g., feels rested after only 3 hours of sleep)

3. more talkative than usual or pressure to keep talking

4. flight of ideas or subjective experience that thoughts are racing

5. distractibility (i.e., attention too easily drawn to unimportant or irrelevant external stimuli)

6. increase in goal-directed activity (either socially, at work or school, or sexually) or psychomotor agitation

7. excessive involvement in pleasurable activities that have a high potential for painful consequences (e.g., engaging in unrestrained buying sprees, sexual indiscretions, or foolish business investments)

C. The episode is associated with an unequivocal change in functioning that is uncharacteristic of the person when not symptomatic.

D. The disturbance in mood and the change in functioning are observable by others.

E. The episode is not severe enough to cause marked impairment in social or occupational functioning, or to necessitate hospitalization, and there are no psychotic features.

F. The symptoms are not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication, or other treatment) or a general medical condition (e.g., hyperthyroidism).

DSM-IV-TR Diagnostic Criteria for Schizophrenia

A. CHARACTERISTIC SYMPTOMS: TWO OR MORE OF THE FOLLOWING, EACH PRESENT FOR A SIGNIFICANT PORTION OF TIME DURING A ONE-MONTH PERIOD (OR LESS IF SUCCESFULLY TREATED)

1. Delusions

2. Hallucinations

3. Disorganized Speech

4. Grossly Disorganized or Catatonic Behavior

5. Negative Symptoms

B. SOCIAL/OCCUPATIONAL DYSFUNCTION

C. DURATION:continous signs for atleast 6 months that must include:

1 month of active symptoms (or < if succesfully treated)± periods of prodromal or residual symptoms

•only negative symptoms•2 or more Criteria A symptoms in attenuated form (eg. Odd beliefs, unusual perceptual experience

D.SCHIZOAFFECTIVE DISORDER EXCLUSION

E. SUBSTANCE/ GENERAL MEDICAL CONDITION EXCLUSION

F. RELATIONSHIP TO A PERVASIVE DISORDER

DSM-IV-TR Diagnostic Criteria for Schizophrenia

Subtypes

PARANOID TYPE

A.PREOCCUPATION WITH ONE OR MORE DELUSIONS OR FRQUENT HALLUCINATIONS

B. NO DISORGANIZED SPEECH, DISORGANIZED OR CATATONIC BEHAVIOR, FLAT OR INAPPROPRIATE AFFECT

DISORGANIZED TYPE

A. ALL OF THE FOLLOWING ARE PROMINENT:

1. Disorganized Speech

2. Disorganized Behavior

3. Flat or Inappropriate Affect

B. THE CRITERIA ARE NOT MET FOR CATATONIC TYPE

CATATONIC TYPE

A type of schizophrenia in which the clinical picture is dominated by at least two of the following:

1. Motoric immobility as evidenced by catalepsy or stupor

2. Excessive motor activity

3. Extreme negativism

4. Peculiarities of voluntary movement as evidenced by posturing, stereotypied movements, prominent mannerisms, prominent grimacing

5. Echolalia or echopraxia

UNDIFFERENTIATED TYPE

A type of schizophrenia in which symptoms meet Criterion A present, but the criteria are not met for the paranoid, disorganized, or catatonic type

RESIDUAL TYPE

A.Absence of prominent delusions, hallucinations, disorganized speech, and grossly disorganized speech and grossly disorganized, or catatonic behavior

B. There is continuing evidence of the disturbance, as indicated by the presence of negative symptoms listed in Criterion A for schizophrenia present in attenuated from