PSYCHIATRY CASE BOOK

U.G.K.M.Udawelagedarda
ME/2009/142
Group E
Faculty of Medicine
University of Kelaniya.

Acknowledgements

This case book was prepared during the professorial psychiatry appointment as a part of our
curriculum with the purpose of improving the necessary knowledge and skills for a doctor.
I would like to express my intense gratitude to our teachers in the Department of Psychiatry,
Faculty of Medicine, Ragama, who guided us wistfully during the appointment,
I would also like to thank to Senior Registrars, Registrars and other Medical Officers who helped
us in every aspect during appointment. And I also thank to all the nursing staff and attendants.
I would be thankful to the patients and their relatives who helped us pensively sharing their
intimate information with us.

Table of Contents
Contents

Page

1. Case 01- Bipolar affective disorder

05

2. Case 02-Schitzophrenia

17

3. Case 03- Recurrent depressive disorder

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CASE 01
BIPOLAR AFFECTIVE DISODER

History
Introduction:
Mrs. Jeewa Lechchami is a 43 year old married lady with 3 children, currently employed as a
caregiver. Presented to the ward on 24th of July 2015.

Presenting complaints:
Increasing suspiciousness towards the family members Poor sleep and irritability
for about 3 weeks
admitted to the hospital due to she started to destroy household items.

History of presenting complaint:

She has been apparently well 2 months back. She claims that she has increased energy & she felt
like she is having abnormal power because of that she thought that she does not need any
treatment so she withheld her treatment 3 weeks back. She has then gradually begun to suspect
her family members for no apparent reason. She complains that they conspire against her and are
trying to harm her. Her suspiciousness has increased overtime leading to inevitable quarrels with
the family &she destroyed household items.
She also has undue optimism and increased self esteem as she believes that she is far more
superior to others. She claims that she has a special protection from Jesus & says that she wants
to raised against the war & wanted to make this country a better place. She also has increased
energy with feelings for dancing and singing all day long with an unduly cheerful mood.
Her normal functional level deteriorate over past 3 weeks.
She did not no suicidal or homicidal ideas.
She said that she had a romantic relationship with a boy lives nearby.
Also she believes that her manager is in love with her
She is easily distractible that makes her more irritable. Hence she gets into endless arguments
with others.
Her day to day activities have been largely interrupted by her behavior.

She denies of her thoughts being controlled, inserted or withdrawn by external agents or feeling
as if others doings have special significance to her. She also has no social withdrawal or lack of
mood.
She admits of having similar symptoms nearly one year back & was hospitalized. No episode
with low mood, lack of energy or lack of enjoyment.
She also denies of any features of underlying organic brain pathology due to thyroid disorders,
Cushings syndrome or SLE.

Past psychiatric history:

She has had similar symptoms about 3 years back with increased activity, energy, irritability,
disturbed sleep and suspiciousness towards family members. Her day to day activities have been
greatly impaired
The episode has lasted about 1 month.There is no evidence of ECT treatment. Her response to
drugs has been good but she has defaulted medicine about 3 weeks back against medical
advice,because she began to believe she is having special power so no need of treatment.
Inter episodic function is satisfactory.

Family history:

37yrs

13yrs

11yrs

9yrs

Her sister is having psychiatric illness.

Personal history:
She denies any significant event during her antenatal & postnatal life & early childhood development.she
is the third out of four siblings. She has educated up to O/L .then started to work as a nursery teacher. She
6

got married at the age of 22.her husband was a laborer. She had three children from that marriage.
Because of the financial problem and as her husband did not support the family. She went abroad ,to
Saudi Arab as a housemaid. Children were looked after by her mother. She did not stay more than 2 years.
After coming to srilanka she started to work as helper for elderly patients .She separated from her
husband because he used to beat her under influence of alcohol .4years ago,she married her new husband,
who is a security officer of highway.one year after her second marriage,she got her first episode of
psychiatric illness.

Past medical history: Uneventful with no past history of DM, HT, IHD and epilepsy
Allergic history: no known allergies.
Past surgical history: Uneventful
Substance abuse: There is no history of alcohol or substance abuse.
Forensic history: Uneventful
Sexual history: There is no evidence of sexual relationships.
Premorbid personality:
She is very helpful lady. Thus she had a good relationship with friends& family members. She is an
impulsive character.Her religious was hindu.but later she became catholic.

Mental state examination

Appearance and behavior:
She is averagly built middle aged female, clad in a bright red coloured blouse with long black
skirts. The clothes are well attired. Her self hygiene seems to be adequate with no signs of self
harm. Her facial expressions and gestures are normal with no inappropriate behaviors. She is
over familiar with others and is easily irritable.
She is able to build up a good rapport soon with reasonably good eye contact.

Speech:
The speech is spontaneous. The rate, amount and the volume is increased. Its relevant and
coherent.

Mood:
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She is subjectively and objectively elated. The mood is labile, & congruent. There are no
homicidal or suicidal ideas.

