Psychosis case management

Dr. Majid Al-Desouki

Consultant & Clinical Assistant
Professor
 Schizophrenia and Other Psychotic
Disorders
• Onset most frequently is in late teens, but can
become evident in 20s or 30s
• From some disease is chronic, for others there
are periods of exacerbation & remission, and
for others it can be one time occurrence.
• Illness affects perceptions, cognition, and
affect
 Most Common Symptoms
• Hallucinations
• Delusions
• Disorganized speech
• Bizarre behavior
• Inappropriate affect
• Confusion/ Disorientation
• “Negative” symptoms
 Hallucinations
• Auditory are most common form of hallucinations
associated with psychosis
• Voices – generally taunting or saying negative things to
person
• Command hallucinations – Hallucinations which tell
the individual to perform certain tasks
• Rare for command hallucinations to tell individual to
commit crimes – unless the crime is incorporated into
a delusional belief system
• Visual, olfactory, and sensory hallucinations can be
associated with neurological disorders, occasionally
with genuine psychosis, or may be feigned.
 Delusions
• Fixed, false beliefs that individual holds
despite evidence to contrary
• Can be bizarre or non-bizarre
• Content may include a variety of themes (e.g.
persecutory, referential, somatic, religious, or
grandiose)
• Persecutory delusions are most common –
being tormented, tricked, spied on, subjected
to ridicule
 Disorganized Speech/Thinking
• Loose Associations – ping ponging from one
subject to another with no clear string of
thoughts connecting the two
• Tangential – responses to questions only
remotely related to question at hand
• Word salad – incomprehensible, disorganized,
incoherent speech.
 Bizarre Behavior
• Disheveled
• Dress inappropriately (multiple layers of
clothing)
• Putting tin foil in strategic places
• Engaging in purposeless behavior repeatedly
• Catatonia
 Inappropriate Affect
• Laughing at inappropriate times
• Labile Affect – up and down rapidly
• Smiling or silly facial expression without any
apparent reason
 Confusion/Disorientation
• Can’t seem to hold and recall concepts after
repeated instruction
• Can’t remember date, location despite
repeated prompts
• Can’t recall who you are
 Differential Diagnosis: Psychosis
• Psychosis due to medical disorder?
• Psychosis due to medication?
• Psychosis due to drug/alcohol intoxication
or withdrawal?
• Psychotic depression or mania?
• Psychosis of schizophrenia?
• Delusional disorder?
 Clues that client may be psychotic
and/or has a history of psychosis
• Cotton or toilet paper in ears
• Disheveled and poor attention to hygiene
• Speech incoherent
• Voices convoluted delusional belief system and is
unresponsive to alternative explanations
• Looks around as if he/she might be hearing
something or is suspicious of surroundings
• Mentions medications such as Haldol, Prolixin,
Thorazine, Geodone, Risperdal, Clozaril,
 Case Study
• A 23 YO man came to an outpatient clinic for
symptoms of psychosis. He has always been a
loner who shows very little emotion and prefers
not to become involved with people. Since high
school, he has had no close friends and prefers
solitary tasks. He chose computers as a major in
junior college because he feels that "computers
are more rational and easier to deal with than
people" and after graduation obtained
employment as a computer programmer.
 Case Study
• He has no friends or hobbies, except working on
his computer, and has little contact with co-
workers or his family. Eight months ago, his
performance at work, which was marginal but
adequate, began to decline. About this same
time, he began to believe that his computer was
trying to communicate with him. Several times,
he heard a voice that he is convinced was the
computer talking to him. This did not disturb him
at first until he began to believe that the
computer was trying to control his thoughts.
 Case Study
• He was referred for inpatient admission, was
treated with antipsychotic medication, but
showed little improvement. Currently, it has
been four months since the onset of his overt
psychotic symptoms; he continues to take
antipsychotics on an outpatient basis but still
believes that his computer is trying to
communicate with him. He has not returned
to work and his parents have been paying his
bills for him.
 Case Study
• He presents as a quiet, shy, and aloof young
man who shows little if any emotion. Although
it was suggested that he also start individual
therapy to work on establishing relationships
and learning to express feelings, he refused.
There are no medical problems or history of
substance abuse.
 Case Study
• DSM-IV
– Axis I - Schizophrenia, Paranoid Type
– Axis II - Schizoid Personality Disorder (premorbid)
– Axis III - None reported
– Axis IV - Unemployment, inadequate social
support
– Axis V - GAF = 30 (current)
• DSM-5 Schizophrenia
– 301.20 Schizoid Personality Disorder (premorbid)
 CASE PRESENTATION
• A 21-year old male, single, college student,
suddenly runs out of his classroom. He shouts,
‘ back off ’ at a friend who follows him. He is
convinced that his teachers and classmates
intend to kill him. He hears the mocking voices
of his teachers coming from the electric fan
and on the classroom walls, talking about him
and calling him nasty names.
 CASE PRESENTATION
• The patient is brought to a GP. PE and lab tests
for illegal drugs are normal. He looks blankly at
the walls. He is inattentive and responds
irrelevantly to questions. He mumbles
incoherently, “A,B, (ZTE) F,G”. He accuses his
parents and the doctor to be in a plot to kill him.
He cannot be convinced otherwise.
• Judgement, impulse control, and insight are poor.
Sensorium is intact.
 CASE PRESENTATION
• Background: socially withdrawn and avoids
group activities; with few friends and lacks
initiative. An only child who relates poorly to
parents who are very busy. Father is very
critical and mother is overprotective. Mother
had a history of similar difficulties. current
episode is his second in two years. No meds
for three months
 CASE PRESENTATION
• A young man’s second episode of behavioural
changes like blank stares, hearing voices,
fixed ideas of being harmed, and irrelevant
speech. These occur in the background of
poor family bonding and lack of social
interactions. There is a positive family history
of psychiatric illness. No maintenance meds.
 LECTCASE PRESENTATION
Identifying Core Symptoms of Psychosis

