Requirement for MASTER OF PSYCHIATRY UNIVERSITI MALAYA

SCHIZOPHRENIA

CANDICATE MATRIC NUMBER EXAMINATION SUPERVISOR

: FATIHAH ADDAWIAH BINTI MOHAMED : : :

This is to certify that the candidate, Dr Fatihah Addawiah binti Mohamed has seen the patient, and to the best of my knowledge, this case protocol is entirely her original work.

DR SATNAM KAUR A/P HARBHAJAN SINGH

CONTENTS 1. IDENTIFICATION DATA 2. CHIEF COMPLAINT 3. HISTORY OF PRESENTING ILLNESS 4. PAST PSYHIATRY HISTORY 5. PAST MEDICAL AND SURGICAL HISTORY 6. DRUG HISTORY 7. FAMILY HISTORY 8. PERSONAL HISTORY 9. PREMORBID PERSONALITY 10. MENTAL STATE EXAMINATION 11. PHYSICAL EXAMINATION 12. INVESTIGATION 13. SUMMARY 14. PROVISIONAL DIAGNOSIS 15. DIFFERENTIAL DIAGNOSIS 16. FORMULATION

17. MANAGEMENT 18. CASE PROGRESS OF PATIENT 19. PROGNOSIS 20. DISCUSSION 21. REFERENCES

IDENTIFICATION DATA Name Age Gender Race Religion Occupation Marital status Address : Mr NM : 41 years old : Male : Malay : Islam : Teacher : Married : No 15, Jalan Bandar Baru Tambun 2, Bandar Baru Tambun, 31400 Ipoh, Perak Date of contact Seen at : 1st April 2013 : Psychiatry ward, Hospital Bahagia Ulu Kinta (HBUK)

Mode of referral Source of infomation

: Self referral : Patient and spouse

CHIEF COMPLAINT Admitted voluntarily to psychiatric ward for having auditory hallucinations which were commanding in nature to harm and kill himself and his family members. HISTORY OF PRESENTING ILLNESS Patient was previously well until 3 months prior to admission to psychiatric ward, whereby he started to be disturbed by auditory hallucinations. The auditory hallucinations were clearly heard by his ears, consisted of multiple voices of men and women voices, and he was able to distinguish one of the voice was his late grandmothers voices. The voices were second person in nature and were talking to him, and sometimes he would respond back to them. They were talking in Malay, derogating and commenting on his actions as well as critising him. The contents of the voices were mainly about bad and negative things. There also presence of third person auditory hallucinations as the voices were talking among themselves but still pertaining to him. The voices also commanding him to do bad things such as to hurt and kill himself and his family by stabbing with knife. However, he was still able to resist and never follow the command.

Apart from that, he could hear his own thoughts outloud which was suggestive of thought echo. He claimed his thoughts could be heard outloud by his ears and they were saying what he was thinking in his mind. There was no thought broadcasting and claimed only he himself could hear his own thoughts. There was no thought withdrawal or thought insertion. He believed that all of these disturbances he has experiencing were true perception and abnormal as only he could hear them. He did clarify with another people whether they could hear anything whilst he experiencing those auditory hallucinations. Initially, the disturbances were irregular in frequency and only presented on and off throughout the day. There were no precipitating factors and would be relieved by distracting himself such as talking to others. However, later on he was not able to ignore the voices as they were progressively increasing in frequency and intensity whereby the voices becoming more clearer and presented for most of the time. He believed that the voices were controlling him in a sense that they wanted to make him crazy and they had caused him to feel depressed. He was afraid if he could lose control of himself and scared if he would follow the voices commands to hurt himself, his family or anyone surrounding him. However, there was no self harm, suicidal and homicidal thoughts or attempts. He also had recurrent thought of death, which he scared he would act towards the commands. As result, he felt depressed as the voices constantly criticising and commanding him. He also had difficulty to fall asleep at night which caused him to feel lethargy at daytime due to lack of sleep. It further affected him at school as he could not concentrate to his teachings for feeling lethargy and disabling to ignore the voices. However there was no anhedonia, hopelessness,

