schizophrenia case presentation
TRANSCRIPT
Case ConferenceIntern 吳易儒
Basic data
Admission: 2014/09/20Name: 林OO
Age: 62 y/oSex: FemaleMarriage: 已婚
Education: 小學
Occupation: 家庭主婦
Source of information: 本人,兒子,女兒
Chief complaint
最近兩周不斷在家自言自語
Present illness
● 62歲已婚女性,與兒子女兒同住,過去無精神
科病史
● 個案小學畢,年輕生活困苦,過去多從事工廠
女工
● 先生因賭博欠債於十年前離家後開始變得憂
鬱,社交鮮少,每天生活安排多待在家裡僅作
家事。有次去社區運動與人吵架後就沒有再
去。
Present illness
● 個案於一年前開始常說以前的事,常表達鄰居
對自己不好(房屋漏水、倒垃圾問題)。● 近兩周表示有人要害自己,開始變得:
○ 不睡
○ 自言自語
○ 突然無故跑出家門大吼大叫
○ 一直指著周遭物品拍打或作法
○ 疑神疑鬼,敵視陌生人
○ 不關自己的事都說成自己的事
○ 不準時吃飯
○ 原本的家事無法做如洗衣不專心會丟錯衣服
Present illness
● 家人擔心而送至本院急診。
● 會談時,個案多自言自語,言談鬆散。
● 表示自己被下符
● 聽到兩個人的聲音持續和自己說話
● 多次提及"飛將軍"但無法澄清
● 另表示自己在救台灣
● 因前述問題,經評估住院檢查治療。
Past history
● 首次呈現精神症狀的時間:61足歲
● Past psychiatric major disorders: denied● Past physical illness: denied ● Head trauma, seizure, allergy, substance
abuse, alcohol abuse, smoking: denied● Recent medication: denied● Herb medicine history : denied● Allergy history: denied
Personal history
● 心理社會問題:○ 主要支持團體的問題:兒子關心個案
○ 社會環境相關的問題:個案十年來社交鮮少
○ 教育問題:小學畢
○ 職業問題:多年從事主婦
○ 居住問題:與兒子住
○ 經濟問題:兒子提供
● 最佳功能狀況:可以工作
● 目前功能狀況:生活嚴重受影響,完全無法工
作,喪失現實感
Family history
酒癮,家暴,車禍 生病
欠債自殺
欠債離家
PE/ NE
● Consciousness: clear● Vital signs: within normal limits● HEENT: Goiter (-), conjunctiva: not pale● Chest/Abdomen: grossly normal● Extremities: tremor (-), ● Cranial nerves: grossly normal● Motor/ Sensation/ Autonomic system:(-)● Babiski sign: (-), grasp relfex(-)
MSE
● General appearance: bizarre● Attitude: cooperative● Attention: can’t focus and can’t sustain● Consciousness: clear● Speech: irrelevant, incoherent● Behavior: mannerism, self-talking● Mood and affect: restricted
MSE
● Perception: hallucination● Thought: persecutory delusion, grandiose
delusion, loosening of association● General intellectual function
○ Judgment: not detectable○ Orientation
■ Time: not impaired■ Place: not impaired■ Person: not impaired
MSE
● Memory○ Immediate: not impaired○ Recent: not impaired○ Remote: not impaired
● Abstract thinking: not detectable● Physical function: initial insomnia, middle
insomnia● Insight: no insight
Diagnosis
● Axis I : Schizophrenia● Axis II : defer● Axis III: nil● Axis IV : defer ● Axis V :
○ GAF = 11~20 (current) ○ GAF = 31~40 (best in past 12m)
Lab data
● EEG: normal or within normal limits● EKG: NSR● CXR: negative● Brain CT: negative● CBC: normal or within normal limits● Serum(Glucose AC, CK, CKMB, Na, K,
BUN, Cr, AST, Ammonia): normal or within normal limits
Lab data
● Urine:BZO(+),APAP(-),AMP(-),BAR(-),COC(-),OPI(-),THC(-),TCA(-)