• Positive Symptoms: HDL method *

Hallucinations – most important ; usually auditory,

multiple voices talking about the patient
Delusions - persecutory, bizarre, systematized
Looseness of associations – irrelevant speech, hard
to understand
* hallucinations and delusions should be present
 LECTCASE PRESENTATIONE
• Negative Symptoms: 4 As *

Alogia - limited speech ; tendency to mutism

Affective blunting – flat; blank stares; no emotion
Avolition – unexplained lack of initiative
Anhedonia – pervasive lack of interest / pleasure
unrelated to depression

* 2 or more enhance the diagnosis

 LECTUCASE PRESENTATIONRETTE
• Other Features: (exclusion criteria) *

At least six months duration

Social/occupational dysfunction
No mood disorder *
No substance abuse / medical condition *
 INTERACTIVE SESSION
• Positive symptoms of our patient:

What is the H?
What is the D?
What is the L?
 INTERACTIVE SESSION
• Negative symptoms of the patient:

Name at least 2 As:

A?
A?
 LECTUCASE PRESENTATIONRETTE
• Other features present in our patient:

Poor functioning: school, parents, peers

Positive family history (mother)
Second episode in two years
High emotional expressivity (or ‘High EE’)-
overcritical and overprotective parents
 PSYCHOTIC?
Positive and negative symptoms plus
impaired functioning but no mood symptoms
Due to substance ←↓→ Due to medical illness?
abuse? If no
↓
Ask duration
< 1month ← ↓ → < 6 months
Brief Psychotic Schizophreniform Disorder
Disorder
> 6 months
Schizophrenia
 Paintings by artist with worsening
psychosis – perceptual disturbances
 Case Report
• 30-year-old Saudi female, who had a normal childhood
and up- bringing. She enjoyed social and leisure
activities. She was an “A” student and then went to
medical school in Jeddah and completed 6 years, but
upon return to the Riyadh, she could not keep
complete her internship or pass any exams. In addition
to her academic decline, she was noted to be
withdrawn, suspicious, and exhibiting bizarre body
gestures for a few years without any medical or
psychiatric evaluation. The sub-psychotic symptoms
appeared gradually and the time frame was unclear.
 Case Report
• The patient had her first psychiatric
hospitalization at the age of 29 following an
argument with her father when she tried to
jump out of the car. She was hospitalized and
she presented with episodes of shaking his
entire body, lying on the floor and inability to
stop her trembles. During the episodes, she
was trying to pull her head backward, stating
that he wanted to break her neck or someone
was pulling her.
 Case Report
• During hospital stay, the patient was
disorganized, paranoid, and believed that she
was being judged by the public. She was
socially isolative with flat affect and neglecting
her personal hygiene. She denied any
perceptual disturbances. There was no history
of mood symptoms, substance use or medical
illness. The patient never self-medicated with
drugs.
 Case Report
• There was no family history of neurologic
condition or psychiatric illness. Her physical
examination was unremarkable. Neurology
consultation revealed nonspecific tic
movements. EEG was noncontributory and
seizure disorder ruled out. Organic pathology
was excluded with normal CT head, MRI brain,
blood work and negative urine toxicology.
 Case Report
• The psychiatric team felt that her body
gestures and shaking movements were
stereotyped and of a psychotic nature.
Interestingly, these episodes responded well
to olanzapine. The patient was discharged to
an outpatient clinic; however, she was
noncompliant with her medication and
appointments after discharge. This resulted in
one other hospitalization with similar
presentation.
 Case Report
• Following discharge, she presented to the
outpatient clinic. She responded fairly well to
olanzapine, with a noticeable decrease in her
shakes, paranoia, and social isolation.
 Case Report
• Within the next two months, despite
increasing olanzapine, the patient complained
of a new symptom which he called “pelvic
thrusts.” This involved shaking of the pelvic
area accompanied with tremors and upper
body movements. Her compliance with
medication was questionable. As per family,
the patient was agitated, pacing the house,
sleeping poorly, and exhibiting frequent
