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PSYCHIATRY

(SPK 3961)

CASE WRITE UP
Brief Psychotic Disorder
FOURTH YEAR MEDICAL STUDENT 2016/2017

Name : Soo Man Jun


Matrix No : 174792
Date : 8/3/17
Supervisor : Dr. Ang Jin Kiat
I. Patients Particular
Name : Yassir
Age : 21 years old
Gender : Male
Race : Moroccan
Religion : Muslim
Marital Status : Single
Occupation : Student
Ward : Psychiatric Ward 2 HKL
Date of Admission : 2/3/2017
Date of clerking : 6/3/2017

II. HISTORY
A: Chief Complaint:
Patient was brought to Hospital HKL by the police due to disorganized behavior one day
prior to admission.

B: History of Present Illness:


Patient came to Malaysia for the first time one month ago to have a vacation and find a
university to continue his study. He landed at KLIA and went Johor Bahru and lived in a
guest house there. During his stay in Johor Bahru, all his belongings were stolen one
night in the guest house. He felt that he was very stressed and lost at that moment as this
was his first time leaving his country and losing all his belongings. He mentioned that
that was his most hopeless moment in his life. Since then, he had been thinking a lot of
things, including how was he going to survive and how was he going to return to
Morocco given that he had lost all his money. He also complained that it had been
difficult to sleep at night, whereby he was able to sleep for about 3 hours every night in
the street. However, there was no suicidal thought or any thought of deliberate self-harm.

He also complained of having 2nd person auditory hallucination as he mentioned to be


hearing voices which he described it to be originated from inside his mind. He claimed
that the God of Creation was talking to him and addressed him as Yassir The voice had
been trying to convince him that his real identity was actually Luffy from a manga called
One Piece and he was asked to go on a journey to search for a fruit that can grant him
special power. He couldnt control the voice and it was almost there throughout the day.
However, he wasnt troubled by it and felt very happy instead and he felt that he was very
special. Otherwise, it was not commanding in nature initially, commenting on each action
he did, or repeating his own thinking.

Few days after he had lost all his belongings, when he was wandering in the street, he
suddenly had an instruction from the voice asking him to take off his clothes. He did not
want to but somehow both of his hands were moving in such a way that his clothes was
taken off without his control. He claimed that something was taking control of his hands
and did all those actions. He was crying and praying to his God while his clothes is taken
off while running on the street. He was then brought by the police to the hospital and
stayed there for a week and was given antidepressants throughout the stay.

He was well and stable with no symptoms after discharge until one week ago when he
decided to come KL, the voice came back again and told him the same thing about him
being Luffy. One night before admission, he felt stressed and lost again, as he was
supposed to go back on 1 March and his flight ticket was lost. He went to Brunei
embassy to hope for some donation or some kinds of help that can help him to return to
Morocco. However, the staff said that he needed his passport for them to help and he
should go Morocco embassy instead of there. Patient suddenly got angry and told them
that he was the Prince of Brunei and he was Brunei citizen and asked them to send him
back to Brunei. The embassy staff called the police and he was then brought to HKL.

On further questioning, patient thought that the reason he was having these voices and
weird behavior is because someone has been jealous of him and putting black magic on
him. However, he could not specify any person that he could identify of.

During his stay in Malaysia, there was no substance usage, like cannabis, alcohol or
amphetamine. He had not smoked in Malaysia. He had no other medical condition. He
denied of any fever or history of head trauma.

C: Past Psychiatric History:


Patient had no past psychiatric history.

D: Past Medical & Surgical History:


Patient had no past medical and past surgical history.

E: Family History:
Both of his parents passed away. His father passed away at the age of 40 years old due to
a motor vehicle accident 6 years ago, while his mother died of leukemia when he was 9
years old. He has only one 18-year-old younger sister with no known medical illness. He
has a stepmother with 2 half-brothers of 9 and 5 years old as well. He has family history
of mental disorder whereby his uncle had one but he was unsure of what illness was that
and he committed suicide by falling from height.

