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This is a case of M.E.

a 50 year old, male, married who lives in


Brgy. Jona, Tubungan, Iloilo. Symptoms started a month prior to
admission, when he had difficulty in falling asleep. Patients wife would
notice that the patient would go to bed uneasy and would twist and
turn every now and then. After a while, he would get up and go to the
rice dryer even at the middle of the night just to place barbed wired
around it. Soon enough other symptoms manifested such as sudden
behavioral changes such as blocking the motorists in their area and
pointing a knife at them. He also had feelings of grandiosity such as
asking the motorists if they knew who he was.
Basing from the history presented, patient is noted to have
psychotic symptom such as auditory hallucinations, inability to
maintain an adequate sleeping pattern and behavioral changes. He is
also having cognitive symptoms such as, disorganized thoughts,
looseness of associations, difficulty concentrating and/or following
instructions, difficulty in completing tasks. Patient has no family history
of psychiatric problems on both sides.
Basing from MSE, patient is noted to be oriented to time, place
and person, poor memory, poor calculation and concentration, good
fund of knowledge, poor impulse control, poor insight, fair judgment.
Abstract reasoning was not elicited due to at the time of admission
patient was uncooperative. Although patient denies to be having visual
and tactile hallucinations; and suicidal or homicidal ideations these still
cannot be ruled out.
Differential Diagnosis:
Disorder
Schizophrenia

Duration
6
month
s

Rule In
Equally
prevalent in
men and
women
Delusion or
hallucination
of illness
during which
for 2 or more
weeks in the
absence of a
major
(Delusion

Rule Out
Peak age in men
is 25 years old
Patient has no
familial tendency
of having
schizophrenia
The 6-month
period must
include at least 1
month of
symptoms
Paranoid type
(late 20s to 30 s)

Schizophrenifo
rm

Schizoaffective

Delusional
Disorder

Substance

During 1month
period

1
month

persecutory)
Level of
functioning
(work) has
been below
the level of
functioning
before

Delusion
persecutory
Disorganized speech
Duration an
episode that lasts at
least 1 month but
less than 6 months
Men with
schizoaffective
disorder are likely to
exhibit antisocial
behavior
and to have a
markedly flat or
inappropriate affect
- Delusion or
hallucination
of illness
during which
lasted for 2 or
more weeks in
the absence of
a major
(Delusion
persecutory)
- Men are more
likely to
develop
paranoid
delusions
-

No hallucination
Grossly disorganized or
catatonic behavior
Negative symptoms
(diminished emotional
expression or avolition)
more than twofold
female to
male predominance
among individuals with
the depressed subtype
of schizoaffective
disorder

Slight
preponderance
in female
population
Patient currently

related
disorders

doesnt smoke
and only drinks a
shot or two of
whisky or up to
three bottles of
beer on
occasions and
celebrations like
town fiestas

Factitious
Disorder

Brief episode

Delirium

Abnormalities
of mood,
perception,
and behavior
are common
psychiatric
symptoms.
Sudden onset
Rapid
improvement
when the
causative
factor is
identified
Patient is
elderly ( 1%
of elderly
persons age
55 years or
older)
Precipitating
factor:
environmental
: prolong sleep
deprivation
Predisposing

Psychiatric
symptoms are
intentionally
done
There is no
evidence from
the history,
physical
examination or
laboratory
findings that the
disturbance is a
direct
consequence of
another medical
condition,
substance
intoxication or
withdrawal

factor: 65
years old and
older, male
sex

Our first consideration in the diagnosis of the patient is Schizophrenia


due to the fact that it is equally prevalent in men and women. There is
also presence of delusion of grandeur and auditory hallucination of
illness during which lasted for 2 or more weeks in the absence of a
major (Delusion - persecutory) and level of functioning (work) has been
below the level of functioning before however, we ruled it out because
the peak age in men would usually be at 25 years old; patient has no
familial tendency of having schizophrenia; the 6-month period must
include at least 1 month of symptoms and a Paranoid type of
schizophrenia would usually manifest at late 20s to 30s. Another
consideration would be Schizoaffective disorder; this is being ruled in
because men are likely to exhibit antisocial behavior and to have a
markedly flat or inappropriate affect however, we ruled this out
because more than twofold of female to male predominance. Another
is delusional disorder, because men are more likely to develop
paranoid delusions however it is being ruled out since the patient
exhibit bizarre delusions. In delusional disorder, delusions are non
bizarre which are about real life such as being followed, infected and
loved at a distance. Another would be, Substance related however,
patient doesnt smoke and only drinks a shot or two of whisky during
occasions and celebrations thus we ruled it out. In factitious disorder,
we considered this because it occurred in a brief duration however its
been ruled out since psychotic symptoms are intentionally done and
lastly we considered delirium due to the fact that it can manifest as
abnormalities of mood, perception, and behavior. It is also sudden in
onset and common among elderly. One precipitating factor noted was
prolonged sleep deprivation and the fact that he is a male would
predispose him to have a higher chance of having delirium. It is being
ruled out since there is no evidence in the history and physical
examination that it is a direct consequence of another medical
condition, substance intoxication or withdrawal.
Considering the following symptoms mentioned above, a diagnosis of
brief psychotic disorder was made.

