KEMENTERIAN PENDIDIKAN DAN KEBUDAYAANUNIVERSITAS SRIWIJAYA

FAKULTAS KEDOKTERANUNIT PENDIDIKAN (UP)

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otou /orJl. dr, Muh. Ali KomplekR5UH Fo'ttott'9"t'to' #

Skenario C Blok20 Tahun 2013

Mrs.CekEla,a30-year-oldhousewife'wasaamitteaigtheemergency-roominmental hospital (RSEB) Palembang with attempted suicide' she looked very depressed

and sometimes cried without any particular reason'

Her family mentioned that there were changes in he-r behavior since 2 yea$ ago"

she gradually became -ore and more withdru* io herself and preferred to stay in her

roomalldaylong' -L^ ^^--r^:-^r aLnrrr rs a conversation or

One year ago she complained .about hearing voices T:h- t

sometimes the voice "o.-"oting on her, while thi person didn't exist' Later on' the

voice became more Oi.iutUi"g, co'mmanding her to do something wlich was difficult or

;;r;ibl; to refuse. The last command forced her to hurt herself'

The premobid ;;;;;J-y was schizoid and after the age of 20 years it was clear

that her personality became more annoying especially to.her family and also the

neighbors. She became isolated and no sociiinteraction at all' In the last one year' she

became more deteriorated, lacked of self care and couldn't do house chores' Her speech

was limited and the sentences were very disorganized'

According to her family there was n6 stressor before these behavioral changes

happened.In autoanamnesis the patient was very quiet, sometimes cried and difficult to

answer the question. Her answirs were in one-or two words, not so clear and sometimes

she refused to talk at all.

Summary of Psychiatric Examination:The psychopathologies of this patient are poor discriminative insight, command auditoric

hallucination, autism, anxiety, and association disorder such as incoherence and

hemmung. The conclusion i, ttt" realrty testing ability of this patient is really disturbed'

Additional Information:The patient tras gooO m;ital history, no history of schizophrenia or affective disorders in

the family, the level #irrJiig"""" i. *i4,i" the normal range, no stressor during the last

12 months and the GAF scale-is around 40-31 at the moment of exarninatiott'

Physical examination: no abnormality is found'

Learning Objectives:The students will be able to:----f

) aiugnose (multiaxial diagnosis) the disorders'

2) manage the disorders,

3) determine the Prognosis'

Learning Issues:1) multiaxial diagnosis,

2) subtYPes of schizoPhrenia,

3i neuto"h"mistry of the mental disorders'

4j management of schizoPhrenia'

Tern Clarification:1) Committed suicide2) Premorbidpersonality3) Behavioral changes

4) Deteriorated5) Discriminativeinsight6) Command hallucination7) Autism8) Anxiety9) Associationdisordersl0) Incoherencel1)Hemmung12) Reality Testing Ability13)GAF scale

Problem Identification:1) Mrs.Cek Ela was admitted to the emergency unit RSEB with committed suicide.2) The onset began 2 years ago, she was gradually withdrawn to herself3) The behavioral changes became more deteriorated/autism.4) Her speech is very disorganized/incoherence.5) There's auditoric hallucination and commanding.6) Her personality is abnormal.7) The deterioration is severe/GAF scale very low.

Problem Analysis:l) What is the cause of committed suicide?8) What is the meaning of onset began 2 years ago and gradually worsened?2) What is the meaning of autism and incoherence for the diagnostic criteria?li Wfrat does command hallucination mean? What is its importance to establish the

diagnosis?How about the patient's premorbid personality, is there any disorder?How about the very low GAF scale and what does it mean?How to manage this case?

How about the prognosis of this patient?

Hypothesis:Mrs.Cek Ela suffers from severe mental disorder; psychotic which is schizophrenia and

there's also schizoid personality disorder.

