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Grand Rounds Case Presentation

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Z. Wang

on 18 February 2014

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Transcript of Grand Rounds Case Presentation

Initial presentation:
42 year old Caucasian female, history of bipolar/psychosis NOS
Mother and stepfather called prior to the patient's arrival
February 13, 2014
Case presentation
Zhenni Wang, MD
Faculty Supervisor: Dr. Zakaria, MD
First Generation Antipsychotics
Second Generation Antipsychotics
High Potency
High EPS risk
Less anticholinergic
Low Potency
Low EPS risk
More anticholinergic
A.) Two or more of the following, each present for a significant portion of time during a one month period (or less if successfully treated).
1. Delusions
2. Hallucinations
3. Disorganized speech
4. Grossly disorganized or catatonic behavior
5. Negative symptoms
At least one of these
must be (1), (2), or (3)
B.) Functioning in school, work, interpersonal relations, or self-care is markedly below the level achieved prior to the onset of symptoms.
C. Continuous signs of the disturbance for at least six months, at least one month of which in clues symptoms in full and active form.
D. Schizoaffective and depressive or bipolar disorder with psychotic features have been ruled out.
E. Not due to substance or medical conditions.
F. If there is a history of childhood disorders such as autism, only diagnose schizophrenia if delusions and hallucinations are prominent.
Only one Criterion A symptom is required if delusions are bizarre or hallucinations consist of a voice keeping up a running commentary on the person’s behavior or thoughts, or two or more voices conversing with each other.
Subtypes: paranoid, disorganized, catatonic, undifferentiated, residual.
Differential Diagnoses
Psychosis: Differential Diagnosis
Sham PC, MacLean CJ, Kendler KS. A typological model of schizophrenia based on age at onset, sex an familial morbidity. Acta Psychiatr Scand. 1994 Feb;89(2):135-41.
Picchioni MM and Murray RM. Schizophrenia (a clinical review). BMJ: Vol. 335, No. 7610, 14 July 2007, p 91-95.
Wyatt RJ, Henter I, Leary MC, et al. An economic evaluation of schizophrenia—1991. Soc Psychiatry Psychiatr Epidemiol. 1995;30: 196–205.
Rice DP. The economic impact of schizophrenia. J Clin Psychiatry. 1999;60:4–6.
Dolder CR, Lacro JP, Leckband S, Jeste DV. Interventions to improve antipsychotic medication adherence: review of recent literature. J Clin Psychopharmacol. 2003 Aug;23(4):389-99. Review.
Didactic material for PGY-I's by Dr. Jibson and Dr. Dalack
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). Arlington, VA: American Psychiatric Publishing.
Bosanac P, Mancuso S, Castle D. Anxiety symptoms in psychotic disorders. Clin Schizophr Relat Psychoses. 2013 Sep 18:1-22.
Nasrollahi N, Bigdelli I, Mohammadi MR, Hosseini SM. The Relationship between Obsessions and Compulsions and Negative and Positive Symptoms in Schizophrenia. Iran J Psychiatry. 2012 Summer;7(3):140-5.
Achim AM, Maziade M, Raymond E, et al. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull 2011; 37:811.
McGlashan TH, Bardenstein KK. Gender Differences in Affective, Schizoaffective, and Schizophrenic Disorders. Schizophr Bull (1990) 16 (2): 319-329.
Test MA, Burke SS, and Wallisch LS. Gender Differences of Young Adults With Schizophrenic Disorders in Community Care. Schizophr Bull (1990) 16 (2): 331-344
Leucht C, Heres S, Kane JM, Kissling W, Davis JM, Leucht S. Oral versus depot antipsychotic drugs for schizophrenia--a critical systematic review and meta-analysis of randomised long-term trials. Schizophr Res. 2011 Apr;127(1-3):83-92.
Lindamer LA, Lohr JB, Harris MJ, Jeste DV. Gender, estrogen, and schizophrenia. Psychopharmacol Bull. 1997;33(2):221-8.
Called her parents this evening, hysterical, rapid speech, labile affect, talking about "god, angels, and how she would become a demon."
Hiding behind a school


Too scared to go to sleep

Hasn't slept since Christmas

Wouldn't tell her mother where she was

Mother kept her on the phone until police were able to triangulate her location and pick her up.
Fixated on a local minister, stating that she knows that he loves her.

This minister had to block her number because of the amount that she was texting and calling him.

