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Mhid sept 2017

  1. Case Discussion NCHD: Dr Harim Mohsin Consultant : Dr Xavier Fluvia Team MHID
  2. Presenting complaint 35 year old female with known (mild) intellectual disability was referred to Mental health Intellectual disability team with complaints of: • Agitation, no communication, poor dietary intake and sleeplessness- 5 days. • Bizarre behavior, suspiciousness and double incontinence- 5 days.
  3. History of presenting complaint • Ms. Gabi* 33 year old female presented to the acute psychiatric unit (Voluntary admission) with sudden onset of restlessness, agitation, poor sleep, decreased communication and urinary incontinence. • Family reported that she had been alright a week ago with sudden change. The mother, however noted that she had ‘not been herself’ two days earlier. She had left the house for a walk and wandered further than usual, but returned without any concern or information. The following day she was alright but the day after, she went to sleep midday and then refused to get out of bed. She became quiet, restless and didn’t sleep all night. • Next morning, mother persuaded her to visit the G.P but she refused to sit in the car, remained irritable, kept pacing and tried to leave the clinic. She didn’t cooperate with the doctor or nurse. She was prescribed a Xanax but she refused to take it. At home she called her mother and sister-in-law and confessed “Something happened…” but gave no further details. • She visited her father over the weekend but only responded to him in nods without verbal communication. She avoided interaction by turning away and appeared ‘fearful’. She was noticed to be ‘trembling’ and agitated. She had poor appetite and only took sips of water or nibbled on food when urged. • She was taken to another GP who prescribed Valium and discharged her home. She remained unsettled and was referred for hospitalization on 5th day.
  4. History of presenting complaint • She had a light dinner and kept pacing the floor. She was disoriented to place and kept soiling her clothes with excreta after which she had to forcefully be changed. Her blood and urine samples were sent for investigation. She completely denied physical examination. She was discharged from Cavan Hospital after observation. • Mother was over-whelmed with caring for Gabi due to personal and family reasons and found it exhausting to safeguard her from leaving the house, frequent soiling, restlessness and lack of sleep. • She had a review in SATU, Mullingar & then readmiited to Cavan General Hospital. She remained mute, didn’t engage in the interviews, appeared fearful, agitated and didn’t trust anyone, including family. She was observed to be self-talking but remained silent otherwise despite prompts. • She quietened the mother with “Mommy Shhh” if mother gave details to the staff. She was anxious, suspiscious, only eating little bites and avoided company. She would not leave her room. She collected her belongings and got angry with anyone touching even dirty laundry. Staff usually had to insist on sanitary care and showers due to reluctance. She would not allow any person to get physically close and got anxious around male staff. • MHID team reviewed her on 3rd day of admission and prescribed Lorazepam. Another consultant on day 5 suggested Olanzapine 5mg which was increased to 15mg but no improvement was observed in 2 weeks hence was stopped.
  5. History of presenting complaint • She was overheard whispering “I shouldn’t be telling anything” with her mouth covered. Staff reported that she screamed “Leave me alone. . . We were never together… “. And on another occasion “I didn’t tell them anything” • When questioned about what was wrong, Gabi would get teary but would give no response & was noted to be crying several times. • She was continued on Sertraline but there was no significant recovery. She took short phone calls from family members and used her own phone after 4 weeks . After she began tolerating company, showering and eating with assistance, she was discharged and sent home. • She was readmitted with initial presentation 2 days later, crying, rolling on the floor, pacing, head-banging/headache and remaining anxious & incontient. She was examined for vaginal soreness but without further intervention she was discharged again & sent to the respite.
  6. Hx Of Presenting complaint • At the respite she remained unsettled with restlessness,confusion, insomnia, suspiciousness & mutism. She hid soiled clothes in handbag and staff found patches of pubic hair. She threw food under the sofa and had lost significant weight. • There was no fever, altered consciousness, neurological disorder or trauma prior to onset. No identified stressors at home or social setting.
  7. Past Psychiatric History • December 2106: There was no significant mood or anxiety symptoms but Gabi had complaints of malaise and dizziness for which the GP prescribed her Sertraline.
  8. Personal History • Birth hx- NVD, no complications. Global developmental delay. • Education: Studied in regular school till 2nd grade then was sent to special school where she completed her studies.
  9. Pre-morbid personality • Gabi was generally a shy but a friendly person. She would enjoy engaging & telling about herself and her family. • She was able to dress and shower independently & loved dressing up. • She was updated about sports -Football and soccer. Watched cartoons on TV and listened to music. • Enjoyed shopping and attended social activities under supervision. • Stress coping: Verbalization with occassional regression noted.