● Blood: RPR(-),HIV Ag/Ab(-),HCV Ab(-)● Immunoassay:Anti-HBc(+),HBsAg(-),VitB12
(-),Folic acid(-), Prolactin(74.42), Free-T4(-), T3(-), TSH(-)
● Serum: Cu(-), Pb(-), Al(-)● PT, aPTT: normal● Stool OB: trace
Plan
● Establish rapport, clarify history● Pharmacotherapy:
○ Estazolam 2mg 1T PO QHS○ Lorazepam 2mg 1A IM QHSPRN○ Risperidone 3mg 1T PO QHS○ Haloperidol 5mg 1A QHSPRN
● Arrange psychological assessment for further evaluation
Hospital course2014/9/20~2014/9/30 (尚在住院中)
2014/9/20
● 情緒偶有起伏● 精神可,活動量略多● Loosening of association, 會愉悅的講述妄想
內容● Persecutory delusion, 表示被人下符,希望這
裡可以保護她● Plan:
○ Estazolam 2mg 1T PO QHS○ Risperidone 3mg 1T PO QHS○ Lorazepam 2mg 1A IM ST○ Haloperidol 5mg 1A ST
2014/9/21● Bizarre behavior,persecutory delusion, self
talking, 不斷對空比劃且出現喃喃自語情形,表示「就是黃依廷一直在對我下符啊!」、「我都跟他說過了」、「叫醫生不用給我吃藥打針」、並出現指著10C病友是救世主,於爾後又表示自己才是救世主。會提及自己陷入「一個陣中」,多以點頭搖頭回應。
● Unsteady gait● Complete denial of illness,堅持表示自己沒
生病,不能吃那些藥物
● Aggressive behavior, 21點服用睡前藥物時仍表示拒絕, 將防跌紅鈴扯毀並預攻擊醫護人員
● 可被動說出被約束之原因● Plan:
○ 為預防其跌倒,給予腰腹約束於病室內○ Estazolam 2mg 1T PO QHS○ Risperidone 3mg 1T PO QHS○ Lorazepam 2mg 1A IM ST○ Haloperidol 5mg 1A ST
2014/9/22
● “我是救世主 寶珠寶珠”,”你們要害我 要對我不利”
● 不斷比手劃腳表示在作法超渡眾生,又表示在與老神仙對話並要不停作法練功,才能抵抗無形的敵人
● Plan○ Estazolam 2mg 1T PO QHS○ Risperidone 30mg/30ml 3cc PO QHS○ Lorazepam 2mg 1A IM QHS PRN○ Haloperidol 5mg 1A IM PRN if 拒藥
2014/9/23
● 我自己很命苦因為天生美麗所以都被忌妒,我
以前小時候雖然我哥哥弟弟對我好但是沒有
錢所以我去工作
● 一開始都還好,但是我都會被人針對尤其寶珠
老闆娘都會叫我做粗重工作,那不是我的事
● 尤其是921那年我要退休又更年期,全部的事
情加雜一起讓我很痛苦,你知道嗎 我美麗是錯
● 921那一年我耳朵都會耳鳴有看了很多醫生都
沒有用後來人家叫我去精神科我吃了一個光
能錠根本沒效我又沒瘋掉
● 這10幾年來我都靠食療讓自己變好,只是這十
年來我都待在家裡,因為我太美了連去菜市場
買東西都會有問題
● 你看菜市場忌妒我都會算比較貴 我們也是這
幾年比較好有買房子 唉但是如果我可以留錢
給我的小孩他們就不用辛苦
● 這兩週來 那些耳鳴聲才變成有人說話的聲音,
我很害怕因為是之前工作的人下我降頭,我聽
到佛祖叫我當救世祖能力很強、我有超能力可
以做法 保護家人 ● Catatonia, 身體僵硬且維持同一姿勢,打完
Haldol後半小時可開始下床, 步態穩可執行工作人員指令
● 不願配合進食早餐● 多以點頭搖頭回應
● Plan○ Lorazepam 2mg 1A IM QHSPRN○ Risperidone 30mg/30ml 5cc PO QHS○ Haloperidol 5mg 1A PRN if 拒藥
2014/9/24
● 提及多年來生活中之辛苦及與工作同事相處之間嫌隙
● 將衣物及生活用品打包,靜坐於床上,維持同一姿勢,且不願配合進食午餐
● 詢問時多以點頭搖頭回應之情形● 晚上有被動配合服用藥物
2014/9/25
● 在房間中比手劃腳傾聽狀
● 拒絕進食
● 對問話點頭搖頭回應,承認現在是佛祖的說話
聲,再給自己指示,自己要救世人,飯和藥有毒,我們會害她
● 打完針劑後對問話不回應,比手畫腳沉浸幻聽
症狀改善
● Plan:add risperidone 6cc/mg
2014/9/26
● 從10幾年前起開始聽到耳邊雜音,會合併頭暈,失眠,當時開始容易緊張,會擔心有人會害他,要保護家人,
● "聽說女兒已經結婚了",都沒有和女兒連絡,不想讓女兒回家,怕會有豬哥男生騷擾他,因為我
女兒和我一樣像雙胞胎,他和我一樣漂亮,● 我從板橋,蘆洲,五股,三重一路佈施到淡水,把
身上的衣服捐出去,她們忌妒我穿金帶銀,所以
不和人連絡,不跟鄰居講話,她們忌妒我
● 最近聽到很多聲音,在做法,要救眾生,救世人,很害怕,怕自己和家人受傷害,不知道自己在怕
什麼
● 現在好多了,沒有聽到聲音,也比較不會害怕
● 會覺得身體無力,這幾天不敢吃飯,怕被下毒,現在不會了