Reports that God can text and fax her.
Paranoia about evil
spirits has led her to live
in a hotel.
Review of her records in CPRS reveals that during a past admission
to AIMH several months earlier, she had been hearing voices, thinking
she is having sex with God, thinking she is a "direct vessel from the Savior." She was sleeping in her car, afraid to go back into her apartment because she hears voices there and "could fall prey
to sexual relations with God."
Per mother, she was standing in the bathtub earlier today with a razor, "having decided she would die."
When you talked to the patient, she is evasive. Says she has had "spiritual breakdowns" but minimizes her symptoms. Flatly disagrees that she has a mental illness and doesn't see any reason to take her medication. Says that school, work, finances, and housing aren't going well, but does not think any of it is related to her mental state. However, she is unsure what else it could be. When you point out her 3 hospitalization within the last 3 months, she says that's just the doctor's opinion.
Elyn Saks, J.D., Ph.D.
Thirty years ago, I was given a diagnosis of schizophrenia. My prognosis was “grave”: I would never live independently, hold a job, find a loving partner, get married. My home would be a board-and-care facility, my days spent watching TV in a day room with other people debilitated by mental illness. I would work at menial jobs when my symptoms were quiet. Following my last psychiatric hospitalization at the age of 28, I was encouraged by a doctor to work as a cashier making change. If I could handle that, I was told, we would reassess my ability to hold a more demanding position, perhaps even something full-time.
Then I made a decision. I would write the narrative of my life. Today I am a chaired professor at the University of Southern California Gould School of Law. I have an adjunct appointment in the department of psychiatry at the medical school of the University of California, San Diego, and am on the faculty of the New Center for Psychoanalysis. The MacArthur Foundation gave me a genius grant.

Although I fought my diagnosis for many years, I came to accept that I have schizophrenia and will be in treatment the rest of my life. Indeed, excellent psychoanalytic treatment and medication have been critical to my success. What I refused to accept was my prognosis.
Elyn R. Saks is a law professor at the University of Southern California and the author of the memoir “The Center Cannot Hold: My Journey Through Madness.”
A typological model of schizophrenia based on age at onset, sex an familial morbidity. Acta Psychiatr Scand. 1994 Feb;89(2):135-41.
Cost of Schizophrenia
$33 - 65 billion dollars
Direct treatment costs
Loss of productivity
Expenditures for public assistance
Anxiety and Schizophrenia
Social anxiety disorder...........................14.9%
Post-traumatic stress disorder..............12.4%
Obsessive compulsive disorder...............12.1%
Achim AM, Maziade M, Raymond E, et al. How prevalent are anxiety disorders in schizophrenia? A meta-analysis and critical review on a significant association. Schizophr Bull 2011; 37:811.
The Relationship between Obsessions and Compulsions
and Negative and Positive Symptoms in Schizophrenia
Yale-Brown Obsessive-Compulsive Scale (Y-BOCS)
Positive And Negative Syndrome Scale (PANSS)
Conceptual disorganization
Lack of insight (97%)
Auditory hallucinations (74%)
Ideas of reference (70%)
Delusions of reference (67%)
Suspiciousness (66%)
Delusional mood (64%)
Delusion of persecution (64%)
Thought alienation (52%)
Thoughts spoken aloud (50%)
Blunted affect
Emotional withdrawal
Poor rapport
Passive/apathetic social withdrawal
Difficulty in abstract thinking
Lack of spontaneity and flow of conversation
Stereotyped thinking
Negative scale
Positive scale
How was OCD related to positive and negative symptoms?
Nasrollahi N, Bigdelli I, Mohammadi MR, Hosseini SM. The Relationship between Obsessions and Compulsions and Negative and Positive Symptoms in Schizophrenia. Iran J Psychiatry. 2012 Summer;7(3):140-5.
Obsessive symptoms inversely predict negative symptoms.
No significant relationship was found between OCD and positive symptoms .
Major limitations of study:
Small sample size,
Retrospective study
................but nonetheless interesting!
Summary (take-home points)
Your thoughts?
Gender differences in schizophrenia
Women with schizophrenia tend to have a less severe clinical presentation and clinical course.
Are less likely than male patients to have negative symptoms, social withdrawal, and blunted or incongruent affect, substance abuse, and antisocial behavior.
Are more likely than male patients to present with mood disturbances, depressive symptoms and atypical affective features.
Gender differences in schizophrenia
Schizophrenia, Schizoaffective, Brief Psychotic, Delusional
Bipolar (manic episode) or Major depression, with psychosis
Substances, GMC, Dementia/Delirium
1st admission (10/2013)
First break
In 2010, when patient was 38 years old and at outside hospital
Prior to that, functioned OK. Worked for 13 years as medical assistant at U of M
Diagnosed as a brief psychotic episode
Received Haldol, with akasthesia
From her brother, we learn that she was "always strange and socially awkward with few close friends", even before she started hearing voices in 2010. For example, one time, she got keys made, and said the clerk gave her a poem about the Prince of Darkness, and she suddenly knew he was evil. Also reported a strange man showing up at her door in the past; he knew her name and told her she was supposed to live with her.
Offered lithium or Depakote. She was resistant to both, but eventually chose lithium.
Was discharged on lithium, ziprasidone, and lorazepam.
Past medical/psychiatric history:
Distant history of anorexia nervosa
Brief psychotic episode in 2010
Family history:
Mother with mild OCD
What happened....
Declined all meds
Inpatient team got an ATO
Lithium was titrated and was therapeutic on discharge, risperidone was started, with Cogentin
Due to reported history of akasthesia on risperidone and Haldol, we trialed her on another antipsychotic. We chose aripiprazole, as it is available in an IM depot form.
Tolerated a trial of oral aripiprazole, denied side effects except for dry mouth, but was extremely anxious about side effects. Politely but repeatedly refused injectable formulation. ATO was still in effect, but we wanted patient's cooperation. Whenever we discussed an injection, she said maybe she was feeling very restless and probably had akasthesia.
After 1 week on oral Abilify, she showed some improvement. She continued to have auditory hallucinations of a religious nature, although she was able to hide it better and stated it was only 10% of the time.
Lithium was subtherapeutic
She had stopped taking risperidone, stating she had akasthesia
Eventually had a family meeting, with patient, inpatient team, outpatient psychiatrist, a 2 brothers and 2 sister-in-laws (one lived close by, the other lived farther away), and father with teleconferencing. Everyone expressed their deep concern.
Continued to deny any psychiatric diagnosis, except anxiety, but was agreeable to injectable Abilify Maintena.
Depot formulations significantly reduced relapses with relative and absolute risk reductions of 30% and 10%, respectively (RR 0.70, CI 0.57–0.87, NNT 10, CI 6–25, P = 0.0009),
Leucht C, Heres S, Kane JM, Kissling W, Davis JM, Leucht S. Oral versus depot antipsychotic drugs for schizophrenia--a critical systematic review and meta-analysis of randomised long-term trials. Schizophr Res. 2011 Apr;127(1-3):83-92.
Ms. D received 18 on Y-BOCS (moderate symptoms)
Any guesses on relationship of positive/negative symptoms to OCD?
Social withdrawal
Self neglect
Loss of motivation and initiative
Emotional blunting
Paucity of speech
Positive Symptoms:
Negative Symptoms:
What happened....
Women can have an atypical presentation of schizophrenia, involving later onset, better prognosis, and affective component.
Depot injections can lead to better compliance.
Outcome depends on psychiatric and medical care, but also, critically on having a stability in one's life, including income, housing, and social support.
There is significant overlap of anxiety and schizophrenia.
(take-home points)

