Download Submission template for Capstone Project Case Report

Submission template for Capstone Project Case Report
TITLE OF CASE
Schizophrenia: Splitting of the mind.
AUTHORS OF CASE Please indicate corresponding author by *
Joshua Buskirk
SUMMARY Up to 150 words summarising the case presentation and outcome
The patient is a 52 year old male who presented to the office with worsening mood
and psychosis. He states that satan is making him do things and is hearing the
voice of satan instructing him to hurt himself and others. Satan is also making him
do things that he typically wouldn’t do such as steal. He hears satan through radio
messages as well. At the current time in the office he was not having any suicidal
ideations. However, he presents because he has “had enough.” The patient has a
long history of paranoid schizophrenia and is using Invega 6mg qHS to control his
psychosis. He is also taking Lexapro 10 mg qd to help control depression. Vital
signs and laboratory work-up were unremarkable.
The patient was admitted to the psychiatric unit for treatment of acute
exacerbation of schizophrenia. His psychotropic medication was adjusted and he
was exposed to group and psychosocial therapy. He was hospitalized for 4 days
after which he was stabilized and discharged. The voice ceased and he has decided
to avoid listening to the radio. He will follow-up with community mental health
under the care of Dr Rangwani.
BACKGROUND Why you think this case is important – why you decided to write it
up
Schizophrenia is a complex disorder that encompasses both genetic and
environmental risk factors. It is important as a provider to understand the
symptoms of schizophrenia and how to adequately treat them. Treatment consists
of much more than one or two medications. Medications combined with
psychosocial treatments have shown greatest efficacy in maintaining relapse of
symptoms. Along with the disease itself, it is important to understand the
comorbidities associated with schizophrenia. The medications can lead to weight
gain, diabetes, and other severe comorbidities. Therefore, these patients must be
monitored carefully and treated as needed. Schizophrenia is a disorder that leads
people to feel isolated and alone and thus, often engage in behaviors that are
detrimental to their health. These behaviors may include poor dietary and exercise
habits, drug abuse, and other risky behaviors. Therefore, it is important to learn
how to educate these patients about the risks of their behaviors. This case is a
good magnifier of some of these complications and how to manage a patient with
schizophrenia.
CASE PRESENTATION Presenting features, medical/social/family history
CC: “I’ve had enough.”
HPI: 52 yr old white male admitted to the psychiatric unit due to worsening of mood and
psychosis. Satan is controlling his thoughts and making things happen against his will. He is
hearing Satan through messages on the radio station as well. Satan telling him to hurt
himself and others. He has been hearing Satan for about 7 days and “just cannot take it
anymore.” Patient is quite irritable and angry. He is concerned that his apartment manager
is releasing gas inside his apartment which was revealed to him by satan. He has become
very suspicious of people around him.
PMHX: None
PPHX: Paranoid schizophrenia since 1991. Has used Haldol, Risperdal, and Klonopin in the
past for psychosis with limited efficacy.
Med: Invega 6 mg qd and Lexapro 10 mg qd.
Allergies: Bactrim
Family Hx: Mother with dementia.
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Social HX: Patient is currently divorced. Married twice. Has 2 children with first wife and a
seven yr old daughter with second wife. He is on disability due to his mental illness.
Smokes 2 ppd, denies alcohol use or illicit drug use.
ROS: As per history. Denies any chest pain, SOB, abdominal pain, changes in urine or bowel
habits. Has decreased appetite and is unable to sleep at night.
PE: BP 132/95, respirations 20, pulse 96, temperature 97.7.
HEENT: Normocephalic, atruamatic. Extra ocular movements intact. Sclera is nonicteric.
Neck: Supple, no JVD
HEART: normal rate and rhythm
Lungs: CTA
Abdomen: Soft, nontender, normoactive bowel sounds
Extremities: No clubbing or cyanosis
Rectal/Genital: deferred
Neurological: II-XII intact. Gait WNL.
Mental status exam: White male who appears his stated age. Hygiene and grooming fair.
No abnormal psychomotor activity. Intermittent eye contact. Speech is underproductive.
Mood is dysphoric. Irritable affect. Thought content reveals paranoid delusions and
delusions of control as per HPI. Believes satan is putting thoughts into his mind. Currently
denies SI or HI. However, prior to admission, he has been experiencing SI and HI.