Thinking:
Flight of ideas- she changes the topic very rapidly but there is a relationship between her topics
Persecutory delusions- She believes that she is being harmed by the family members.
Grandiose ideas- She believes that she is far more superior to others,& she has special
protection from Jesus.she claim that she wanted to raise against the war.
No abnormal preoccupations, obsessional and compulsive thoughts.

Perception:
no auditory or visual hallucination.no illusions.

Cognition:
She is oriented in time, place and person. Her attention and concentration is impaired. Both short
term and long term memory is intact.

Insight:
She knows that others think that her behavior is abnormal. She is not aware of her symptoms and
does not acknowledges them as abnormal. Though she denies that they are due to a psychiatric
illness, she is willing to take treatment. Hence her insight is partial.

Physical examination
General examination:
She isan averagly built. She is not febrile and her hydration is good. She is not pale or icteric.
There is no lymphadenopathy, finger clubbing or pitting ankle oedema.
Weight- 57kg height-153cm BMI-24.3kgm2

Abdomen:

There are no signs of chronic liver disease or abdominal tenderness. There is no

hepatosplenomegaly and kidneys are not ballotable. Bowel sounds are audible.

Cardiovascular system:
PR- 88bpm, regular, normal volume and normal character
BP- 120/70 mmHg
Apex- 5th intercostals space, just medial to the midclavicular line
Heart sounds are normal with no added sounds.

Respiratory system:
RR- 20/min
Trachea is central. Chest movements are normal and symmetrical.
Chest expansion, vocal fremitus and the percussion note are normal.
On auscultation, air entry is normal and equal in both sides of all 3 zones. Vesicular breathing is
present with no added sounds.

Central nervous system:

Conscious and oriented
Cranial nerve functions are normal.
Motor- No involuntary movements with normal gait. Tone, power, reflexes and plantar response
are normal.
Sensory- Normal
Cerebellar functions- Normal

Summary
37 years old lady currently employed as a caregiver for patients with a past history of psychiatric
illness for last 3 years with defaulted treatment, this time presented with increasing
suspiciousness towards family members for 3 weeks, poor sleep & irritability for 2weeks &
started to destroy household items She also has undue cheerfulness, increased energy and self
esteem with no suicidal or homicidal ideas. She had one similar episode. She has a family history
9

of mental illness.On mental state examination, her self care is adequate. There is delusions of
grandiosity and persecution and flght of ideas. Her attention span is poor and her insight is
partial.

Differential diagnoses
1. Bipolar affective disorder, current episode manic, with psychotic symptoms
2. Schizoaffective disorder
3. Organic brain damage

Definitive diagnosis
According to ICD 10 criteria, in Bipolar affective disorder, current episode manic, with
psychotic symptoms the following features are found.
a) Mood must be predominantly elevated, expansive or irritable and definitely abnormal for
the individual concerned.
b) At least 3 of the following signs must be present leading to severe interference with
functioning in daily living.
Increased activity or physical restlessness
Increased talkativeness or pressure of speech
Flight of ideas
Reduced need to sleep
Inflated self esteem or grandiosity
Distractibility or constant change in activity plan
Behavior that is foolhardy or reckless
Marked sexual energy or sexual indiscretions
c) The episode is not attributed to psychoactive substance use or organic mental disorder
d) There has been at least one other affective episode in the past meeting the criteria for
hypomania , mania , depression or mixed episode.
Hence the diagnosis would be Bipolar affective disorder, current episode manic with
psychotic symptoms.

List of problems
Psychological:
- Increasing suspiciousness towards the family members and grandiose ideas
leading to inevitable quarrels with the family
- Poor sleep and increased energy leading to physical exhaustion
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Relapse of the manic episode

Partial insight with prior history of defaulted treatment

Care for the children is impaired.

Aggression towards others may lead to harm to self along with harm to others
Social stigmatization

Social:

Management
1) Risk assessment:
Risk to self:
1. She presents with suspiciousness and irritability towards family members. Hence she
can be subjected to physical violence at some point.
2. She also has increased energy and over activity which might lead to physical
exhaustion.
3. Her over familiarity with other people might impose a risk for getting physically or
sexually abused.
4. Social stigmatization along with difficulty in finding a new job.
Risk to others:
1. Risk of violence towards family members
2. Damage to properties
3. Social stigmatization

2) Deciding the treatment setting:

As the patient presents with an acute manic episode, she imposes risks to both self and
others with undue irritability and social disinhibition. Hence she should ideally be
managed as an inward patient as this minimizes risks and ensures compliance with
medication.
She should be offered a place near the nursing station with frequent nursing observations
for probable agitation and aggression.