F: Past Personal History:


Patient was born by spontaneous vaginal delivery, however he was unsure of any
complication during or after she was born. He mentioned that he was an excellent student
in both primary and secondary school. During primary school, he could maintain to stay
his ranking in the first 10th position. He completed high school in a private school using
German language. He described himself to be very friendly, funny and helpful. He had
many friends that he could hang out with and he had no problem dealing with his peers.
He had no history of relationship before. He planned to continue his study in Malaysia.

G: Current Social History:


He is a student currently trying to pursue his tertiary education in Malaysia. He just
finished his high school in Morocco. He was an occasional smoker back in Morocco but
he claimed that he wants to quit and he had never smoked once he reached Malaysia. He
also drank alcohol occasionally about 8 units per month since he was 18 years old but he
had never taken any during his stay in Malaysia. There was no history of illicit drug
usage. He currently live alone in the street as he had no money spent on accommodation.

III. MENTAL STATUS EXAMINATION


A: General Appearance and Behavior
The patient was dressed in hospital attire, walking around with bare foot. He looked clean
and tidy. No abnormal gait or posture was observed. There were no abnormal movement
and no sign of anxiety for example sweaty hands, wide eyes, frequently changing posture
and frequent swallowing. He was co-operative and made good eye contact. Rapport was
superficial. He was very friendly to strangers and talking to random people.

B: Speech
Language: English
Amount: Normal
Volume: Normal
Speed: Normal
Tone: Normal

C: Mood and Affect


Mood: The patient felt happy. He ranked his mood 7/10.
Affect: The patient looked elated. He had broad affect, and was appropriate and
consistent.

D: Thinking
Form: Her thought was coherent but relevant.
Flow: There was no flight of ideas and circumstantiality noted.
Content: He had delusion of grandiosity and persecution. There was no suicidal attempt.
Possession: There was no thought insertion, withdrawal or broadcasting.

E: Perceptual Disturbances
He had auditory hallucination.

F: Cognition
Orientation: Patient was orientated to time, place and person.

G: Attention and Concentration


Patient had good attention and concentration. She was able to complete the serial 7
subtraction test within 120 seconds without mistake.

H: Memory
The patient memory was intact.
Immediate: Patient was able to complete the digit span test until 5 numbers.
Recent: Patient was able to recall all 5 different objects after 5 minutes of distraction.
Remote: Patient was able to give her identification number correctly.

I: Information and Intelligence


Comprehension: Patient had good understanding on my questions during clerking.
General knowledge: Intact.
Arithmetic: He was able to solve simple mathematics.
Vocabulary: He had good vocabulary.

J: Abstract Thinking
Patient was able to understand the meaning of the proverb that given.
Patient was able to tell similarity and difference of objects given. The abstract thinking
was intact.

K: Judgment
Social judgment: He thinks that the actions and the voices he heard were not normal, he
felt ashamed of what he did
Test judgment: If the hospital were on fire, he will try to escape from the hospital and call
for help.
Personal judgment: The patient wanted to continue his study after discharge.
Patients judgment was intact.

L: Insight
Patient had poor insight. He knew he had psychiatric illness but he thinks that he is
normal. He was compliant to the medication and he knew that the medication is going to
help to treat his psychiatric illness.

IV. PHYSICAL EXAMINATION


1. Vital Signs
Temperature : 37.0C (36.6 - 37.2)
Pulse Rate : 60 bpm (60 - 100)
Blood Pressure : 120/60 mm Hg (100-140 / 60-90)
Respiratory Rate : 20 breath/min (16 -20)
SpO2 : 99% on room air

Patients vital signs were normal.