Sensorium is clear. Oriented to self and surroundings. Memory is grossly intact. Insight
and judgement are limited.
Labs: CBC, Renal/Liver function, electrolytes, UA, Drug screen, TSH: unremarkable.
Impression:
AXIS I: Acute exacerbation of chronic schizophrenia, paranoid type.
AXIS II: Deferred
AXIS III: None.
AXIS IV: Moderate stressors.
AXIS V: Global Assessment of functioning on admission 30; highest within past yr 55.
INVESTIGATIONS If relevant
Labs:
BMP: WNL
Electrolytes: WNL
LFTs: WNL
CBC: WNL
UA: WNL
Drug chemistry: WNL
TSH: WNL
Renal Function: WNL
DIFFERENTIAL DIAGNOSIS If relevant
Schizoaffective disorder
Mood disorder with psychosis
Medically induced psychosis
Paranoid Schizophrenia
TREATMENT If relevant
1) Placed on suicidal precautions.
2) Continued current medications
3) Increase Invega to 6 mg bid to maintain effective therapeutic dose and
decrease psychotic symptoms.
4) Individual cognitive behaviour therapy: 5 times a week for 60 minutes.
5) Group (social skills) therapy: 3 times daily for 45 minutes.
6) Goals were attained to reduce paranoia, regulate sleep, and increase
appetite.
OUTCOME AND FOLLOW-UP
The patient became free of suicidal ideations. His paranoia diminished and the satanic voice
decreased. The homicidal ideations ceased. His sleeping and eating habits were stabilized.
He became very cooperative during the individual and group therapy sessions. He was
discharged home after 4 days and was instructed to continue his therapy as an outpatient at
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community mental health with Dr Rangwani. Arrangements were made for a short term stay
in an adult foster care unit for additional social therapy and group interactions.
DISCUSSION including very brief review of similar published cases (how many
similar cases have been published?)
1) What are the current guidelines for diagnosis schizophrenia?
2) What are current theories on etiology?
3) Current medication standards?
4) Side effects of medications?
5) Comorbidities of Schizophrenia?
1) The current diagnosis guidelines for schizophrenia are directly drawn from the
Diagnostic And Statistical Manual of Mental Disorders published by the American
Psychiatric Association. The fourth edition is the current gold standard for diagnosis
(DSM-IV-TR) (20,21). To make the diagnosis of schizophrenia the following criteria
must be met:
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 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)
B. Social/occupational
dysfunction
For a significant portion of the time since the onset of the disturbance, one or more major areas
of functioning, such as work, interpersonal relations, or self-care are markedly below the
level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to
achieve expected level of interpersonal, academic, or occupational achievement).
C. Duration Continuous signs of disturbance persist for at least six months. This six-month period must
include at least one month of symptoms (or less if successfully treated) that meet criterion A
(i.e., active-phase symptoms) and may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the disturbance may be manifested
by only negative symptoms or two or more symptoms listed in criterion A present in an
attenuated form (e.g., odd beliefs, unusual perceptual experiences).
D. Schizoaffective and mood
disorder exclusions
Schizoaffective disorder and mood disorder with psychotic features have been ruled out
because either (1) no major depressive, manic, or mixed episodes have occurred concurrently
with the active-phase symptoms; or (2) if mood episodes have occurred during the activephase
symptoms, their total duration has been brief relative to the duration of the active and
residual periods.
E. Substance/general medical
condition exclusion
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.
F. Relationship to a pervasive
developmental disorder
If there is a history of autistic disorder or another pervasive developmental disorder, the
additional diagnosis of schizophrenia is made only if prominent delusions or hallucinations are
also present for at least a month (or less if successfully treated).
2) The Finnish Adoption Study was a landmark study on the genetic link of
schizophrenia. The study has been going on for the last 21 years. The latest results
found in reference number (19) indicate that schizophrenia results from chromosomal
abnormalities and environmental stressors. These genetic risk increase exponentially
based on degree removed. Therefore, 1st degree relatives have the highest risk factor.
Multiple chromosomal abnormilties are associated with schizophrenia. (2) postulated
that at least 10 chromosomes are associated with schizophrenia. Data from (19)
indicates that mutations on chromosome 22 doubles the risk of schizophrenia.