3) Further assessment:
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She should be further assessed with regard to any prevailing suicidal or homicidal ideas.
Collateral history should be obtained by family members and from previous medical
institutions.
The timeline of the illness should be noted to identify the disease pattern with details of
each episode. Information on types of medication should be taken if possible with
response to treatment and drug compliance.
Assessment of family support, available social resources, ongoing life stressors and
impact on daily living is also important for the long term management plan.
Investigations: To exclude any treatable cause and as a baseline prior to commencement
of antipsychotics.
1. Full blood count- Hb 10.8g/dl, WBC 6.83103, Plt 411103
2. Fasting blood sugar level- 92mg/dl
3. Liver biochemistry- Normal
4. Serum electrolytes and blood urea- Normal
5. Serum creatinine- Normal
6. Thyroid function tests
7. ECG- Normal
8. Non contrast CT- to exclude any frontal lobe pathologies

4) Short term management:

Acute managementIf the patient becomes aggressive with increased risk to self and others, she should be
managed in a separate section in the ward with frequent nursing observations and
minimal confrontations with other patients.
De-escalation technique- Initially calm down the patient verbally
If it fails,
Initially treat with oral drugsClonazepam 2 mg
Chlopromazine 50 mg
If the patient refuses oral drug treatment, parenteral medications should be used.
IM midazolam 5mg
IM Haloperidol 5mg
IM Promethazine 25mg
If there is still no response the drug regime can be repeated after 20 minutes.
The respiratory rate, pulse rate, blood pressure, temperature and the conscious level
should be monitored every hourly for 2hours and hourly until she recovers.
But as she got aggressive this treatment regime was used for several time within hospital
stay.

12

Subsequent management:
The patient and the family should be educated about the disease, clinical features,
prognosis, available treatment options and side effects of the drugs. They should also be
actively engaged in prescribing a suitable drug.
As the patient presented with manic features along with psychosis, antipsychotics are of
increased benefit in controlling behavioral changes.
She was on,
Olanzapine 5mg bd
Haloperidol 5mg IM SOS
Mood stabilizer- Lithium should be started after checking renal functions. It should
initially be started in a dose of 500mg nocte initially.
Lithium level should be checked 5 days later. In acute manic phase it should be
maintained at the range 0.8-1.2 mmol/l.
She is not on lithium.
She should be monitored for improvement of symptoms, behaviors, sleep, drug
compliance and side effects of the drugs.

5) Long term management:

Biological:
- As the patient has had 2 manic episodes, the continuation with antipsychotics
along with a mood stabilizer for at least 5 years.
- As olanzapine is an atypical antipsychotic, she should be educated about the
side effects of the drug, especially of the metabolic side effects.
- She should be investigaeted for FBS and lipid profile every 6 months.
- If she is started on,She should also be educated about lithium thoroughly, with
its side effects, the frequency of which the lithium levels should be checked
and when to stop the drug.
Psychological- Psycho education- The patient and the family should be educated on the disease
pattern, prognosis and treatment options.
- Cognitive behavioral therapy to improve coping skills, sleep hygiene and drug
compliance
- Social skills training to improve activities of daily living.
- Vocational training
- Introduce her to supportive groups to share one and anothers experiences of
similar disease patterns.
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Family therapy to build up the relationships with family members.

Observe the patient for post psychotic depression and rapid recycling episodes.

Social-

The family should be educated about the disease pattern, nature, treatment
options, prognosis and importance of compliance.
Educate the family of probability of sexual promiscuous behaviour with the
disease pattern, and to be protective over the patient.
Advice the family to monitor compliance, side effects of the drugs and signs of
relapses and advice to readmit her if there are any risks.

6) Follow up:
The patient can be discharged once the acute symptoms have resolved.
1. Before discharge, if she started on lithiumt should be acknowledged about the drug
lithium.
Serum lithium levels should be monitored weekly till the levels stabilize. It
should be checked after 12 hours of the last dose. After lithium levels
stabilize, it should be checked every 3 months and 6 months afterwards.
She should be advised to inform other doctors that she is on lithium when
seeking for treatment for other illnesses. Ideally, she should be given a
clinical record indicating that she is on lithium.
She should drink adequate water, at least 1.5l/day.
Side effects of the drug such as nausea, diarrhoea, fine tremors, polyuria,
polydipsia, acne and weight gain should be acknowledged and she should
be asked not to stop the drug with these symptoms.
Symptoms of frank lithium toxicity should be told and she should be asked
to stop the drug if she develops these features and to come to the hospital
immediately. Features include severe vomiting, diarrhoea, coarse tremors,
blurred vision, ataxia, muscle weakness and dysarthria.
Renal function tests, thyroid function tests, ECG should be checked yearly.
Weight and the BMI should also be checked yearly.

14

Compliance is important as abrupt quitting of the drug might trigger

rebound mania.

2. She should be monitored weekly in the clinic in the period immediately after
discharge.
Then the frequency can be adjusted depending on the symptoms.
The following should be assessed at each visit- Extent and severity of the symptoms,
compliance, side effects of the drugs and level of functioning

15

CASE 02
SCHIZOPHRENIA

16

History
Introduction:
J.M. Naveen Madhushanka 21 year old unmarried boy from Badulla who is current unemployed.he lives
with his aunt.presented to the ward on 1st of august 2015.

Presenting complaints:
He is having poor sleep,hearing voices,suspiciouseness over one month and,then
he jumped out of a slowly moving train & he was admitted by accompanying people.