A 25-year-old male is admitted to the hospital for his belief that the world is going to end. He states that the television and newspapers have told him the world is soon coming to an end, although he is unsure of the exact date. He also states that he feels his family wants to kill him because they believe the world could be saved if he were dead. He denies feeling depressed, and denies suicidal or homicidal ideation. He has been hospitalized with similar symptoms seven time in the past four years. He usually responds well to treatment, but then stops taking his medication shortly after leaving the hospital. He has no medical problems except for childhood asthma, and has no known drug allergies. His father has a history of schizophrenia and his mother has bipolar disorder. Physical examination reveals no abnormalities. He is 5 feet 10 inches tall and weighs 163 pounds. His BMI is 23. Which of the following is the most appropriate maintenance medication for this patient?

A) Aripiprazole
B) Chlorpromazine
C) Fluoxetine
D) Haloperidol decanoate
E) Olanzapine
She denied this later in the admission, saying that she knew she wasn't going to do it, even though she got in the tub anyway.

But she also said that she had filled the tub with water to prevent her blood from clotting.

She then minimized the entire event and said it was weeks ago.
Sending a friend (30 to 100) excessive numbers of text messages and e-mails, complaining of anxiety. Also made suicidal statements.
Missed an outpatient appointment, prompting a wellness check. Police officers were unable to find her.
Eventually called outpatient provider, saying she was hearing voices telling her she wasn't going to heaven, thoughts taken from her head, somatic delusions (ie: heart being pulled out), says she is being possessed by dead spirits.
She was on sertraline for 1.5 weeks for presumed OCD diagnosis but stopped taking it. Also started lamictal recently.
When interviewed in ED, very evasive, saying that she is "calm" and anxiety was "gone."
Hadn't been sleeping, had pressured speech, speaking quickly, but stated this was only out of concern for the doctor, who has "limited time."
2nd admission (12/2013)
Cost of

Gender differences
in schizophrenia

Anxiety and

Multiple family members expressed concerns for patient's safety since her discharge.
Med non-compliant, and missed a follow-up appointment, again prompting a wellness check.
Took her first dose of lithium the day prior to 2nd admission (about a month after last discharge), but later stated in the interview she disagreed with her bipolar diagnosis and saw no need to take medication.
Passive suicidal thoughts, hyperverbal with circumstantial speech
Denied distractibility, elevated mood, grandiosity, flight of ideas, or impulsivity.
Continued have derogatory auditory hallucinations of a religious nature.
Chalked everything up to anxiety.
To be discussed at the
Psych Book Club:

Saturday, February 22 at 7:30pm

Dan Wurzelmann
Full transcript