Case ConferenceIntern 吳易儒

Basic data

Admission: 2014/09/20Name: 林ＯＯ

Age: 62 y/oSex: FemaleMarriage: 已婚

Education: 小學

Occupation: 家庭主婦

Source of information: 本人,兒子,女兒

Chief complaint

最近兩周不斷在家自言自語

Present illness

● 62歲已婚女性，與兒子女兒同住，過去無精神

科病史

● 個案小學畢，年輕生活困苦，過去多從事工廠

女工

● 先生因賭博欠債於十年前離家後開始變得憂

鬱，社交鮮少，每天生活安排多待在家裡僅作

家事。有次去社區運動與人吵架後就沒有再

去。

Present illness

● 個案於一年前開始常說以前的事，常表達鄰居

對自己不好(房屋漏水、倒垃圾問題)。● 近兩周表示有人要害自己，開始變得：

○ 不睡

○ 自言自語

○ 突然無故跑出家門大吼大叫

○ 一直指著周遭物品拍打或作法

○ 疑神疑鬼，敵視陌生人

○ 不關自己的事都說成自己的事

○ 不準時吃飯

○ 原本的家事無法做如洗衣不專心會丟錯衣服

Present illness

● 家人擔心而送至本院急診。

● 會談時，個案多自言自語，言談鬆散。

● 表示自己被下符

● 聽到兩個人的聲音持續和自己說話

● 多次提及"飛將軍"但無法澄清

● 另表示自己在救台灣

● 因前述問題，經評估住院檢查治療。

Past history

● 首次呈現精神症狀的時間：61足歲

● Past psychiatric major disorders: denied● Past physical illness: denied ● Head trauma, seizure, allergy, substance

abuse, alcohol abuse, smoking: denied● Recent medication: denied● Herb medicine history : denied● Allergy history: denied

Personal history

● 心理社會問題：○ 主要支持團體的問題：兒子關心個案

○ 社會環境相關的問題：個案十年來社交鮮少

○ 教育問題：小學畢

○ 職業問題：多年從事主婦

○ 居住問題：與兒子住

○ 經濟問題：兒子提供

● 最佳功能狀況：可以工作

● 目前功能狀況：生活嚴重受影響，完全無法工

作，喪失現實感

Family history

酒癮,家暴,車禍 生病

欠債自殺

欠債離家

PE/ NE

● Consciousness: clear● Vital signs: within normal limits● HEENT: Goiter (-), conjunctiva: not pale● Chest/Abdomen: grossly normal● Extremities: tremor (-), ● Cranial nerves: grossly normal● Motor/ Sensation/ Autonomic system:(-)● Babiski sign: (-), grasp relfex(-)

MSE

● General appearance: bizarre● Attitude: cooperative● Attention: can’t focus and can’t sustain● Consciousness: clear● Speech: irrelevant, incoherent● Behavior: mannerism, self-talking● Mood and affect: restricted

MSE

● Perception: hallucination● Thought: persecutory delusion, grandiose

delusion, loosening of association● General intellectual function

○ Judgment: not detectable○ Orientation

■ Time: not impaired■ Place: not impaired■ Person: not impaired

MSE

● Memory○ Immediate: not impaired○ Recent: not impaired○ Remote: not impaired

● Abstract thinking: not detectable● Physical function: initial insomnia, middle

insomnia● Insight: no insight

Diagnosis

● Axis I : Schizophrenia● Axis II : defer● Axis III: nil● Axis IV : defer　● Axis V :

○ GAF = 11~20 (current)　○ GAF = 31~40 (best in past 12m)

Lab data

● EEG: normal or within normal limits● EKG: NSR● CXR: negative● Brain CT: negative● CBC: normal or within normal limits● Serum(Glucose AC, CK, CKMB, Na, K,

BUN, Cr, AST, Ammonia): normal or within normal limits

Lab data

● Urine:BZO(+),APAP(-),AMP(-),BAR(-),COC(-),OPI(-),THC(-),TCA(-)