History of presenting complaint:

He is a known epileptic patient who has had psychiatric care for the past 4 years with poor drug
compliance. But he has been apparently well about a month back.
He was working as a security officer in Borella for 3 months.So he quit the job because he was
sexually abused. then he joined the cleaning service with his aunt. But he does not like to do it.
So supervisor of that cleaning serviceBandara sir tried to help him by searching a security job
for him. But he had to work in a cleaning service on that day also. After the work he was
travelling from Maradana to Ragama with Bandara sir. When the train reached the Ragama the
speed was reduced,he claimed that he heard a voice telling him to jump out of the train. He said
he saw another train was coming toward the train he was travelling and going to have a train
crash. He also felt that he is abandoned &this is the last chance to escape. He jumped out of the
train.
He said that he did not have any intension to die.
No head or other injuries.
He is a known patient with epilepsy on treatment.he has short history of cannabies abuse. No
evidence of underlying organic brain pathology due to SLE or thyroid dysfunction.

He denies lack of energy or increased energy, sleep disturbances or appetite disturbances.

He also does not have negative symptoms like apathy,social withdrawal,paucity of speech.
His mother is having psychiatric illness & on treatment.

17

Past psychiatric history:

he has been taking treatments for psychiatric illness since age of 17 years. He had several
admissions to different hospitals.ECT has given nearly 8 times.His treatment compliance is very
poor and has defaulted treatment.

Family history:
Father has died from a chronic liver disease due to alcohol.mother has psychiatric illness, & has
had admitted to NIMHseveral times..His aunt complains that his mother is having extra marital
relationships may be due to illness,because of that all the children did not gET a proper care. His
2 sisters are in an orphanage. Younger brother is with another aunt in Dehiaththakandiya.

43yrs

20yrs

16yrs

10yrs

Personal history:
His antenatal & post natal life was uneventful. In his childhood he has exposed to the domestic
violence, because his alcoholic father has beaten his mother
He has educated upto O/L.neraly one year after the O/L he worked as security officer for 3
months duration.Naveen and his mother moved from badulla to Ja-Ela as his mother got a job in
a cleaning searvice.he was sexually abused by a man when he was working as a security office.as
his mother also does not well then his aunt was taken him to her house.then he started to work in
a cleaning service with his aunt.but only for 13 days.

Past medical history:

He has a history of epilepsy since the age of 11 years. Initially he was followed by the clinic in
Badulla.now he is following up at NCTH.
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Past surgical history: no surgical history

Forensic history:Uneventful
Sexual history: he had a romantic relationship with a girl who is 3 years older than him for 3
months. But he denies any sexual relationship.

substance abuse:
He started smoking at the age of 15,and still continuing with 3-4 cigarettes per day. That is one
pack years. Then he started to use cannabis 3 times per day for 3 months. Now he is not using.
He takes alcohol occasionally.1/4 bottle amount.

Premorbid personality:
he has not had good relationships with his family members. he loves to enjoy the life but prefer to be
alone. He loves to listen songs and loves cricket. He was born as Buddhist. Later he changed his religion.
Then involved in many religious activities.

Mental State Examination

Appearance and behavior:
he is thin built young male wearing clean clothes which are properly attired. His self hygiene
seems to be adequate with no signs of self harm.
His facial expressions and gestures are reduced. Though he seems to be relaxed he is detached
and it took time to make a good rapport. he has adequate eye contact.

Speech:
Speech is spontaneous. The rate, amount, & volume normal. Its relevant and coherent with no
neologism.

Mood:Subjectively he feels distressd and objectively he is perplexed. Mood is blunted .he has
suicidal ideas. But no active plans, no homicidal ideas.

Thinking:
Persecutory delusions- he believes that his work mates are trying to harm him
Delusion of control- he believes that his thought and actions are being controlled by an external
agent.

19

Delusions of thought possession- he believes that thoughts are implanted in his mind by an
external agent (thought insertion) and that some are withdrawn (thought withdrawal
Delusions of reference- he believes that TV and radio programme have special significance to
him and that they are joking at him.(they wink at him.)
Religious delusion- he believes that he will be given a special significance from his religion
There is loosening of association.
No obsessive or compulsive thoughts.

Perception:
3rd person auditory hallucinations- he hears two voices discussing about him.he also had
commanding hallucination.

Cognitive function:
he is oriented in time, place and person.
But Attention, concentration, short and long term memory is reduced.

Insight:
he is aware that others think that his behavior and thinking are abnormal.but he does not want to
take medications,hence his insight is partial.

Physical Examination
General examination:
Height- 165cm Weight- 50kg BMI- 18.3kg/m2. he is thin built and is not febrile. Hydration is
good. he is not pale or icteric. There is no lymphadenopathy, finger clubbing or pitting ankle
oedema.

Abdomen:
There are no signs of chronic liver disease or abdominal tenderness. There is no
hepatosplenomegaly and kidneys are not ballotable. Bowel sounds are audible.

Cardiovascular system:
PR- 76bpm, regular, normal volume and normal character
20

BP- 140/70 mmHg

Apex- 5th intercostals space, just medial to the midclavicular line
Heart sounds are normal with no added sounds.