worthlessness or other depressive symptoms. He claimed that the depressed mood started few weeks after the onset of auditory hallucinations, but it was not sustained for most of the day and only presented on and off for a shortwhile. Upon further questioning, Mr NM admitted that he had started to experience these auditory hallucinations for the past 2 years but there were only few recurrent brief episodes. Previously, he could hear the voices for about 2 to 3 times per month and only lasted for less than 30 minutes duration. They were second person auditory hallucinations of his grandmothers voice and not commanding or disturbing him. He could ignore the voices and was able to get along with it. Mr NM also had experience visual hallucinations since 3 months ago. He explained that he saw a white shadow which he believed it was a ghost and it only occured briefly for less than a minute. This only happened on and off and usually it happened at night time. Otherwise, there was no other perceptual disturbances. He denied of persecutory delusion and other delusions. Other Shneiderians first rank symptoms were not present. There were no manic symptoms and anxiety symptoms. None of his colleagues, students and family members noticed any changes in him except he was appeared a bit quiet and withdrawn than before. His wife noted patient did not talking much and kept to himself, but she thought he might had problems at school. Despite of the symptoms that he experienced, he was still able to go to work everyday. However, he was not able to concentrate in his teachings and classes as he was disturbed with the voices. He found this situation was distressing as he could not carry out his teachings properly as before.

Patient denied of substance abuse.

PAST PSYCHIATRY HISTORY Mr NMs first psychiatric contact was on 2009 which was 4 years ago. He was 37 years old on that time, whereby he first had experienced auditory hallucination for one month duration. The auditory hallucination was a single woman voice which patient described as a second person in nature. It was commenting on his actions as well as commanding him to do bad thing such as to kill his neighbours dog who wont stop barking. There was presence of thought echo which patient described he was able to hear his thought outloud and it was really distressing. There was no visual hallucination or other Schneiderians first rank symptoms. He was diagnosed with Schizophreniform Disorder, and was started with Tablet Risperidone 2mg ON. He claimed the treatment was helpful as the voice was disappeared after he took the medication for one month. Thus, he did not turn up to subsequent follow- up and defaulted his medication. Unfortunately, the auditory hallucinations recurred a year after. However, he did not seek for any medical help as they were not disturbing him like before, and he was able to get along with it.

PAST MEDICAL AND SURGICAL HISTORY Nil.

DRUG HISTORY No known drug allergies. Patient denied of taking any illicit drugs or alcohol. FAMILY HISTORY Patient is the second out of 3 siblings. 65 years old 63 years old

Patient 41 years old

His late grandmother (maternal side) had mental illness and had been hospitalized to Hospital Bahagia Ulu Kinta previously. She had suffered from Schizophrenia and had passed away 10 years ago due to old age. Father His father is a farmer. Patient described his father as a quiet person but a caring and loving father. He was not a strict person, but very concerned about his childrens educations. He had always encouraged his children to study hard. Mother

Patient claimed he is closed to his mother compared to his father. He described her as a cheerful and lovely person. She is very supportive and pays attention towards all family members. His mother is a salesperson and held a small business in health and beauty. Siblings Patient has 2 sisters. He is very closed to both of them. PERSONAL HISTORY

He was born full term, spontaneous vertex delivery. It was uneventful antenatal, intrapartum and postpartum history. His developmental milestones were normal and he grew up as a healthy and active boy. He related his childhood as a wonderful experiences. He grew up with two sisters and is very closed to them. He also closed to his uncle and even had help him at his restaurant since he was in primary school. He claimed he was very interested in cooking and he had learned a lot from his uncle about cooking. Education and occupation history Patient was a very active and outgoing student. He described his schooling years as a happy time and he had many friends at school. He was active in sports and had become a state of Kedah representator for hockey and a district representator for athletic games. He even had an excellent acedemic performance whereby he had obtained 5As in UPSR, 17 Aggregates in PMR, 24 Aggregates in SPM and 4 Principles in STPM.

He then further his studies in Diploma in Bahasa Malaysia and Music from Maktab Perguruan Sungai Petani. After finished his 3 years of diploma, he began to work as a Bahasa Melayus teacher at Sekolah Kebangsaan Terisu, Cameron Highland for 5 years. He started working at the age of 25 years old and got married 2 years later. He then requested and was transferred to Sekolah Kebangsaan Melayu Penang as to follow his wife, and he was teaching there for another 5 years. Subsequently, he was teaching at Sekolah Kebangsaan Gopeng, Perak after he had requested for another transfer as his wife was posted to Ipoh, Perak. He taught in Bahasa Melayu, Music and Pendidikan Jasmani. He pursuited his study in Degree in Music on 2009 from Open University Malaysia (OUM) as a Pendidikan Jarak Jauh . He passed his degree in 4 years with Currently, he is teaching at Sekolah Kebangsaan Pos Raya,Perak since 3 years ago. He teaches Bahasa Melayu as a main subject and Music and Pendidikan Jasmani as minor subjects.