● Blood: RPR(-),HIV Ag/Ab(-),HCV Ab(-)● Immunoassay:Anti-HBc(+),HBsAg(-),VitB12

(-),Folic acid(-), Prolactin(74.42), Free-T4(-), T3(-), TSH(-)

● Serum: Cu(-), Pb(-), Al(-)● PT, aPTT: normal● Stool OB: trace

Plan

● Establish rapport, clarify history● Pharmacotherapy:

○ Estazolam 2mg 1T PO QHS○ Lorazepam 2mg 1A IM QHSPRN○ Risperidone 3mg 1T PO QHS○ Haloperidol 5mg 1A QHSPRN

● Arrange psychological assessment for further evaluation

Hospital course2014/9/20~2014/9/30 (尚在住院中)

2014/9/20

● 情緒偶有起伏● 精神可，活動量略多● Loosening of association, 會愉悅的講述妄想

內容● Persecutory delusion, 表示被人下符，希望這

裡可以保護她● Plan:

○ Estazolam 2mg 1T PO QHS○ Risperidone 3mg 1T PO QHS○ Lorazepam 2mg 1A IM ST○ Haloperidol 5mg 1A ST

2014/9/21● Bizarre behavior，persecutory delusion, self

talking, 不斷對空比劃且出現喃喃自語情形，表示「就是黃依廷一直在對我下符啊！」、「我都跟他說過了」、「叫醫生不用給我吃藥打針」、並出現指著10C病友是救世主，於爾後又表示自己才是救世主。會提及自己陷入「一個陣中」，多以點頭搖頭回應。

● Unsteady gait● Complete denial of illness，堅持表示自己沒

生病，不能吃那些藥物

● Aggressive behavior, 21點服用睡前藥物時仍表示拒絕, 將防跌紅鈴扯毀並預攻擊醫護人員

● 可被動說出被約束之原因● Plan:

○ 為預防其跌倒，給予腰腹約束於病室內○ Estazolam 2mg 1T PO QHS○ Risperidone 3mg 1T PO QHS○ Lorazepam 2mg 1A IM ST○ Haloperidol 5mg 1A ST

2014/9/22

● “我是救世主 寶珠寶珠”,”你們要害我 要對我不利”

● 不斷比手劃腳表示在作法超渡眾生，又表示在與老神仙對話並要不停作法練功，才能抵抗無形的敵人

● Plan○ Estazolam 2mg 1T PO QHS○ Risperidone 30mg/30ml 3cc PO QHS○ Lorazepam 2mg 1A IM QHS PRN○ Haloperidol 5mg 1A IM PRN if 拒藥

2014/9/23

● 我自己很命苦因為天生美麗所以都被忌妒，我

以前小時候雖然我哥哥弟弟對我好但是沒有

錢所以我去工作

● 一開始都還好，但是我都會被人針對尤其寶珠

老闆娘都會叫我做粗重工作，那不是我的事

● 尤其是921那年我要退休又更年期，全部的事

情加雜一起讓我很痛苦，你知道嗎 我美麗是錯

● 921那一年我耳朵都會耳鳴有看了很多醫生都

沒有用後來人家叫我去精神科我吃了一個光

能錠根本沒效我又沒瘋掉

● 這10幾年來我都靠食療讓自己變好，只是這十

年來我都待在家裡，因為我太美了連去菜市場

買東西都會有問題

● 你看菜市場忌妒我都會算比較貴 我們也是這

幾年比較好有買房子 唉但是如果我可以留錢

給我的小孩他們就不用辛苦

● 這兩週來 那些耳鳴聲才變成有人說話的聲音，

我很害怕因為是之前工作的人下我降頭，我聽

到佛祖叫我當救世祖能力很強、我有超能力可

以做法 保護家人 ● Catatonia, 身體僵硬且維持同一姿勢，打完

Haldol後半小時可開始下床, 步態穩可執行工作人員指令

● 不願配合進食早餐● 多以點頭搖頭回應

● Plan○ Lorazepam 2mg 1A IM QHSPRN○ Risperidone 30mg/30ml 5cc PO QHS○ Haloperidol 5mg 1A PRN if 拒藥