Respiratory system:
RR- 16/min
Trachea is central. Chest movements are normal and symmetrical.
Chest expansion, vocal fremitus and the percussion note are normal.
On auscultation, air entry is normal and equal in both sides of all 3 zones. Vesicular breathing is
present with no added sounds.

Central nervous system:

Conscious and oriented
Cranial nerve functions are normal.
Motor- No involuntary movements with normal gait. Tone, power, reflexes and plantar response
are normal.
Sensory- Normal
Cerebellar functions- Normal

Summary
21 years old known epileptic patient with psychiatric illness for 4 years,but not on proper
treatment or follw ups.This time admitted to the ward after jumped out of a slowly moving train
with no intention to die.His mother is also having psychiatric illness and under treatments. On
mental state examination, his self care is not compromised and maintains a rapport with time. his
mood is perplexed and has delusions of persecution, control, thought possession, reference and
religious delusions. There are also 3rd person auditory hallucinations ,commanding
hallucinations,and his insight is partial.

Differential diagnoses
1. Schizophrenia
2. Organic delusional schitzophrenic disorder
3. Delusional disorder

21

Definitive diagnosis
The patient has features compatible with the ICD 10 diagnostic criteria of schizophrenia.
he has, a) thought insertion, thought withdrawal
b) Delusion of control
c) 3rd person auditory hallucinations
d) Persistent delusions-persecutary delusions, religious delusions and delusion of
reference for about a month.
Hence the definitive diagnosis would be schizophrenia.

List of problems
Psychological
- 3rd person auditory hallucination leading to distress & risk his life
-

Delusion of persecution leading to aggressive behavior toward others

Frequent relapses
Poor insight with poor compliance of drugs

Functional Impairment-he could not involve in one job.he repeatedly changing

the job.
He does not have good family support.
Social stigmatization

Social:

Management
1) Risk assessment:
Risk to self
1. Presence of psychotic symptoms makes the patient distressed & risks his life.
2. he has poor insight which leads to poor compliance of drugs with frequent relapses of
the illness
22

Risk to other
1. Risk of violence towards others due to psychotic symptoms.

2) Deciding the setting of the treatment:

As patient presents with acute severe illness with disturbed behavior and threats of harm
to himelf he should ideally be managed as an inpatient.
he should be placed near the nursing station with frequent nursing observations for
probable aggression and any risk behaviour

3) Further assessment:
The patient should be further assessed with collateral history from family members, work
place and past medical records.
The severity of the current episode with degree of disability should be assessed to
formulate a management plan.
Assessment of family and social support, financial background, ongoing stressful life
events, social stressors and impact on daily living is also important for the management
plan.
Investigations- Prior to commencement of antipsychotic drugs
- Full blood count- Hb 12.1, WBC 8.87 103, Plt 204 103
- Fasting blood sugar level- 106mg/dl
- Liver biochemistry- Normal
- Renal function tests- Serum creatinine 75
- serum electrolytesNa+- 146mmol/l, K+- 4.1mmol/l
Blood urea 10.1
- ECG- Normal

4) Short term management:

Acute managementIf the patient becomes aggressive with increased risk to self and others, he should be
managed in a separate section in the ward with frequent nursing observations.
De-escalation technique- Initially calm down the patient verbally
If it fails,
Treat the patient Initially with oral drugsClonazepam 2 mg
Chlopromazine 50 mg
23

If the patient refuses oral drug treatment, parenteral medications should be used.
IM midazolam 5mg
IM Haloperidol 5mg
IM Promethazine 25mg
The respiratory rate, pulse rate, blood pressure and temperature should be monitored
every hourly 1hour. Hourly until he recovers.
Subsequent managementThe available treatment options, side effects of the drugs and the importance of good
compliance should be discussed with the patient and the family.
An atypical antipsychotic should be started, He was on Resperidone 2mg mane,6mg
nocte
the patient should be monitored for extrapyramidal side effects such as dystonic
reactions, tremors and akthesia for 4 days.

The patient should be assessed for extrapyramidal side effects continuously and if
develops, 2mg of benzhexol should be started.
The patient should be monitored for- appetite, sleep, behavior, drug compliance,
interaction with others and regular BP monitoring.
He was on sodium valproate 200mg bd for epilepsy

5) Long term management:

Biological- The same antipsychotic medications should be carried out for 6 weeks and the
response should be assessed.
- If the patient doesnt respond, consider increasing the dose with concomitant
monitoring for side effects or changing the drug regime.
- Hence consultant advice should be taken for treating with clozapine.
- Pre clozapine assessment with FBC, FBS, LFT, lipid profile, renal function
tests and ECG should be done before starting clozapine.
It should be started with 12.5mg daily and the dose can be increased slowly
upto a maximum of 900mg/day.
While the patient is on clozapine,
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1. Check FBC weekly for 18 weeks, once in 2 weeks for the next year
and then monthly therafter.
They should seek medicine immediately if he developes fever when on
clozapine due to risk of agranulocytosis.
2. Check lipid profile, liver functions and FBS in every 3 months.