Schizophrenia has a significant gentic factor that predisposes an individual, but
multiple studies indicate that environmental stressors during fetal development and
during birth “sets off” these gene mutations. A cohort study published in the British
Journal of Psychiatry concludes that some of these risk factors are trauma and
infections occurring during fetal development. These stressors coupled with the
genetic componement make up the etiology of schizophrenia and lead to the
anatomical and physiological changes that are seen.
3) Hundreds of similar cases of chronic exacerbation of schizophrenia were analyzed in
the CATIE study (10). This was a landmark study completed in 2005 comparing the
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efficacy and side effects of Geodon, Risperdal, Seroquel, Trilafon, or Zyprexa. The study
indicated that Zyprexa had the largest weight gain of the 5 drugs, but was also the most effective
in treating the positive and negative side symptoms. Trilafon, a 1st generation antipsychotic, was
just as effective as the others and the nueroleptic side effects did not occur until high doses. The
results of the study indicate the need for treatment of comorbidities associated with the use of
antipsychotic medications. Specifically weight gain, diabetes, and heart problems. The results of
the study are still being released and new studies are following up on the outcomes. Current
guidelines still promote using atypical antipsychotics for acute treatment and mantanence
treatment of psychosis. Clozapine is used once two or more atypicals have failed.
Reference number (16) was a randomized study looking at the results of cognitive behavior
therapy published in 2006. CBT is based on the evidence that emotional processes, information
processing deficits, and reasoning biases contribute to the prolongation of delusions and
hallucinations. The results of the study indicate that CBT reduces the prolongation of delusions
and hallucinations by 50%. Patients who combine CBT and antipsychotic medications adjusted
easier to regular life versus patients with simpily antipsychotic treatment. A study prior to this one
(15) also looked at the efficacy of cognitive behaviour therapy. Both studies indicate that CBT
paired with antipsychotic medication increases the length of remission of the positive symptoms of
schizophrenia.
Social skills deficits are also present in patients with schizophrenia. Again, these patients are often
withdrawn from society so it is important to reteach them how to operate effectively in society.
Reference (1) indicates that social skills training increases the specific behaviors necessary to
communicate effectively. Social skills training helps to sustain the remission process versus simply
using antipsychotic medications.
Finally, it is important to incorporate family members into the rehabilitation of a patient with
schizophrenia. Research has consistenly indicated that family treatment lowers rates of relapse.
McFarlane (11) conducted a literature review that consisted of data from the last 20 years. All of
the research verifies the claim that family involvement decreases the risk of relapse. Training
family members about the disease of schizophrenia and other mental disorders prepares them to
deal with the changes in mood and affect.
4) A study (6) published in the Journal of General Internal Medicine surveyed family physicians and
schizophrenic patients with common complaints and comorbid mental illness showed that
physicians underestimate the pretest probability of disease and obtain fewer appropriate tests.
Patients with mental illness who have been diagnosed with diabetes and hyperlipidemia are only
29 percent as likely to be prescribed a statin medication . These patients also reported poor
communication between primary care physcians and mental health professionals.This study
combined with the results from the CATIE trials indicate that health care providers must make a
concerted effort to screen and treat schizophrenic patients for comorbid conditions. The American
Psychiatric Association verifies that if a patients weight increases by more than 5% with
medication, the provider should consider changing the medication slowly to a different
antipsychotic medication that is less likely to cause weight gain.
LEARNING POINTS/TAKE HOME MESSAGES 3 to 5 bullet points
1) Schizophrenia is a complex disorder that combines genetic predisposition and
environmental risk factors.
2) We must understand the risk factors of antipsychotic medications although we may
not be manageing the medications directly. We also need to be in direct contact with
the mental health provider.
3) We must make an effort to prevent and treat the comorbidities associated with
schizophrenia. Individuals with mental health disorders are less likely to be active and
may engage in riskier behavors.
4) Patients have better outcomes and decrease the risk of relapse when medications are
combined with CBT, psychosocial training, and family psychoeducation.
REFERENCES
1) Bellack As. “Skills Training for People with Severe Mental Illness.” Pyschiatric
Rehabilitation Journal. 2004; 27(4): 375-91.