Diagnosis
A. In order to come up with a diagnosis of Brief Psychotic Disorder, the
presence of 1 or more of the ff. symptoms or at least one of these must
be (1), (2) or (3):
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
B. Duration of an episode of the disturbance is at least 1 day but less
than 1 month, with eventual full return to premorbid level of
functioning
C. The disturbance is not better explained by major depressive or
bipolar disorder with psychotic features or another psychotic disorder
such as schizophrenia or catatonia and is not attributable to the
physiological effects of a substance or another medical condition.
Specify if:
With marked stressor: (brief reactive psychosis): if symptoms occur
in response to events that, singly or together, would be markedly
stressful to almost anyone in similar circumstances in the individuals
culture.
Without marked stressors: If symptoms do not occur in response to
events that singly or together, would be markedly stressful to almost
anyone in similar circumstances in the individuals culture.
With postpartum onset: If onset is during pregnancy or within 4
weeks postpartum,
Specify if:
With catatonia
Specify current severity:
Severity is rated by quantitative assessment of the primary symptoms
of psychosis including delusions, hallucinations, disorganized speech,
abnormal psychomotor behavior, and negative symptoms. Each of
these symptoms may be rated for its current severity (most severe in
the last 7 days) on a 5 point scale ranging from 0 (not present) to 4
(present and severe)
Note: A diagnosis of brief psychotic disorder can be made without
using this severity specifier.
BRIEF PSYCHOTIC DISORDER
Epidemiology

Acute and transient psychotic disorders are rare, especially in


industrialized settings. As a result, data on their incidence or
prevalence are limited with a particular paucity of research on their
occurrence in developing countries such as the Philippines. Much of the
present knowledge of these disorders has come from clinical samples,
but their brief nature means that many individuals with acute and
transient psychoses will never come to the attention of mental health
services. Age of onset was also younger (mid-20s) in the developing
than developed (mid-20s to 30s) countries. Age of onset was even
higher (30s to 50s) in a German clinical sample. The most common
specific disorder in the group of ICD-10 acute and transient psychotic
disorders is likely polymorphic psychotic disorder without symptoms of
schizophrenia, comprising between a third to a half of all cases of
acute and transient psychotic disorders, followed in frequency of
occurrence by polymorphic psychotic disorder with symptoms of
schizophrenia. Brief psychotic disorder is perhaps even less common
than acute and transient psychotic disorders, although the two
disorders overlap considerably. Similar to acute and transient psychotic
disorders, brief psychotic disorder is more common among women
than men. Also similar to acute and transient psychotic disorders, age
of onset of brief psychotic disorder in industrialized settings appears to
be higher than in developing countries.
Etiology
Little is known about the etiology of acute and transient
psychotic disorders and even less is known about brief psychotic
disorder. The available evidence for acute and transient psychotic
disorders points to both biological and sociocultural factors as possible
causes. Information on the biochemical, physiological, and anatomical
correlates of these disorders is limited, and the available data do not
reveal any distinctive abnormalities that would suggest a specific
etiology. No genetic studies and few family studies of ICD-10 acute and
transient psychotic disorders or brief psychotic disorders have been
conducted. The high incidence rate of acute and transient psychotic
disorders in developing country settings has also led to speculations
about the role of sociocultural factors in the etiology of these
syndromes. It has been suggested that rapid cultural change and
modernization in the developing countries expose individuals to loss of
status and stress arising from role confusion, making individuals
vulnerable to psychotic reactions.
Treatment:
PHASES OF TREATMENT IN SHIZOPHRENIA
A. Acute Phase

Requires immediate attention


Focuses on the most severe psychotic symptoms
This phase usually lasts for 4-8weeks
With highly agitated patients, intramuscular administration of
antipsychotics produces a more rapid effect. An advantage of an
antipsychotic is that a single intramuscular injection of
haloperidol (Haldol), fluphenazine (Prolixin, Permitil), olanzapine
(Zyprexa), or ziprasidone (Geodon) will often result in calming
effect without excessive sedation.

B. Stabilization or Maintenence Phase


The illness is in a relative stage of emission
The goals during this phase are to prevent psychotic relapse and
to assist patients in improving their level of functioning.
patients are usually in a relative state of remission with only
minimal psychotic symptoms. Stable patients who are
maintained on an antipsychotic have a much lower relapse rate
than patients who have their medications discontinued.
It is generally recommended that multiepisode patients receive
maintenance treatment for at least 5 years.

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