Psychological- Psychoeducation- The patient should be educated on the disease pattern,

prognosis and treatment options.
- Cognitive behavioral therapy to improve coping skills and drug compliance
- Social skills training to improve activities of daily living.
- Family therapy to build up the relationships with family members.
- Observe the patient for post psychotic depression.
- Management of Nicotine dependence
Social-

The family should be educated about the disease pattern, nature, treatment
options, prognosis and importance of compliance.
Advice the family to monitor compliance, side effects of the drugs and signs of
relapses and advice to readmit him if there are any risks.
Dietary advice should also be provided as he is on atypical antipsychotics.
Address the benefits of good family and social support and avoidance of high
expressed emotions.

6) Follow up:
-

Once the acute symptom resolve, the patient can be discharged.

1st follow up visit in the clinic is ideally after 1 week of discharge. The
frequency of follow ups depends on the clinical response and later monthly
follow ups should be done.
At each visit, mental state examination, side effects of the drugs, response,
social skills and support and relevant investigations should be monitored.

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CASE 03
RECURRENT DEPRESSION
DISODER

26

History
Introduction:
Thilak abeysinghe is 47 years old patient from weyangoda.he is married with 3 children. He has worked
as an army officer for 13 years, retired 14 years back. Now he is not doing any job. He was taken to the
ward by his wife on 23rd july 2015.history was taken from the patient & his wife.

Presenting complaints:
Fearfulness &irritability for 2 days
Poor sleep for 1-2weeks

History of presenting complaint

He has had psychiatric care for 7 years after the death of his only son, with the treatment and follow ups.
On 18th July 2015 his sons alms giving was held.he reminds his son on that day and had cried .after that
he was well for 2 days. Then on 21st of July he developed low mood persitant throughout the day
&continous for days.it was worsen in the morning& sometimes associated with crying spells.
He claimed that he developed lack of energy& fatigability, he prefer to be alone without doing nothing.
Previously he was working in the garden in the morning &watching television during day time. He has
lost his interest regarding them.
He admits that he is having sleep disturbances for 1-2 weeks. He had delay in falling asleep also he had
early morning awakening. He started to waking up at unduly early hours at about 2am-3am& difficulty in
falling back. He lies on the bed thinking &worrying about his son.
He also developed fearfulness, anxiety& claims that CID wanted to kill him because they think that he is
a thief. But he is worrying that he has not done anything wrong. He hears voices talking about him.
All these things have led to develop irritability in him. He also complains his appetite is reduced.& has
lost some weight. He is also having constipation.
He denies any guilt regarding his past except he has intense worry about his son. he had thought like life
is worthless but he denies any suicidal act. He is not having hopelessness regarding future. Or he is not
thinking that he is helpless. But he claims that his memory is poor now.
He is having 2 brothers with psychiatric illness.
He is having diabetes ,hypertension for 2 years &on treatments. But he denies features of hypothyroidism
like weight gain, cold intolerance or body swelling. He did not have recent stressful event. But he
reminded the death of his son.

27

He had 3 similar previous episodes, but no episodes with features like increased energy, elated mood or
happiness no history of substance or alcohol abuse. Not on drugs like beta blockers or calcium channel
blockers.

Past psychiatric history:

The first episode has manifested 7 years ago, when his son was dead by an accident. As soon as he heard
that he was distressed. It has progressed up to persistent low mood with time along with lack of interest
over normally pleasurable things. Initially they ignore symptoms try to find out relieve from cultural
aspects. In the first episode he had loss of appetite &loss of weight. But he did not have any thought that
someone is going to kill him. He stayed nearly one month at hospital & had 12 ECT. He responded well
to ECT .he was on regular clinic follow-ups & treatment.
He had similar episodes several times since then initially 6 monthly, each lasting for 3-4 months. Then 810 monthly. His last episode was nearly one year back. It was the same as this episode. He had
irritability,fearfulness,& he had thought that someone is going to kill him after that episode he was
completely normal.
His inter episodic functioning is satisfactory. He has worked in a wood mill by helping others.

Family history:
He is having two brothers with psychiatric illness.

DM

DM
47yrs
46yrs

18yrs

22yrs

19yrs

Personal history:
His birth & development was normal. He is the youngest of the family ,he had reasonable family support
during his childhood.
He had educated up to grade 9.Then he started to work in the SL ARMY, as a soldier at the age of 18,he
continued to work up to the age of 35.when he was working in the army, he accidently injured due to gun
shot by himself. He was unable to walk after that. So he quit the job& then he has worked as security
28

officer. His son has passed away after 2 years of retirement. He married at the age of 28.& had 3 children.
Elder son died due to sudden accident. Elder daughter works in a phone shop younger daughter is doing
A/L. wife is working in a tea factory.

Past medical history: past history of DM for 2 years.he is taking metformin 500mg bd.but
not on proper clinic follow ups.no history of hypothyroidism.

Allergic history: no known allergies.

Past surgical history: Uneventful
Substance abuse: he had taken alcohol occasionally while he was working in the army.
Forensic history: Uneventful
Sexual history: They are not having sexual relationship after the death of their son.