SynthesisThe diagnosis is Schizophrenia, the possible subtypes are schizo-paranoid, schizo-

affective, or undifferentiated schizophrenia (need more additional information).The premorbid is schizoid personality disorders, no mental retardation, no abnormality inphysical examination, no stressor as a precipitating factor, the GAF Scale around 40-3 1,

and the prognosis is not good.

4)s)6)7)

Axis I

Axis IIAxis IIIAxis [VAxis V

: Schizophrenia, the possible subtypes are

affective, or undifferentiated schizophreniaschizoid personality disorders, no mental retardation

no abnormality in physical examinationno stressor as a precipitating factorthe GAF Scale around 40-31

schizo-paranoid, schizo-

The diagnostic criteria of Bleurer for schizophrenia (aA) is fulfrlled, includes the primary

symptoms: (1) association disorders (incoherence, hemming and spemrng which can be

detected in her limited and very disorganised speech), (2) clear autism (there are many

autistic behavior and thought), but (3) affective disorders (flat or inappropriate) and (a)

ambivalence are not clearly involved. The secondary symptoms is very clear, especially

the command auditoric hallticination (which is nearly pathogomonic for schizophenia).

Another condition that contributes to the diagnosis is the prodromal syrnptoms: there

were changes in her behavior during the last 2 years, gfadually became more and more

withdrawn to herself and frnally the patient became deteriorated.

F.2O.SCHIZOPHRENIAThe schizophrenic disorders are characterized in general by fundamental and

characteristic distortions of thinking and perception, and by inappropriate or blunted

affect. Clear consciousness and intellectual capacity are usually maintained, although

certain cognitive deficits may evolve in the course of time. The disturbance involves the

most basic functions that give the normal person a feeling of individuality, uniqueness

and self-direction. The most intimate thoughts, feelings, and acts are often felt to be

known to or shared by others, and explanatory delusions may develop, to the effect that

natural or supematural forces are at work to inJluence the affiicted individual's thoughts

and action in ways that are often bizarre. The individual may see himself or herself as

the pivot ofall that happens.

Although no stri-ily pathognomonic symptoms can be identified, for practical

purposes iiis useful to divide the symptoms into group that have special imporlance for

the diagnosis and often occur together such as:

a) thought-echo/insertion or withdrawaVbroadcast;b) delusions of control, influence or passivity, clearly referred to body or limb

movements or specific thoughts, actions, or sensations; delusional perceptions;

c) hallucinatory voices giving a running commentary on the patient's behavior, or

discussing,the patient among themselves, or other types of hallucinatory voices

coming from some part of the bodY;

d) persistent delusions of other kinds that are culturally inappropriate and completely

impossible, such as religious or political identity, or superhuman powers and abilities(e.g being able to control the weather, or being in communication with alien fromanother world);

e) persistent hallucinations in any modality, when accompanied either by fleeting or

half-formed delusion without clear affective content, or by persistent overvalued

ideas, or when occuring everyday for weeks or month;f) breaks or interpolations in the rain of thought, resulting in incoherence or irrelevant

speech, or neologisms;g) catatonic behavior, such as excitement, posturing, or waxy flexibility, negativism,

mutism, and stupor;h) negative symptoms such as marked apathy, paucity of speech, and blunting or

inconcruity or emotional responses, usually resulting in social withdrawal and

lowering of social performances; it must be clear that these are not due to depression

or to neuroleptic medications;i) a significant and consistent change in the overall quality of some aspects of personal

behavior, manifest as loss of interest, aimlessness, idleness, a self-absorbed attitude,

and social withdrawal.

