Long Case Presentation

1. Case Presentation
By
Dr Aziz Mohammad
PGT, Department of Psychiatry
Khyber Teaching Hospital Peshawar

2. History
Mr AR, a 50 years old man from Jalal
Abad, Afghanistan, married twice, father
of 14 children, not formally educated,
living life as a farmer but not working for
the last two years. He was admitted via
OPD after he failed to show significant
response to treatment on outdoor basis for
over two years.

3. History (cont..)
He presented with complaints of having
centipedes in his brain for the past two years.
He would describe the movements and
nature of these centipedes in great detail as
they would crawl reaching one ear and the
other, the back of the neck and behind his eye
balls. Over the last few months The patient
would shake his head with an attempt to stop
movements of these centipedes but in vain.
He was quite distressed by these symptoms and
his social and occupational life was adversely
effected.

4. History (cont..)
• His mood remains low with diminished
interest in daily activities and extreme
difficulty going to sleep. Every time he feels
movements of these centipedes especially
when it feels behind his eye balls, he fears
getting blind. In desperation he has tried to
kill the centipedes by poisoning them by
ingesting insecticides and kerosene oil on
different occasions. He was still intending to
poison them again with something more
lethal if the doctors did not help him.

5. History (cont..)
• He gets annoyed by alternative
explanation for his symptoms by doctors,
family or relatives and will reject the
finding in CT brain which was performed
an year ago by a local doctor. He visited a
number of local doctors and went to India
for treatment one year ago after a reported
fail surgical attempt to remove the
centipede from his brain.

6. History (cont..)
• The operation was reportedly performed
in Quetta by E.N.T surgeon where the
patient was shown a dead centipede
(Record not available). There was a
surgical scar behind his left auricle.
• The patient believes that the surgeon
failed to remove female pregnant
centipede that has now given birth to
several offspring.

7. Past Hx
• Apart from receiving treatment from
multiple doctors and faith healers, he was
treated by psychiatrist with olanzapine 10
mg daily and fluoxtine 40 mg daily for
about three months with no significant
improvement in his symptoms.

8. Family Hx
His father died 20 years ago because of a
sudden death with no known causes. His
mother is alive and has no known medical
or psychiatric illness. He has 3 brothers
and 4 sisters and is 2nd in birth order. His
elder brother died because of some brain
tumor 4 months ago. There is no other
significant medical or psychiatric history
in the family

9. Personal Hx
• Normal delivery, normal Developmental
Milestones. Reports uneventful happy early
and late childhood. Has received no formal
education. He Can read quran (Nazira).
• Has been working as a farmer in his village
until over the past 2 years. Married, has 2
wives, 10 daughters and 4 sons, living in a
house which consists of 6 rooms.
• Uses snuff, but denies use of any other illicit
drugs. There is no history of any encounter
with the police or law.

10. Premorbid Personality
• Patient describes himself as sociable, with
good coping skills in stressful conditions,
has no known leisure activities and gives
importance to religious and cultural
values. His cousin describes him as a bit
strict by nature, with mild anger outbursts
from time to time but there is no history of
paranoid, schizotypal or schizoid
personality traits.

11. Mental State Examination
• A middle aged bearded man, normal hight and built, dressed
appropriately in shalwar qamees. There were no evidence of
self neglect, abnormal behaviour or movements. He was
cooperative, Rapport was established and maintained till the
end of the interview.
• Mood was subjectively and objectively low, with no explicit
death wishes or suicidal thoughts.
• His speech was relevant, coherent, of normal tone and
volume. There were no formal thoughts disorder.
• He has got delusion of being infested by centipedes along with
Somatic hallucinations. No obsessions, auditory or visual
hullucinations could be illicited.
• His cognitions was intact, with normal attention and
concentration. Both short term and long term memory were
intact.
• Patient did not have insight into his illness.

12. Physical Examination
• His GPE and Systemic Examination
including CNS Examination was
unremarkable with
• BP 130/85, pulse 84/min, and temp 98 F.

13. Diagnoses
• On the basis of history and MSE, my 1st
diagnosis according to ICD-10
• On Axis l
• F22.0 Delusional disorder with comorbid mild to
moderate depression
• (F22 Persistent delusional disorders)
Monosymptomatic hypochondriacal psychosis
• My differential diagnoses include
1. Depressive Illness with Psychotic Features
2. Schizophrenia

14. Diagnoses (cont..)
• On axis ll ( Disabilities).. Score 1-5
• Personal Care: 2
• Occupation: 5
• Family and House Hold: 4
• Broader Social Context: 4
• On Axis lll (contexual Factors)
• Wrong treatment by faith healers and other health
care providers.
• Problem related to education and literacy
• Inadequate social support, has to look after a large
family.
• Death of brother 4 months ago

15. Management
• Short term
• Patient was admitted to Psychiatry ward for
management.
• The patient and his family were reassured and
counseled about nature of the illness and its
management. Informational care was provided
empathatically. Initially direct confrontation was
avoided to build a therapeutic alliance with the
patient.
• He was advised baseline investigations including FBC,
Liver and Renal Functions tests, CXR and ECG.
• He was started on on risperidone 6 mg in divided
doses, fluoxetine 40 mg OD in the morning and
Lorazepam 2 mg at Night.