2014/9/24

● 提及多年來生活中之辛苦及與工作同事相處之間嫌隙

● 將衣物及生活用品打包，靜坐於床上，維持同一姿勢，且不願配合進食午餐

● 詢問時多以點頭搖頭回應之情形● 晚上有被動配合服用藥物

2014/9/25

● 在房間中比手劃腳傾聽狀

● 拒絕進食

● 對問話點頭搖頭回應,承認現在是佛祖的說話

聲,再給自己指示,自己要救世人,飯和藥有毒,我們會害她

● 打完針劑後對問話不回應,比手畫腳沉浸幻聽

症狀改善

● Plan:add risperidone 6cc/mg

2014/9/26

● 從10幾年前起開始聽到耳邊雜音,會合併頭暈,失眠,當時開始容易緊張,會擔心有人會害他,要保護家人,

● "聽說女兒已經結婚了",都沒有和女兒連絡,不想讓女兒回家,怕會有豬哥男生騷擾他,因為我

女兒和我一樣像雙胞胎,他和我一樣漂亮,● 我從板橋,蘆洲,五股,三重一路佈施到淡水,把

身上的衣服捐出去,她們忌妒我穿金帶銀,所以

不和人連絡,不跟鄰居講話,她們忌妒我

● 最近聽到很多聲音,在做法,要救眾生,救世人,很害怕,怕自己和家人受傷害,不知道自己在怕

什麼

● 現在好多了,沒有聽到聲音,也比較不會害怕

● 會覺得身體無力,這幾天不敢吃飯,怕被下毒,現在不會了

● Plan:○ add biperiden 1#bid ○ add haldol 1#qhs○ keep risperidone 6mg/cc

2014/9/27

● 社區裡的監視器有拍到我把衣服放到回收箱,以為我家很有錢很浪費

● 她們喜歡我因為我很好看,有錢,但平常我不太

跟鄰居說話,來往,但她們都知道我

● 不記得前兩週發生的事情

● 不知道住院原因,身體好好的,沒有聽到聲音,以前是有一些耳邊雜音,現在都沒有了

2014/9/28

● 表示現在幻聽干擾情形變少，可說出對幻聽不予理會

2014/9/29

● (經過活動室時對活動室門口踢兩腳),"有壞人

要教訓,踢他們兩腳"● 老闆娘寶珠這10幾年來會起乩,給我下符,讓我

頭痛,兩耳有雜音

● 她忌妒我長的美,大家都認為我美,只是沒有說

出來,到65歲還保養的這麼好,我剛剛用心電感

應讓他知道

● 平時去菜市場時很多人注意我,在那裡很受歡

迎,我不好意思看他們...(對工作人員獻飛吻)

● Plan: ○ Lorazepam 2mg 1A IM QHSPRN○ Biperiden 2mg 1T PO BID○ Haloperidol 5mg 1T PO QHS

2014/9/30

● 在病房走廊不斷來回走動，表示在運動，未出現比手畫腳動作

● 我比較內向害羞，平常本來就不太跟人講話● 妳長得很美，比我女兒還美，我女兒很多人

追，她娃娃臉，大家都看不出來她35歲了。● 妳真的長得很美（不斷重複）● 住院那天（指住院當天症狀）不好意思麻煩大

家了,現在好很多了● （問有沒有聽到什麼聲音）沒有也沒有聽到那

個聲音

● Plan:○ Lorazepam 2mg 1A IM QHSPRN○ Biperiden 2mg 1T PO BID○ Haloperidol 5mg 1T PO QHS○ Risperidone 25mg 1V IM QOW QD

TPR sheet

MSE

● Consciousness:clear1.General appearance: unkempt2.Attitude: cooperative3.Attention: focus and sustain4.Behavior: restless5.Speech: talkative, relevant, incoherent