  10. Family History • Gabi belonged to an Irish family. She had 3 brothers and was 3rd in birth order. • Parents had separation in 2004. • Father lived separately-she visited him over the weekend. • Her elder brother had Down’s syndrome and Diabetes. • The eldest brother was married and lived separately. • She resided with her mother and two brothers. • Grandfather died a year ago- met frequently.
  11. Medical History • Frequent issues with Low Blood pressure. • Mild anemia- 2011 • Hypothyroidism diagnosed- 2011
  12. Medication and allergies Drugs: • Sertraline 50 mg OD -2016 • Eltroxin 25mcg OD • Esomeprazole 40 mg OD
  13. Social history • She was amiable and had 2 friends since school years. • She attended the arch club frequently.
  14. Legal Hx & Substance use. • Not significant
  15. Mental State examination • A petite lady in her 20s, nearly 5.3 ft tall. Underweight with pale complexion. She appeared anxious, frightened and perplexed. She attempted to hide herself within her arms and turned body away. She had no eye contact and rapport was not established. • Mood: (S)-X • Mood:(O)- Anxious. • Affect: Anxious- Congruent. • No Speech • Thoughts/perception/cognition/insight could not be evaluated.
  16. Investigations • ALT- 60, GGT-42, • Na- 142, K- 4.3, Cl-107, Ur-7.5, Cr-55, Total protein-82, Alk Phos- 98 • CRP-0.8, eGFR-0.8 • WBC-9.9, • RBC-5.74 • Hgb- 16.7 g/dl • Plt- 435 • PT- 14.4 – INR- 1.1 • CT scan: No acute intracranial abnormality. • Autoimmune- (Anti-Hu/ Anti Yo/ Anti Ri/ CV2/Ma2/ Amphiphysin) negative. • Prolactin- 235
  17. Vulnerabillity Assesment Clinical symptoms Behavioral symptoms Treatment Support Problems with sleep Wandering Failure to engage/uncooperative Recent stress/Impending crisis Cognitive impairment No self/other injury Admission to secure setting Lack of structured daily acitivity Hallucinations?? No risk taking behavior Concern expressed by relatives Poor insight Inability to communicate effectively with others.
  18. Risk Assessment formulation Suicide/Self harm Harm to others Social circumstances Low Risk Vulnerability (ID) Medium risk Neglect (hygiene/appetite) High Risk
  19. Discussion
  20. Course of Illness • The patient was referred to MHID on June 27th, June 2017- 5 days after discharge from the Hospital with complaints of restlessness, mutism, double incontinence, anorexia and insomnia. She had day-care admissions for dehydration in acute unit twice. She refused to change soiled clothes and accepted assistance only from brother. There were reports of bizarre behavior (screaming for the devil/ shouting/ inappropriate undressing/ phone use with it switched off etc). • She was prescribed Olanzapine with dose optimization within 2 weeks. Recovery was noticed within a week with incomplete remission & 2 relapses in the course of 12 weeks. • There was a query of Tinnitus. • There was an addition of Haloperidol & Serc. • Complete recovery by 16th week of onset.
  21. Provisional Diagnosis • Axis I • Mild Intellectual disability • Axis II • Hypothyroidism • Axis III • Acute Psychotic disorder • Axis IV • GAF- 31 to 40 (major impairment in several areas) • Axis I Severity of retardation and problem behaviors • Axis II Associated medical conditions • Axis III Associated psychiatric disorders • Axis IV Global assessment of psychosocial disability • Axis V Associated abnormal psychosocial situations.
  22. Differential diagnosis Acute stress disorder Post traumatic stress disorder Acute psychotic episode Affective Mood Disorder Lujan-Fryns syndrome Dissociative disorder Physical distress/organic Illness
  23. Exposure to trauma Acute Stress reaction Acute Stress disorder PTSD
  24. Acute Stress reaction-ICD 10 • Acute Stress Reaction refers to the development of transient emotional, cognitive and behavioural symptoms in response to an exceptional stressor such as an overwhelming traumatic experience involving serious threat to the security or physical integrity of the individual or of a loved person(s) (e.g. natural catastrophe, criminal assault, rape), or an unusually sudden and threatening change in the social position and/or network of the individual. • The symptoms usually appear within hours to days of the impact of the stressful stimulus or event, and typically begin to subside within a week after the event or following removal from the threatening situation.