2) Collier, D.A. "Schizophrenia:the polygene princess and the pea." Psychological Medicine:
A Journal for Research in Pyschiatry and the Allied Sciences 38 (December 2008).
3) Crow, T.J. "The emperors of the schizophrenia polygene have no clothes." Pscyhological
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Medicine: A Journal for Research in Pyschiatry and the Allied Sciences 38 (December
2008): 1681-685.
4) Freedman R. “Schizophrenia.” New England Journal Of Medicine. 2003; 349: 1738-49.
5) Geddes JR, Verdoux H, Takei N, et al. “Schizophrenia and complications of pregnancy
and labor: an individual patient data meta-analysis.” Schizophrenia Bull 1999; 25 (3):
413-23.
6) Graber MA, Bergus G, Dawson JD, Wood GB, Levy BT, Levin I. “Effect of a patient’s
psychiatric history on physicians’ estimation of probability of disease.” J Gen Intern
Med. 2000; 15(3):204-206.
7) Kiraly, Bernadette, Karen Gunning, and Jennifer Leiser. "Primary Care Issues in Patients
With Mental Illness." American Family Physician 78 (2008): 355-62.
8) Kreyenbuhl J, Dickerson FB, Medoff DR, et al. “Extent and Management of
Cardiovascular Risk Factors in Patients With Type 2 Diabetes and Serious Mental
Illness.” J Nerv Ment Dis. 2006;194(6):404-410.
9) Leask SJ., Done Dj., Crow Tj,. “Adult psychosis, common childhood infections and
neurological soft signs in a national birth cohort.” Br Journal of Psychiatry 2002; 181:
387-92.
10) Lieberman JA, Stroup TS, McEvoy JP, Swartz MS, Rosenheck RA, et al. “For the clinical
antipsychotic trials of intervention effectiveness (CATIE) investigators. Effectiveness of
antipsychotic drugs in patients with chronic schizophrenia.” New England Journal of
Medicine. 2005; 353: 1209-23.
11) McFarlane WR, Dixon LB, et al. “Family Psychoeducation and Schizophrenia: a Review
of Literature.” Journal of Marital Family Therapy. 2003; 29 (2): 223-45.
12) Messias, Erick L., Chuan-Yu Chen, and William W. Eaton. "Epidemiology of
Schizophrenia: Review of Findings and Myths." Psychiatric Clinics of North America 30
(2007): 323-38.
13) Moore, Troy A., Nancy H. Covell, and Susan M Essock. "Real world antipsychotic
treatment practices." Psychiatric Clinics of North America 30 (2007): 401-16.
14) Schultz, Stephen H., Stephen W North, and Cleveland G. Shields. "Schizophrenia: A
Review." American Family Physician 75 (2007): 1822-829.
15) Tarrier N, Wykes T. “Is There Evidence that Cognitive Behavior Therapy is an Effective
Treatment for Schizophrenia? A Cautious or Cautionary Tale?” Behavioral Research
Therapy 2004; 42: 1377-401.
16) Turkington D, Kingdon D, Weiden PJ. “Cognitive Behavior Therapy for Schizophrenia.”
American Journal of Psychiatry. 2006; 163: 365-73
17) Velligan, Dawn I., and Jodi M. Gonzalez. "Rehabilitation and Recovery in
Schizophrenia." Psychiatric Clinics of North America 30 (2007): 535-48
18) Wahlberg KE, Wynne LC, Hakko H, Laksy K, Moring J, Miettunen J, et al. “Interaction
of genetic risk and adoptive parent communication deviance: Longitudinal prediction of
adoptee psychiatric disorders.” Psychol Med. 2004; 34: 1531-41.
19) Wynne, Lyman C., Pekka Tienari, and P. Nieminen. "Genotype-Environment Interaction
in the Schizophrenia Spectrum: Genetic Liability and Global Family Ratings in the
Finnish Adoption Study." Family Process 45 (December 2006): 419-34.
20) Andreasen, Nancy, Donald Black. Introductory Textbook of Psychiatry 4th Edition.
American Psychiatric Publishing Company 2006. Pg: 108-125.
21) Blueprints Psychiatry. Philadelphia: Lippincott Williams & Wilkins, 2008.
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Date: January 27, 2009
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