Premorbid personality:He did not have much relationship with friends. but he had a good
attachment with family members. He has impulsive personality, but does not involve in quarrel with
others. He is quite religious, do religious activity like worshiping every evening.& involve in religious
events at the temple.

Mental state examination

Appearance and behavior:
He is an averagely built elderly male wearing a shirt & sarong which are not very clean.. His self
hygiene seems to be poor. There are no signs of self harm. Facial expressions and gestures are
reduced.
There is downward gaze, downward corners of the mouth, and bent head with hunched
shoulders. It took time to build up a rapport and the eye contact is poor. He is easily irritable.

Speech:
The speech is spontaneous with reduced rate and amount and volume. Its relevant and coherent.

Mood:
Subjectively he feels fearfulness and objectively he is distressed.
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Mood is blunted and is congruent.

There are no homicidal or suicidal ideas.

Thinking:
Poverty of thought- Thoughts are unusually slow, few and unvaried.
Delusion of persecution- he believes that CID wanted to kill him.

Perception:
He is having 3rd person derogative auditory hallucinations. He hears voices discussing to kill
him.

Cognition:
He is oriented in time, place and person. His attention span is reduced. Short term memory also
reduced.

Insight:
he believe that others think that his behaviour is abnormal. he also accept that his symptoms are
due to a psychiatric illness. Hence his insight is good.

Mini mental state examination

he scored 25/30. He is not giving wrong answers. But clamed that he does not know the answer.

Physical examination
General examination:
He is averagely built. He is not febrile and his hydration is good. he is not pale or icteric. There
is no lymphadenopathy, finger clubbing or pitting ankle oedema.
Weight- 56kg height-163cm BMI-21.1kgm2

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Abdomen:
There are no signs of chronic liver disease or abdominal tenderness. There is no
hepatosplenomegaly and kidneys are not ballotable. Bowel sounds are audible.

Cardiovascular system:
PR- 68bpm, regular, normal volume and normal character
BP- 130/80 mmHg
Apex- 5th intercostals space, just lateral to the midclavicular line
Heart sounds are normal with no added sounds.

Respiratory system:
RR- 16/min
Trachea is central. Chest movements are normal and symmetrical. Chest expansion, vocal
fremitus and the percussion note are normal.
On auscultation, air entry is normal and equal in both sides of all 3 zones. Vesicular breathing is
present with no added sounds.

Central nervous system:

Conscious and oriented
Cranial nerve functions are normal.
Motor- No involuntary movements with normal gait. Tone, power, reflexes and plantar response
are normal.
Sensory- Normal
Cerebellar functions- Normal

Summary
47 years old father with 2 grown up children. He is having psychiatric care for 7 years after death of his
son. He had several admission with ECT.this time presented with reduced speech, irritability due to

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fearfulness that CID wants to kill him. He started symptomatic after the alms giving of his son; he is
diabetic for 2 years& has two brothers with psychiatric illness.
MSE ,he is having depressed facial expression, reduced amount of speech,volume,rate,blunted mood with
persecutory delusion, having 3rd person auditory hallucination. Insight is good.

Differential diagnoses
1.
2.
3.
4.

Recurrent depressive disorder, current episode severe with psychotic symptoms.

Recurrent mood disorder
Dementia with 2ry depression
Organic brain damage

Definitive diagnosis
According to the ICD 10 diagnostic criteria if,
a) There has been at least one previous episode, mild, moderate or severe lasting a minimum
of 2 weeks and separated from the current episode by at least 2 months free from any
significant mood symptoms.
b) At no time in the past has there been an episode meeting the criteria for hypomania or
manic episode
c) The episode is not attributable to psychoactive substance use or to any organic mental
disorder,
Its defined as recurrent depressive disorder.
ICD 10 criteria of depression is as follows,
A) Major symptoms
- Depressed mood
- Anhedonia
- Lack of energy leading to increased fatigability
B) Minor symptoms
- Reduced concentration and attention
- Reduced self esteem and self confidence
- Ideas of guilt and unworthiness
- Bleak and pessimistic views on future
- Ideas or acts of self harm or suicide
- Disturbed sleep
- Diminished appetite

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C) Psychotic symptoms
- Delusions, hallucinations and stupor
As this patient presents with all 3 major symptoms and more than four of minor symptoms along
with psychotic symptoms (persecutory delusions), the diagnosis is recurrent depressive
disorder, current episode severe with psychotic symptoms.

List of problems
Psychological-

Features of severe depression

Presence of psychotic symptoms leading to distress and worry
Presence of suicidal ideation but no active plan
Poor insight

Presence of diabetes

Presence of persecutory delusions which might lead to aggression

Physical-

Social-

Management
1) Risk assessment:
Risk to selfHe has persecutory delusions which can lead to harm himself.
1. he has loss of appetite leading to reduced food which might deteriorate the physical
health with dehydration
2. He can be subjected to neglect at some point of his life due to lack of social
interactions.
3. Self neglect might lead to forgetting drugs for his medical conditions leading to flareups.
Risk to others
1. He might get aggressive towards his family members.
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2. He might become irritable and suspicious about his family members due to his
forgetfulness.