  25. Acute stress disorder-DSM 5 • A. Exposure to actual or threatened death, serious injury, or sexual violation in one (or more) of the following ways: Directly experiencing or witnessing the traumatic event(s). • B. Presence of nine (or more) of the following symptoms from any of the five categories, beginning or worsening after the traumatic event(s) occurred: • Intrusion symptoms Recurrent, involuntary, and intrusive distressing memories of the traumatic event(s). • Negative Mood Persistent inability to experience positive emotions. • Dissociative Symptoms An altered sense of the reality of one's surroundings or oneself. • Avoidance symptoms: Efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s). • Arousal symptoms Sleep disturbance (e.g., difficulty falling or staying asleep, restless sleep) • Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects. • Hypervigilance: Problems with concentration Exaggerated startle response • C. The duration of the disturbance (symptoms in Criterion B) is 3 days to 1 month after trauma exposure. Note: Symptoms typically begin immediately after the trauma, but persistence for at least 3 days and up to a month is needed to meet disorder criteria. • D. The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.
  26. PTSD
  27. Mood disorder with psychosis Depression with psychosis Mania with psychosis • Disturbance & change in affect or mood- depression or elation. • Irritability • Psychomotor agitation/retardation • Sleep disturbance • Appetite disturbance • Inattention/ distractibility • Hallucination/Delusions • Disturbance in behavior
  28. Physical/ Organic Illness • Endocrinological disease (Thyroid disorder/Cushing’s) Autoimmune: (SLE/NMDA receptor encephilitis) • Infection (cerebral malaria, Neurosyphillis, toxoplasmosis) • Metabolic Disease (Porphyria) • Complex partial seizures
  29. AUTOIMMUNE ENCEPHALITIS • Anti-NMDA receptor encephalitis — Anti-NMDA receptor encephalitis is the best characterized of the autoimmune encephalitis syndromes and is associated with a predictable set of symptoms that combine to make up a characteristic syndrome. • Clinical features — Many patients present with prodromal headache, fever, or a viral-like process, followed in a few days by a multistage progression of symptoms that include: • Prominent psychiatric manifestations (anxiety, agitation, bizarre behavior, hallucinations, delusions, disorganized thinking); isolated psychiatric episodes may rarely occur at initial onset or at relapse • Insomnia • Language dysfunction: diminished language output, mutism, echolalia • Decreased level of consciousness, stupor with catatonic features • Memory deficits/ Seizures • Frequent dyskinesias: orofacial, choreoathetoid movements, dystonia, rigidity, opisthotonic postures • Autonomic instability: hyperthermia, fluctuations of blood pressure, tachycardia, bradycardia, cardiac pauses, and sometimes hypoventilation. Clinical spectrum The autoimmune encephalitis syndromes have a wide clinical spectrum that ranges from typical limbic encephalitis to syndromes with complex neuropsychiatric symptoms such as deficits of memory, cognition, psychosis, seizures, abnormal movements, or coma.
  30. Acute and transient psychotic disorders- ICD 10 • A heterogeneous group of disorders characterized by the acute onset of psychotic symptoms such as delusions, hallucinations, and perceptual disturbances, and by the severe disruption of ordinary behaviour. • Acute onset is defined as a crescendo development of a clearly abnormal clinical picture in about two weeks or less. • For these disorders there is no evidence of organic causation. Perplexity and puzzlement are often present but disorientation for time, place and person does not justify a diagnosis of delirium. • Complete recovery usually occurs within a few months, often within a few weeks or even days. • The disorder may or may not be associated with acute stress, defined as usually stressful events preceding the onset by one to two weeks.
  31. Acute psychotic episode
  32. • The aetiology of schizophrenia in intellectual disability is probably similar to that of the general population, but the higher prevalence suggests that this population have an increased risk due to obstetric complications (O’Dwyer, 1997) and genetic risk factors.
  33. Dissociative disorder • Dissociative disorders are characterized by a disruption of and/or discontinuity in the normal integration of consciousness, memory, identity, emotion, perception, body representation, motor control, and behavior. • Dissociative symptoms can potentially disrupt every area of psychological functioning. • Includes dissociative identity disorder, dissociative amnesia, depersonalization/derealization disorder, other specified dissociative disorder, and unspecified dissociative disorder.
  34. Lujan-Fryns syndrome • Lujan-Fryns syndrome (LFS) is an extremely rare, X-linked disorder, for which the full clinical spectrum is still unknown. Usually, it presents with neuropsychiatric problems such as learning disabilities, Marfanoid features, and behavioral issues. • It is frequently associated with psychotic or other psychiatric symptoms. In all patients with symptoms of schizophrenia and mental retardation Lujan-Fryns syndrome should be considered in the differential diagnosis.

Hinweis der Redaktion

  1. Byrne P. Managing the acute psychotic episode. BMJ : British Medical Journal. 2007;334(7595):686-692. doi:10.1136/bmj.39148.668160.80.
  2. 14.6% of first-episode psychosis patients had primary negative symptoms (PNS). Premorbid, clinical and cognitive correlates of primary negative symptoms in first-episode psychosis- 30 August 2016,
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