● Plan:○ add biperiden 1#bid ○ add haldol 1#qhs○ keep risperidone 6mg/cc
2014/9/27
● 社區裡的監視器有拍到我把衣服放到回收箱,以為我家很有錢很浪費
● 她們喜歡我因為我很好看,有錢,但平常我不太
跟鄰居說話,來往,但她們都知道我
● 不記得前兩週發生的事情
● 不知道住院原因,身體好好的,沒有聽到聲音,以前是有一些耳邊雜音,現在都沒有了
2014/9/28
● 表示現在幻聽干擾情形變少,可說出對幻聽不予理會
2014/9/29
● (經過活動室時對活動室門口踢兩腳),"有壞人
要教訓,踢他們兩腳"● 老闆娘寶珠這10幾年來會起乩,給我下符,讓我
頭痛,兩耳有雜音
● 她忌妒我長的美,大家都認為我美,只是沒有說
出來,到65歲還保養的這麼好,我剛剛用心電感
應讓他知道
● 平時去菜市場時很多人注意我,在那裡很受歡
迎,我不好意思看他們...(對工作人員獻飛吻)
● Plan: ○ Lorazepam 2mg 1A IM QHSPRN○ Biperiden 2mg 1T PO BID○ Haloperidol 5mg 1T PO QHS
2014/9/30
● 在病房走廊不斷來回走動,表示在運動,未出現比手畫腳動作
● 我比較內向害羞,平常本來就不太跟人講話● 妳長得很美,比我女兒還美,我女兒很多人
追,她娃娃臉,大家都看不出來她35歲了。● 妳真的長得很美(不斷重複)● 住院那天(指住院當天症狀)不好意思麻煩大
家了,現在好很多了● (問有沒有聽到什麼聲音)沒有也沒有聽到那
個聲音
● Plan:○ Lorazepam 2mg 1A IM QHSPRN○ Biperiden 2mg 1T PO BID○ Haloperidol 5mg 1T PO QHS○ Risperidone 25mg 1V IM QOW QD
TPR sheet
MSE
● Consciousness:clear1.General appearance: unkempt2.Attitude: cooperative3.Attention: focus and sustain4.Behavior: restless5.Speech: talkative, relevant, incoherent
6.Mood and Affect: euphoric7.Thought: perscecutory delusion(-).suicidal
ideation(-)8.Perception:AH(-),VH(-)9.Drive: Sleep:no decrease need of sleep, Self-care:
fair Appetite:fair10.Insight: partial
JOMAC
● Judgement: normal● Orientation: oriented to time(黃昏)/place(馬
偕)/people(吳醫師)● Memory: impaired recent memory, fair
immediate memory(綠色,生氣,救護車)● Abstrac thinking: fair(青梅竹馬:小時候一起長
大的人)● Calculation:7 series=93,86,79,72,65
DicussionVLOSLP-Very late onset schizophrenia like psychosis
Schizophrenia
Case report
Late onset Schizophrenia
● usual onset at:○ Male:15-25 y/o○ Female: 25-35 y/o
● late onset >40(45)y/o
● very late onset >60 y/o
Case 1
● A 72 y/o widow without past history● Rather distraught state for 2 years● 6 weeks ago- Certain her daughter-in-law
poisoning her food since● Quarrels ensued at home● Decreased appetite and sleep● An unfamiliar men voice commented on her
daily activities● 2 weeks ago- try to strangulate herself to
make the voice stop
● Medication then started, but she refused due to she believed it was poisonous
● Suspicious and introverted● Well physical condition● Well oriented● No affective symptoms● MMSE 28/30● MRI: age related cortical atrophy● Treated by Risperidone 1mg and
symptomatically better
Case 2
● A 84 y/o educated till 10th grade● brought by her children due to:
○ suspiciousness○ social impairment○ persecutory delusion-complain of neighbor’s
malicious intent○ restless as kept checking the doors○ place her ears on the wall as if eavesdropping○ had an avid interest in writing poems