6.Mood and Affect: euphoric7.Thought: perscecutory delusion(-).suicidal

ideation(-)8.Perception:AH(-),VH(-)9.Drive: Sleep:no decrease need of sleep, Self-care:

fair Appetite:fair10.Insight: partial

JOMAC

● Judgement: normal● Orientation: oriented to time(黃昏)/place(馬

偕)/people(吳醫師)● Memory: impaired recent memory, fair

immediate memory(綠色,生氣,救護車)● Abstrac thinking: fair(青梅竹馬:小時候一起長

大的人)● Calculation:7 series=93,86,79,72,65

DicussionVLOSLP-Very late onset schizophrenia like psychosis

Schizophrenia

Case report

Late onset Schizophrenia

● usual onset at:○ Male:15-25 y/o○ Female: 25-35 y/o

● late onset >40(45)y/o

● very late onset >60 y/o

Case 1

● A 72 y/o widow without past history● Rather distraught state for 2 years● 6 weeks ago- Certain her daughter-in-law

poisoning her food since● Quarrels ensued at home● Decreased appetite and sleep● An unfamiliar men voice commented on her

daily activities● 2 weeks ago- try to strangulate herself to

make the voice stop

● Medication then started, but she refused due to she believed it was poisonous

● Suspicious and introverted● Well physical condition● Well oriented● No affective symptoms● MMSE 28/30● MRI: age related cortical atrophy● Treated by Risperidone 1mg and

symptomatically better

Case 2

● A 84 y/o educated till 10th grade● brought by her children due to:

○ suspiciousness○ social impairment○ persecutory delusion-complain of neighbor’s

malicious intent○ restless as kept checking the doors○ place her ears on the wall as if eavesdropping○ had an avid interest in writing poems

● MSE:○ cooperative famale○ no affective disturbance○ no thought disorders

● Referential delusions to “evil” neighbors● The neighbors would purchase her house

after she died● Third person intermittent auditory

hallucinations discussing her● No insight into her illness● MMSE=30/30● MRI: normal● Risperidone as previous case+ psychosocial

intervention● following with significant improvement

Epidemiology/ Clinical presentation

● Paranoid ideation in general elderly population: 4-6%(most with dementia)

● Female with persecutory delusions: 83%● India, schizophrenia onset after 40 y/o:

2.04%● In india, LOS Male:Female=1:1.67● LOS and VLOSLP are more likely to:

○ exhibit persecutory delusion○ Visual/tactile/auditory hallucination○ Running commentary and abusive content

LOS=late onset schizophreniaVLOSLP=very late onset schizophrenia like psychosis

Risk factors

● EOS: more common in men● LOS: Female:Male=3:1● VLOSLP: Female:Male=20:1● Associated with

○ decline of estrogen levels○ relative excess of dopamine D2 receptors○ better coping behavior strategies->delay onset

● Relatives develope schizophrenia:○ EOS: 10.2%○ LOS and VLOSLP: 2.9%

EOS= early onset schizophreniaLOS= late onset schizophreniaVLOSLP= very late onset schizophrenia like psychosis

● VLOSLP: ○ higher association of sensory imapirment○ more likely to have schizoid or paranoid

personality traits● Recently, elevated CRP was reported to

increase risk for LOS and VLOSLP.○ 6 times increased risk in case with very small

elevations of CRP was reported at 2013 American Psychiatric Association meeting.

● smoking, BMI, alcohol, education, income, DM are all risks.

Management

● Patients with VLOSLP must exclude underlying cause: PE, NE, Lab, Neuroimaging

● Antipsychotics: use in acute symptoms and reduce risk of relapse.○ but side effects must concern in elderly people○ Chlorpromazine 300 mg/day in younger p’t=148

mg/day in older people

● Atypical antipsychotics are preferred due to light SE and lower risk of EPS.○ Risperidone, Olanzapine and Quietiapine in low

dose-> effective and well tooerated in VLOSLP->start low, go slow

○ Clozapine in low dose has shown promising effects, but adverse effects like agranulocytosis makes it use only in resistant p’t.

● Nutritional supplement is very important● No sufficient data for ECT treatment in

VLOSLP patients● Cognitive behavior therapy, social skills

training and supportive psychotherapy are valuable in improving function.

Thanks for your attention :)