Marital history Patient is married, blessed with 4 childrens. He was married when he was 27 years old, and it was a love marriage. His wife is working as Pembantu Tadbir Kewangan at Ulu Kinta. PREMORBID PERSONALITY MENTAL STATE EXAMINATION Middle age with medium sized Malay gentleman.

PHYSICAL EXAMINATION Conscious, alert and comfortable. Patient was pink, was not cyanose or jaundice. Blood pressure Pulse rate Temperature Weight Height BMI Cardiovascular system Respiratory system Abdomen Neurological Endocrinology : 113/64 mmHg : 77bpm : 37 degree celcius : 51kg : 160cm : 19.92 kg/m2 : Normal : Normal : Normal : Normal :Normal. There was no stigmata of hypothyroidism or

hyperthyroidism. INVESTIGATION Full blood count Renal profile Liver function test - normal - normal - normal

Facting blood sugar Fasting lipid profile Urine dipstick

- normal - normal - negative for amphetamine and metamphetamine

SUMMARY PROVISIONAL DIAGNOSIS Schizophrenia, Paranoid Type Reasons for Provisional Diagnosis The diagnosis of Schizophrenia for this patient was made according to the Diagnostic and Statistical Manual of Mental Disorder, IV Edition, Text Revision (DSM-IV-TR). He had presented with hallucinations and delusions which are the characteristic symptoms of Schizophrenia according to Criterion A of DSM-IV-TR for more than a month duration. Patient had been having auditory hallucinations for the past 2 years which was a single woman voice, second person in nature and not disturbing him. However, the symptoms were worsened since 3 months ago, as the number of the voices was increasing to multiple men and women voices. It was becoming more severe in term of increasing frequency and intensity of the voices. The auditory hallucinations were second and third person in nature, running commentary on his actions as well as commanding him to do bad things. Apart from that, he also had experiencing thought echo whereby he could hear his own thoughts.

Patient had delusion of control as he believed that he was being controlled by the auditory hallucanations as they had made him feel depressed and crazy. Eventhough he was still able to go to work during this period, he had difficulty to concentrate in his teaching and classes and further caused him to feel distress with this situation. This signified a marked disturbance in his occupational performance as a teacher. (Criterion B).

DIFFERENTIAL DIAGNOSIS FORMULATION MANAGEMENT CASE PROGRESSION PROGNOSIS DISCUSSION Schizophrenia is a severe mental disorder characterised by hallucinations, delusions disorganized speech, thinking and behaviour. It is an example of psychotic disorder whereby the affected person is withdrawn from the reality with illogical thinking (1). It is a complex disorder, whereby each individual who developed Schizophrenia will have different symptoms and presentation, influenced by different individual circumstances. It is listed in a top ten burden of medical disorders that caused disability worldwide (2).

The incidence and prevalence are approximately equal worldwide. Reported lifetime prevalence by Epidemiologic Catchment Area (ECA) is 0.6 to 1.9 percent. (3). In Malaysia, the incidence rate of Schizophrenia is 5 cases in 100,000 populations per year. The causes of this disorder is uncertain, but it is believed that genetic is the strong heritability and risk factor of Schizophrenia (5), with likelihood to develop this disorder is influenced by the closeness of relationship to the affected relative (3). The risk to develop this disorder is by 10-15% in the first degree relatives (5), and there will be reduce in genetic loading in subsequent second degree and third degree relatives (3). As for this patient, there is presence of genetic risk factor of developing Schizophrenia, which is contributed by his maternal grandmother. There is 5% risk of developing Schizophrenia in grandchildren whose any of grandparents had Schizophrenia. In general, the risk increased by 2-6% in second degree relatives (6). REFERENCE 1. Schizophrenia, Wikipidea (homepage on internet). Available from :

http://en.wikipedia.org/wiki/Schizophrenia. 2. Schizophrenia. The Nice Guideline on Core Interventions in the Treatment and Management of Schizophrenia in Adults in Primary and Secondary Care (Updated Edition), National Institute for Health and Clinical Excellence, The British Psychological Society and The Royal College of Psychiatrist, 2010. 3. Benjamin James Sadock, Virginia Alcott Sadock, Kaplan and Sadocks Concise Textbook of Clinical Psychiatry, Third Edition, Lippincott William and Willkins,2008

4. The National Mental Health Registry (NMHR), Med J, Malaysia, Volume 63, Supplement C, September 2008, p 15-17 5. Michael Gelder, Richard Mayou, John Geddes. Psychiatry Oxford Core Texts, Third Edition, Oxford University Press, 2005 6. Paul H Blaney, Theodore Millon. Oxford textbook of Psychopathology, Second Edition, Oxford University Press, 2008