● MSE:○ cooperative famale○ no affective disturbance○ no thought disorders
● Referential delusions to “evil” neighbors● The neighbors would purchase her house
after she died● Third person intermittent auditory
hallucinations discussing her● No insight into her illness● MMSE=30/30● MRI: normal● Risperidone as previous case+ psychosocial
intervention● following with significant improvement
Epidemiology/ Clinical presentation
● Paranoid ideation in general elderly population: 4-6%(most with dementia)
● Female with persecutory delusions: 83%● India, schizophrenia onset after 40 y/o:
2.04%● In india, LOS Male:Female=1:1.67● LOS and VLOSLP are more likely to:
○ exhibit persecutory delusion○ Visual/tactile/auditory hallucination○ Running commentary and abusive content
LOS=late onset schizophreniaVLOSLP=very late onset schizophrenia like psychosis
Risk factors
● EOS: more common in men● LOS: Female:Male=3:1● VLOSLP: Female:Male=20:1● Associated with
○ decline of estrogen levels○ relative excess of dopamine D2 receptors○ better coping behavior strategies->delay onset
● Relatives develope schizophrenia:○ EOS: 10.2%○ LOS and VLOSLP: 2.9%
EOS= early onset schizophreniaLOS= late onset schizophreniaVLOSLP= very late onset schizophrenia like psychosis
● VLOSLP: ○ higher association of sensory imapirment○ more likely to have schizoid or paranoid
personality traits● Recently, elevated CRP was reported to
increase risk for LOS and VLOSLP.○ 6 times increased risk in case with very small
elevations of CRP was reported at 2013 American Psychiatric Association meeting.
● smoking, BMI, alcohol, education, income, DM are all risks.
Management
● Patients with VLOSLP must exclude underlying cause: PE, NE, Lab, Neuroimaging
● Antipsychotics: use in acute symptoms and reduce risk of relapse.○ but side effects must concern in elderly people○ Chlorpromazine 300 mg/day in younger p’t=148
mg/day in older people
● Atypical antipsychotics are preferred due to light SE and lower risk of EPS.○ Risperidone, Olanzapine and Quietiapine in low
dose-> effective and well tooerated in VLOSLP->start low, go slow
○ Clozapine in low dose has shown promising effects, but adverse effects like agranulocytosis makes it use only in resistant p’t.
● Nutritional supplement is very important● No sufficient data for ECT treatment in
VLOSLP patients● Cognitive behavior therapy, social skills
training and supportive psychotherapy are valuable in improving function.
Thanks for your attention :)