Subtvoes of schizophreni a. F 20.0 Paranoid schizophrenia

The general criteria for a diagnosis of schizophenia must be satisfied. In addition,

hallucinations and/or delusions must be prominent, and disturbances of affect, volition

and speech, and catatonic symptoms must be relatively inconspicious. Delusions can

be ofalmost any kind but delusions ofcontrol, influence, or passivity, and persecutory

belief of various kinds are the most characteristic.

r F20.1 Hebephrenic schizophreniaA form of schizophrenia in which affective changes are prominent, delusions and

hallucinations fleeting and fragmentary, behavior irresponsible and unpredictable, and

mannerisms "o*-onl The mood is shallow and inappropriate and often accompanied

by giggling or self-satisfied, self-absorbed smiling, or by a lofty mannor' grimaces,

*utitJiir*i, pranks, hypochondriacal complaints, and reiterated phrases' Thought is

disorganizei -attA

speectr rambling and incoherent' There's a tendency to remain

rotitity, and behavior seems empty of purpose and feeling. Usually starts between the

age of 15 and 25 years and tends to have a poor progngs!1 because of the rapid

dlvelopment of negative symptoms, particularly flattening of affect and loss of volition.

c F 20.2 Catatonic schizophreniaProminent psychomotor disturbances axe essential and dominant features and may

alternate between exhemes such as hyperkinesis and stupor, or automatic obedience

and negativism. Constrained attitude and postures maybe maintained for long periods.

Episodes of violent excitement maybe a striking feature of the condition.

r F 20.3 Undifferentiated schizophreniaCondition meeting the general diagnostic criteria for schizophreni4 but not conforming

to any of the above subtypes, or exhibiting the features of more than one of them

without a clear of predominance of a particular set of diagnostic characteristic'

r F 20.5 Residual schizophreniaA chronic stage in the development of a schizophrenic disorders in which there has

been a ciear progression frorn an early stage comprising one or more episodes ofexacerbation to a later stage.

o F 20.6 Simple schizophreniaSlowly progressive development of the characteristic negative symptoms of residual

Schizoplrenia without any history of hallucinations, delusions or other manifestations

of eariier psychotic episode, and with significant changes in personal behavior,

manifest as a marked loss of interest, idleness, and social withdrawal.o F 25 Schizoaffective disorders

These are episodic disorders in which both affective and schizophrenic symptoms are

prominent within the same episode of illness, preferably simultaneously, but at least

within a few days of each other.o F 25.0 Schizoaffective disorder, manic type

There must be a prominent elevation of mood, or a less obvious elevation of mood

combined with increased initability or excitement. Within the same episode, at least

one and preferably two typically schizophrenic symptoms should be clearly present.

r F 25.1 schizoaffective disorder, depressive type.A disorder in which schizophrenic and depressive symptoms are both prominent in the

same episode of illness. Depression of mood is usually accompanied by several

characteristic depressive symptoms or behavioral abnormalities such as retardation,

insornnia, lost of energy, appetite or weight reduction of normal interests, impairment

of concentration guilt, feelings of hopelessness, and suicidal thoughts. At the same time

or within the same episode, other more typically schizophrenic symptoms are present.

This subtype is usually less florid and alarrning than manic t1pe, but they tend to last

longer and the prognosis is less favorable. Although the majority of patients recover

completely, some eventually develop a schizophrenic defect.

o F 25.2 Schizoaffective disorder, mixed type

Disorders in which symptoms of schizophrenia coexist with those of a mixed bipolar

affective disorder.

Pattern ofcourseTh. **t" of schizophrenic disorders can be classified by using the following five

character codes:F20.x0 -Continuous

.x1-Episodic with progressive deficit

.x2-Episodic with stable deficit

.x3-Episodic remittent

.x4-lncomplete remission

.x5-Complete remission

.x8-Other

.x9-Period ofobservation less than one year

DIAGNOSTIC CRITERIAS FOR SCHIZOPHRENIAThere are many diagnostic criteria for schizophnenia e.g Bleuter's, Schneider's, WHO-

ICD, ApA-DSiuL hlonesian PPDGJ etc but the classical criteria Bleuter's is still very

useful and very practical for clinical and educational purpose'

The Bleurer's criteria includes Primary symptoms-4A (disorders of associations,

uff""tiu., autism and ambivalence) and the Secondary symptoms like delusions,

hallucinalions etc.