2. General assessments:
On general examination, the patient was conscious and alert. He was pink and well
nourished. He was not in any IV drip or restrained. There were no superficial cuts noted
on the arms. There was no abnormal movements and posture noted. The thyroid was not
palpable and there were no signs of hyperthyroidism such as sweating, tremors and
thyroid eye signs. Examination of other systems was unremarkable.
V. SUMMARY
Yassir, a 21-year-old single Moroccan gentleman, with no known medical illness, was
brought by the police to HKL due to disorganized behavior in Brunei embassy one day
prior to admission associated with one month of 2nd person auditory hallucination,
delusion of grandiosity, control and persecution. Mental state examination revealed that
he was depressed

VI. PROVISIONAL DIAGNOSIS


Brief Psychotic Disorder
1. Patient fulfilled 3 out of 4 criteria for brief psychotic episode according to DSM-V:
- 2nd person auditory hallucination which is commanding in nature
- Delusion of persecution, control and grandiosity
- Disorganized behavior
2. The disturbances lasted at least 1 day and persisted throughout the month he was here
in Malaysia in which he was previously well.
3. There was no substance uses involved and he had no other medical condition.
4. His disturbances did not fit into criteria of schizophrenia, bipolar disorder with
psychotic features or major depressive episode with psychotic features.

VII. DIFFERENTIAL DIAGNOSIS


1. Schizophreniform Disorder
Points For Points Against
2nd person auditory hallucination The duration of disturbances was less
which is commanding in nature than one month
Delusion of persecution, control and No negative symptoms
grandiosity
Disorganized behavior
His functioning was certainly
impaired as he was unable to solve his
problem faced in Malaysia
There was no substance uses involved
and he had no other medical
condition.
His disturbances did not fit into
criteria of schizophrenia, bipolar
disorder with psychotic features or
major depressive episode with
psychotic features.

2. Delusional Disorder
Points For Points Against
He had delusion of persecution, He had auditory hallucination and
control and grandiosity. disorganized behaviour
Criterion A for schizophrenia was The duration of disturbances was less
never met than one month
His disturbances did not fit into His functioning was certainly
criteria of schizophrenia, bipolar impaired as he was unable to solve his
disorder with psychotic features or problem faced in Malaysia
major depressive episode with
psychotic features.

VIII. INVESTIGATION
Biological investigation:
1. Full Blood Count
Component Result Normal Range
White Blood Cells (WBC) 7.80 x 109/L (5.0-15.0)
Haemoglobin (Hb) 13.1 g/dL (11.0-14.0)
Platelet (Plt) 234 x 109/L (150-400)
Haematocrit (Hct) 37.0% (40-54)
Interpretation: There was no sign of infection.

2. Renal profile
Component Result Normal Range
Urea 4.7 mmol/L (3.2-9.2)
Sodium 137 mmol/L (136-145)
Potassium 3.7 mmol/L (3.5-5.1)
Creatinine 70 umol/L (62-115)
Interpretation: Renal Profile was normal.

3. Liver Function Test


Component Result Normal Range
Total Protein 67 g/L (64-83)
Albumin 44 g/L (35-50)
Total Bilirubin 12 umol/L (3.4 20.5)
Alkaline Phosphatase 70 U/L (40-150)
Alanine Transaminase 15 U/L (<42)
Interpretation: Renal Profile was normal.

4. Urine Toxicology
Interpretation: Negative

5. Serum Ca, Mg & PO4


Component Result Normal Range
Calcium 2.24 mmol/L (2.2-2.7)
Magnesium 0.86 mmol/L (0.75-0.95)
Phosphate 1.17 mmol/L (0.8-1.5)
Interpretation: Serum Calcium, Magnesium were within normal range.

Psychosocial investigation:
I would like to obtain more premorbid history from his family members, but it would be
not possible since he was alone in Malaysia. I would also like to trace back his psychiatry
history when he was admitted into the hospital in Johor Bahru.

X. MANAGEMENT
This patient was admitted because of his disorganized behavior and the possibility of
causing chaos to the public. During his stay in the Emergency Department, he was given
rapid tranquilisation, which contains IM haloperidol 10mg, which serves as a high-
potency typical antipsychotics, and also IM midazolam 10mg which was a short-acting
benzodiazepine.