16. Management (cont..)
• Intermediate
Serial MSE were carried out.
HAM-D was applied to assess severity of
depression which showed mild to
moderate depression.
He was assessed for Psychosocial support.
The dose of risperidone was increased to
10mg daily after 2 weeks of admission.

17. Management (cont..)
Attempts were made to shake the belief of the
patient. Psychodynamic formulation was wade and
he was assessed for suitability for Cognitive
Behaviour Therapy.
CBT sessions were started, however patient was not
very keen on continuing CBT sessions and wanted
a quicker relief. He insisted to be discharged so
that he could go to a Neurosurgeon for removing
the centipedes completely.
In view of the poor response to medications in the
past, he was started on ECT along-with his
antipsychotic medication.

18. Management (cont..)
• Intermediate
The patient showed improvement with
medications and ECT with reduction in his
distress, low mood, improved sleep and he
no longer needed to shake his head
because of reduction in movement of the
centipedes and healing of the wounds.
Although he was still convinced about the
dormant state of centipedes and expressed
fear of their reactivation after getting
discharged from the hospital.

19. Management (cont..)
• Long Term Management
• Patient was discharged on will after
improvement with 3 ECTs.
• we have to assure good compliance with
medications and set realistic treatment goals
without instilling false hopes.
• We would have continued with CBT sessions but
he could not stay longer in the ward because of
his personal problems.
• We will monitor him for complete recovery by
regular follow up to our OPD.

20. Prognosis
• Short Term:
• In view of response to medications and ECT the short
term prognosis seem satisfactory.
• Long Term:
• Inspite of good prognostic factors like absence of 1st rank
symptoms of schizophrenia, negative family history,
stable and sociable pre-morbid personality and late onset
of the disorder at the age of 53, the long term prognosis
would depend on patient’s adherence with treatment,
social support and health belief system and hence seems
guarded.

21. References
1) Semin Cutan Med Surg. 2013 Jun;32(2):73-7.
Delusions of parasitosis.
Levin EC, Gieler U.
Source
Department of Dermatology, University of California, 515 Spruce Street, San Francisco,
CA 94118, USA. Levine@derm.ucsf.edu
2) J Drugs Dermatol. 2012 Dec;11(12):1506-7.
Successful treatment of patients previously labeled as having "delusions of
parasitosis" with antidepressant therapy.
Delacerda A, Reichenberg JS, Magid M.
Source
Department of Dermatology, University of Texas Southwestern, Austin, TX, USA.
delacerda.ashley@gmail.com

22. References (cont..)
3) J Am Acad Dermatol. 2000 Oct;43(4):683-6.
Therapeutic update: use of risperidone for the treatment
of monosymptomatic hypochondriacal psychosis.
Elmer KB, George RM, Peterson K.
Source
Medical Service, Yokota AB, Japan.
4) J Clin Psychiatry. 1999 Aug;60(8):554.
Risperidone for the treatment of monosymptomatic hypochondriacal psychosis.
Cetin M, Ebrinç S, Ağargün MY, Yiğit S.

23. References (cont..)
5) Dermatol Clin. 1996 Jul;14(3):429-38.
Delusions of parasitosis and other forms
of monosymptomatic hypochondriacal psychosis. General discussion and
case illustrations.
Koo J, Gambla C.
Source
UCSF Psonasis Treatment Center, University of California, San Francisco Medical
Center, USA.
6) J Clin Psychiatry. 2005 Jun;66(6):800-1.
Monosymptomatic hypochondriacal psychosis: atypical presentation and
response to olanzapine.
Chand PK, Anand S, Murthy P.

24. References (cont..)
7) The British Journal of Psychiatry, Vol 153(Suppl 2), Jul 1988, 37-40.
Monosymptomatic hypochondriacal psychosis.
Munro, Alistair
8) Afr J Psychiatry (Johannesbg). 2013 Mar;16(2):87, 89.
Monosymptomatic Hypochondriacal Psychosis (somatic delusional disorder): a
report of two cases.
Ajiboye PO, Yusuf AD.
9) Br J Psychiatry. 1991 Sep;159:428-31.
Monosymptomatic hypochondriacal psychosis in developing countries.
Osman AA.
Source
Jeddah Psychiatric Hospital, Saudi Arabia.

25. References (cont..)
10) World J Biol Psychiatry. 2012 Feb;13(2):96-105.
Using ECT in schizophrenia: a review from a clinical perspective.
Zervas IM, Theleritis C, Soldatos CR.
Source
Department of Psychiatry, Athens University Medical School, Athens, Greece.
zerian@vivodinet.gr
11) Encephale. 2008 Oct;34(5):526-33.
[Maintenance electroconvulsive therapy and treatment of
refractory schizophrenia].
[Article in French]
Lévy-Rueff M, Jurgens A, Lôo H, Olié JP, Amado I.

26. References (cont..)
12) Psychiatry Res. 2001 Dec 15;105(1-2):107-15.
Combined ECT and neuroleptic therapy in treatment-
refractory schizophrenia: prediction of outcome.
Chanpattana W, Chakrabhand ML.
Source
Department of Psychiatry, Srinakharinwirot University, 681 Samsen, Dusit,
10300, Bangkok, Thailand. worch@loxinfo.co.th