2) Deciding the setting of the management:

As this patient presents with features of severe depression along with persecutory
delusions, he should ideally be hospitalized and should be managed as an inpatient.
he should be offered a bed near the nursing station with frequent nursing observations.
he should be provided with support and encouragement. he should be monitored for
behaviors, interaction with others, suicidal attempts, sleep, appetite, symptoms of
depression and side effects of drug therapy.

3) Further assessment:
The patient should be assessed further with collateral history gained from the family
members and previous medical records.
The past episodes should be assessed thoroughly noting the frequency, details of
individual episodes, treatment given, response to treatment, inter episodic functioning
with trigger events.
Investigations- To identify underlying treatable causes and as a baseline prior to
commencement of the drugs
1. Full blood count- Hb 13g/dl, WBC 9.3 103, plt 252103
2. Fasting blood sugar level- 93mg/dl
3. Liver biochemistry- Normal
4. Thyroid function tests
5. Serum electrolytes and blood urea- Normal
6. Serum creatinine- Normal
7. ECG- Normal

4) Short term management

Acute managementIf the patient becomes aggressive with increased risk to self and others, he should be
managed in a separate section in the ward with frequent nursing observations and
minimal confrontations with other patients.
De-escalation technique- Initially calm down the patient verbally
If it fails,
Initially treat with oral drugsolanzapine mg
Chlopromazine 50 mg
If the patient refuses oral drug treatment, parenteral medications should be used.
IM midazolam 5mg
IM Haloperidol 5mg
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IM Promethazine 25mg
If there is still no response the drug regime can be repeated after 20 minutes
The respiratory rate, pulse rate, blood pressure, temperature and the conscious level
should be monitored every hourly for 1hour & hourly until he recovers
But as he didnt get aggressive this treatment regime was not used.
Subsequent management- The first line treatment would be treating with SSRIs.
Fluoxetene 20mg mane
a mood stabilizer can be added which has augmentation properties.he was on
Lithium 250mg bd
-

As he also has poor sleep, a short course of antipsychotics can be prescribed.

If he presents with severe depression with psychotic features not responding to
treatment, electroconvulsive therapy should be considered. Hence preparations
for ECT should be made.

5) Long term management:

Biological- The patient and his family should be acknowledged of available treatment
options and side effects of the drugs and they should be engaged actively in
selecting appropriate drugs.
- As the patient has had several relapses even while on drugs, the treatment
regime should be continued for several years, ideally lifelong.
- ECT treatment should be continued frequently at least weekly, until a
satisfactory response occurs
- As the patient is on atypical antipsychotics, he should be monitored frequently
for metabolic abnormalities.
- Response to drugs and side effects of the drugs should be monitored and the
drug doses should be adjusted accordingly.
- Liaise with the medical team to optimize the treatment with his co morbid
illnesses diabetes,sexual dysfunction.

Psychological-

The patient and the family should be educated about the aetiology, symptoms,
treatment options and prognosis of the illness.
Psychotherapy
35

 Identifying stressors and minimizing them

Cognitive behavioral therapy Activity schedule to occupy the patient

Social-

The family should be acknowledged about the disease pattern and the risks of
self harm. Hence they should monitor the patient regularly and provide a
supportive environment with minimum risks.
Family therapy is an option to build up relationships
Care for the careres should also be considered.

6) Follow up:
-

Once the acute symptoms have resolved and the risks are low, he can be
discharged.

Before discharge, the patient should be acknowledged about the drug lithium.

Serum lithium levels should be monitored weekly till the levels stabilize. It
should be checked after 12 hours of the last dose. After lithium levels
stabilize, it should be checked every 3 months and 6 months afterwards.
He should be advised to inform other doctors that he is on lithium when
seeking for treatment for other illnesses. Ideally, he should be given a
clinical record indicating that he is on lithium.
he should drink adequate water, at least 3l/day.
Side effects of the drug such as nausea, diarrhoea, fine tremors, polyuria,
polydipsia, acne and weight gain should be acknowledged and he should be
asked not to stop the drug with these symptoms.
Symptoms of frank lithium toxicity should be told and he should be asked
to stop the drug if he develops these features and to come to the hospital
immediately. Features include severe vomiting, diarrhoea, coarse tremors,
blurred vision, ataxia, muscle weakness and dysarthria.
Renal function tests, thyroid function tests, ECG should be checked yearly.
Weight and the BMI should also be checked yearly.
Compliance is important as abrupt quitting of the drug might trigger
rebound mania.

A risk assessment should be carried out prior to discharge.

On discharge, he and the family should be given a clear overview of the long
term plan, doses of drugs and frequency of ECT treatment.
36

Initially he should be followed up at the clinic weekly. Once the symptoms

subside, monthly follow ups are adequate.
At each visit, the following should be assessed.
Extent and severity of symptoms
Risk to self
Drug compliance
Side effects of drugs
Ongoing psychological treatment
Level of functioning

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