MULTIAXIAL DIAGNOSISAxis I : -Clinical disorders

-otherconditionthatmaybeasafocusofclinicalattentionAxis II : -PersonalitY disorders

-Mental RetardationAxis III: -General Medical ConditionsAxis IV :-Psychosocial & Environmental problems

Axis V :-Global Assessment of Functioning (GAF)

TREATMENTS/MANAGEMENTTHERAPYoFSCHIZOPHRENIAa. Hospitalizationb. Somatic treatments/biological therapies

r pharmacotherapy: usually using major tranquillizers (anlipsychotic/neuroleptic

irugs;, frrst choice is the classii typical antipsychotic and if no progress use the

o"w.i g"tt"tation of drugs, it's the atypical antipsychotic drugs'

o other drugs : lithium, anticon'ulsants, benzodiazepines

r other biological therapiesr ECT as the last choice if there's no progress in drugs therapy

c. Psychosocial theraPies. Social skills trainingr Family-orientedtheraPieso Case managementr Assertivecommunity treatment(ACT)o Group therapyr Cognitive behavioral therapyr IndividualpsychotheraPYo Vocational therapy

PROGNOSISTo evaluate the prognosis it's better to look up the longitudinal history of illness begins

with the family history arrd at last how about the suppott system'

Features weiglting towards good to poor prognosis in schizophrenia

Good prognosis-Family history of mood disorders

-Good premorbid social, sexual & work histories

-Late onset-Manied-Acute onset

Poor prognosis-Family history of schizoPhrenia-History of perinatal trauma

-Young onset

-Obvious precipitating factors-Mood disorder symptoms (esp, depressive disorders)

-Positive symptoms-Good support systems

-Poor premorbid social, sexual &works histories

-Single, divorced or widowed-Insidious onset; no precipitatingfactors

-Neurological signs & symptofils-Withdrawn, autistic behavior-Negative symptoms-No remission in 3 years

-Many relapses-History of assaultiveness-Poor support systems

REALITY TESTING ABILITY

There are 3 aspects of the personality, wether psychotic or not'it'sdependsonthedysfuntion/disorder/disturbanceoftheseaspect.

Affective lStimmung-afeftlve state :normoleuthymia,hyperthymia,

hypothymia, poikilothymia,disthymla'bl u nted/flaUi na PPriate affect

-emotional stateThought /Denken

-i nte ll e ctu a I f u n cti o n : m e m ory' co n ce ntra ti o n'

o ri e nta tio n, d i scri m i n a tive j ud g em e nU i nsi g ht'

intelligencY leve l,dementia etc€en€ation & perce ption:illu don,ha llucination-thought pro ce ss: -psych omotility'qua lity

-associatione,co ntent a nd form etc

Behaviour and instinctual drive/ Handlung-a bu lia/hypobu I ia,stu por, ra ptu g i m pu t sivity' se x u a I

deviati on, va 9a bonda ge, pyrom a nia, ma n ne risrn'

mutisrne,autisrne etc

GlobalAssesment of Functioning (GAF) Scale100-9'l : superior functioning, no symptom s

90{1 : absent or minimal sYmtoms

80-71 : transient symptoms,slight impairment in soclal,

occupational or school functioning70-61 : some mild symptoms'8ome difficulty in functioning

60-5t: moderate symptomd difficulty in functioning

50-41 : serious symptomsrimpairment in functioning

40€l: some impairment in reality testing or communication/

major impairment in several areas'

30-2{: behaviour is considerably influenced by delusions or

ha llucinations/se rioue im pai rment in com m unication

or iudgmenUinability in almosl areas

20-11: some danger of hurting self or others/occasionally fails to

maintain minimmal personal hygienelgross impairment in

communication10{1 : persistent danger of severely hurting self or others/persistent

inabilitytomaintainminimalpersonalhygiene/serioussuicidalact