Pschiatry learning issues - example

Psychiatry tests your ability to integrate the biological with the psychosocial.....

Case example

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weeks of treatment, the patient complained of excessive appetite and weight gain but remained amotivated, socially withdrawn and poorly communicative.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.

Learning issues