In the ward, he was started on atypical antipsychotic drug, T. Risperidone 1 mg BD and


intermediate-acting benzodiazepine T. Lorazepam 1 mg BD. He was given assault and
absconding caution and put on behavioral chart to monitor his progress. Vital signs were
monitored from time to time. Morocco embassy was called in order to seek help for him
to return back to his own country.

During his stay in the ward, he has been progressing well. His T. Lorazepam was reduced
to ON from BD, and was taken off 2 days later. Assault and absconding caution was
taken off two days as well as his psychotic features were improving.

He was given psychosocial therapy, in which he was psychoeducated about the disease
and the need of compliance of the medication as well as the reassurance of the prognosis
of the disease. He was also counselled about the help he can seek for him to return back
to his country. He was also advised about the proper procedure of getting study offer
from Malaysian university.
XI DISCUSSION
This patient is a Moroccan gentleman, with no known medical illness was brought to
HKL by the police due to disorganized behavior in the Brunei embassy. From his history,
his symptoms fit into the criteria of brief psychotic disorder as he fulfilled 3 out of 4
criteria for brief psychotic episode which include a 2 nd person auditory hallucination
which is commanding in nature, delusion of persecution, control and grandiosity and
disorganized behavior. The disturbances lasted at least 1 day and persisted throughout the
month he was here in Malaysia in which he was previously well. There was no substance
uses involved and he had no other medical condition. His disturbances did not fit into
criteria of schizophrenia, bipolar disorder with psychotic features or major depressive
episode with psychotic features.
This Moroccan gentleman in his early adulthood, left his country for his first time to
Malaysia and lost his belongings in one week. This is very stressful for him as he
described to be the most depressing and hopeless moment in his life. It is understandable
as this was his first time of him leaving without any guidance and friends or family to
support or seek help to. This could be his marked stressor for this brief psychotic
disorder. From his past personal history and personality before illness, he seemed to be a
very optimistic person with an friendly and helpful personality in which he described
himself to have many friends back in Morocco. However, he revealed that he has family
history of mental illness in which his uncle committed suicide due to an accident as a
result of the mental illness but he was unable to recall the diagnosis. This can serve as a
predisposing factor for him to develop an episode of brief psychotic disorder.

This patient had history of admission when he was in Johor Bahru. That was his first
episode of acute psychosis. He was stayed there for one week before discharge and it was
relapsed within one week. This is probably due to the inadequate course of antipsychotic
medication given to him as a foreigner was only entitled to have 5 days of antipsychotic
medication. That was why after 1 week of discharge he was still able to have auditory
hallucination. The moment when he realized the people in Brunei embassy were unable
to help him and on top of his initial plan that he was supposed to go back Morocco at the
3rd of March made him feel very hopeless. This could be the perpetuating factor for him
to develop the second episode of acute psychosis.

Various investigations were done to rule out other causes of acute psychosis, especially
infection or other metabolic derangement. Full blood count was done in order to detect
any signs of infection by looking at the total white cell count and there was not any in this
patient. Renal profile was done together with serum Ca, Mg and phosphate to rule out
possible metabolic derangement, but this patients serum electrolyte level was all normal.
Urine toxicology was done to rule out substance overdose as cannabis, alcohol and
amphetamine overdose could lead to acute psychosis, fortunately, it was negative in this
patient. Meanwhile, liver function test was done in order to look for any overdose signs
that could lead to liver failure. Because of the diagnosis of brief psychotic disorder and
the treatment of antipsychotic on this patient is probably short-term, therefore fasting
blood glucose and lipid profile were not done for baseline investigation to monitor side
effects.

XII REFERENCE

1) Desk Reference to the Diagnostic Criteria From DSM-5


2) Kaplan & Sadocks Synopsis of Psychiatry, 11th edition

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