Psychiatry tests your ability to integrate the biological with the psychosocial.....
17 yo unemployed male living with his family. Several
months of social withdrawal, unkemptness and poor hygiene. Heavy tobacco smoker
and regular cannabis user. Previous experimentation with amphetamines and LSD.
Experiences paranoid beliefs that he is under surveillance by bikie gangs, phone
is tapped and that listening devices are in his house. Also experiences auditory
hallucination of persecutory nature and more recently, command hallucinations to
commit suicide.
Examination revealed casually dressed male with evidence of poor self-care. He
was orientated to time, place and person but appeared anxious, fearful and
agitated. Conversation was often tangential and preoccupied by themes of being
killed by bikie gangs. He demonstrated impairment in concentration and memory.
He showed poor insight and judgment and was resistive to admission and
treatment.
The patient was detained to the locked ward of a mental health unit whereupon he
became increasing agitated and paranoid and attempted to abscond. This required
temporary physical restraint. He spontaneously settled without chemical
sedation. Commenced on risperidone and agitation settled overnight but paranoia
persisted. Later in the week, behaviour improved and patient was transferred to
open ward. Patient begans complaining of muscle stiffness and pain, stiff gait
and hand tremor which was temporarily relieved with benztropine but followed by
blurred vision and dry mouth. Persistent stiffness resulted in medication being
changed to olanzapine responding with gait improvement a few days later. The
patient continued with individual supportive counseling and family meetings were
organised for education.Outpatient group sessions were offered and various
community support groups suggested. Symptoms resolved by the end of week 3 and
the patient was discharged.
After several weeks of treatment, the patient complained of excessive appetite
and weight gain but remained amotivated, socially withdrawn and poorly
communicative. Exercise was recommended and heeded with temporary weight
improvement. Erectile dysfunction became problematic later and psychiatric
symptoms worsened again with paranoia and poor sleep. Compliance to exercise and
psychotherapy was therefore affected. The patient was switched to clozapine with
regular blood counts arranged. The patient experienced sleepiness and increased
salivation but after several weeks of treatment, paranoia settles and patient
begins to develop insight into his illness. Participating in living skills and
vocational rehabilitation allowed the patient to enter a trade apprenticeship.
Sexual function improved but weight gain remains an issue (associated with mild
glucose intolerance) which required dietetics input. Several months later, the
patient re-experiences mild paranoid ideation in the context of missing his
medication and experimenting with amphetamines. This quickly resolves with
resumption of medication and further education is given. During his studies
experiences a failed relationship with a woman but despite this coped well. The
patient remains compliant to medication and follow-up and advised that treatment
will be life-long.