episodes of bizarre body gestures.
 Case Report
• Quetiapine was added and titrated with some
benefits. She was also tried on lorazepam and
clonazepam to relieve her anxiety and help
her sleep. A referral to a movement disorders
outpatient clinic was made; nevertheless, the
patient did not follow through. Eventually, she
stopped all her medications and refused to
come for appointments.
 Case scenario
• Sami
• Sami is a 16-year-old, who has been taken to a psychiatrist by his mother.
She is concerned that for the past 2 months he has been isolating himself.
His family have noticed he is staying awake most nights and seems to be
talking to himself. He admits to hearing voices that others cannot hear. He
says he has been using cannabis on a regular basis.
• Question:
• The psychiatrist suspects he has psychosis with comorbid substance
misuse. How should they assess Sami?
 Case scenario
• Answer:
• He should ask Sami about his use of cannabis and conduct an assessment
of dependency.
• The Psychiatrist should take time when assessing Sami, using a flexible
and motivational approach.
• Question:
• After assessment, the psychiatrist confirms that Mark has auditory
hallucinations and finds that he has been using SR60 worth of hashish on
most days for the last 3 months. What should happen next?
 Case scenario
• Answer:
• Sami should be referred to his local child and adolescent mental health
service to receive care and treatment for both his psychosis and his
substance misuse.
• When working with Sami, mental health workers should ensure that all
discussions take place within a confidential setting and that clinical
language is avoided.
• Sami’s mental health workers should ensure they are familiar with the legal
framework that applies to young people.
 Case scenario
• Answer continued:
• Sami and his family should be provided with written and verbal information
about both his psychosis and his substance misuse, and they should be
informed of the risks associated with substance misuse.
• Services provided for Sami should be age appropriate.
• Sami’s family should be encouraged to be involved in his treatment to help
promote recovery.
 Case study
• You have been seeing a 36-year-old male
client in therapy for several months. The client
has been diagnosed with schizophrenia and,
for some time, has been taking
phenothiazines that were prescribed when he
was in an in-patient psychiatric facility.
 Case study
• He has been in and out of such facilities since
the age of 27. He now lives in a halfway house
and you are helping him readjust to life in the
community. The client has been progressing
well and is becoming less and less anxious
about coping outside the hospital, but one day
you notice that he is experiencing involuntary
rhythmic facial tics and movements in his legs.
 Case study
• You should:
a. refer him to his psychiatrist since you suspect
he has stopped taking his medications
b. refer him to his psychiatrist since this may be a
side effect of his medication
c. understand that this is a side effect of the
phenothiazines and therefore reassure the client
d. for now attribute the tics to the client's anxiety
about readjusting to life outside of a hospital but
refer him to his psychiatrist if the symptoms
persist
 Case study

•What is the major difference between

schizophreniform disorder and schizophrenia:
a. schizophrenia is not accompanied by a flat
affect
b. the duration of the disorder
c. schizophreniform does not involve the loss of
adaptive functioning
d. age of onset
 Case study
• A social worker on the staff of a community
clinic evaluates a person brought in by the
police. The patient is a 75-year-old member of
the Navajo nation who was found sleeping on
top of a hill in a park. He told police he had
been in the park for two days and that he was
speaking to the spirits in preparation for his
death.
 Case study
• The most appropriate diagnosis for this patent
is probably:
a. schizophrenia
b. schizoaffective disorder
c. adjustment disorder
d. no diagnosis
 Question
• Restlessness, psychomotor agitation, flushed
face, diuresis, rambling speech, and muscle
twitching are most suggestive of:
a. alcohol withdrawal
b. caffeine intoxication
c. cocaine intoxication
d. hyperthyroidism