UNIVERSITY OF ZIMBABWE

FACULTY OF MEDICINE

DEPARTMENT OF PSYCHIATRY

PSYCHIATRY CASE REPORT 2

NAME : NYAMAREBVU
JOSEPH K

REG. NUMBER :R089360J

PROGRAM : MBChB IV

CONSULTANT : DR W.O.
MANGEZI
DEMOGRAPHIC DATA

Name : Agness Chatonzwa

Sex : Female

Age : 34 years

Occupation: Unemployed

Marital status: Single

Address : Zimre Park

Informant : Patient.

Referral : brought by sister because of violence behavior

Presenting complaints

Violence physical and verbal 3 days

Not sleeping and wandering around 3 days

Undressing outdoors 3 days

History of presenting complain

This is a known psychiatric patient who was, previously, doing fine on medications. Three days
prior to admission she said she had reduced need for sleep and she could hear a voice, even at
the middle of the night, telling her to walk around or to visit a distant relative. She could obey
the voice. No other voices discussing about her. During the same period she could see other
people naked and as a result could undress in public. She became violent; she beat her older
sister saying she had told her that she was a fool. She could remember all the events and did
not resist being brought to the hospital.

Past psychiatry history

First episode was in 2002.She presented with the same symptoms after the death of sister
whom she was very close to. She stayed at a traditional healer for 6 months but the symptoms
could not resolve. She was then given some medications at Harare hospital without an
admission. She later defaulted treatment she said she was well and the medications were
making her to gain excess weight. Since then she had multiple episodes with almost the same
symptoms but could not remember the number of the episodes. She said she return to normal
functions between episodes.

PAST MEDICAL AND SURGICAL HISTORY

No history of hypertension, epilepsy, or diabetes.

No history of any surgical operations or trauma to the head.

HIV status unknown

FAMILY HISTORY
Both parents are deceased. Mother died in 1996 due to kidney problems. Father died in 2002
and cause of death is not known .Of note father drinks excessively.

She is a fifth born in a family of six and relate well with siblings.

FAMILY PSYCHIATRY HISTORY

One of the elder brothers had a history of mental illness, he had an episode of physical violence
and destroying property in 1996.He was treated at Harare hospital and recovered completely.

No history of suicide.

PERSONAL HISTORY
Pregnancy - no history of pregnancy induced hypertension or any other illnesses

- the mother did not take any medication during pregnancy, she didn’t drink
alcohol

Birth - normal vertex delivery, there were no any complications during or after
delivery

- No history of febrile convulsions or neonatal jaundice.

Childhood - normal development and she reached the developmental milestones at the
expected times
 - She was reserved but would interact with friends

Education - She went up to form 4 but could not write her examinations- she got met in the
second term.

Occupation -She worked in South Africa as a manual labor at an apple farm from 1999 to
2002.Quit when she came to sister’s funeral and get ill since then she had never
been employed.

Psychosexual -she was married in 1995 to the first boyfriend and divorced in 1996.The mother
in law could not acknowledge their marriage.

- had another boyfriend in 1999 to2000 and they had one child.

- She had never used protection

Substance abuse - Started drinking 2 weeks prior to admission alone. She said this was
because of stress from her daughter. She could take, on average, 2 pints
per day usually in the afternoon. She scored zero on the cage
questionnaire.

- No history of smoking

Forensic history - no criminal record, charges or history of punishment.

Premorbidy personality -Was quiet and reserved, had few friends. She would get easily
angered and problem with her temper.

MENTAL STATE EXAMINATION

Appearance and behavior

Patient was kempt, rapport was established easily and she was co-operative and maintained eye
contact. However she was agitated

Speech

Speech was of normal volume, rate and tone.

Was coherent and was not pressured

No neologisms or word salad

Mood and affect

The patient said she was happy

Affect was mood congruent

Neurovegetative symptoms

 No diurnal variation of mood.

 Reduced need for sleep
 Increased appetite
 no significant weight change
 energetic
 Increased pleasure and interest
 no feelings of self blame, guilt or worthlessness
 no suicidal ideation

Thought process
Thought form

No flight of ideas

No thought insertion, withdrawal, or block

Thought content

No paranoid delusions

No grandiose delusions

No ideas of reference

No phobias

No obsessions

Perception
No visual hallucinations

No auditory hallucinations

No gustatory hallucinations

No tactile hallucinations

No illusions

No somatic hallucinations

No déjà vu
No jamais vu

No depersonalization or derealisation.

COGNITIVE STATE
Level of consciousness: clear

Orientation : well oriented in time place and person

Attention and concentration: normal she could say days of the week starting from Saturday
going backwards

Memory –

Immediate: normal she could remember a 6 digit number which l gave her

Short term: normal, she could remember the numbers l gave her after 5 minutes

Long term: normal, she could remember the day of independence of Zimbabwe

Abstract thinking: normal she could tell could interpret the idiom ( kurekwegava ndokusina
mutsubvu)

Judgment : was normal, she said she will take a dumped baby to the police station

Intelligence: was average

Insight was good, she understood the condition she was suffering from and also she was taking
medication because she said the drugs was going to stop the symptoms.

Physical Examination
GENERAL EXAMINATION

 Hands were warm to touch, not sweaty, no splinter hemorrhages, no clubbing.

 No jaundice
 No pallor
 No central cyanosis
 No lymphadenopathy
 No edema
Other systems were essentially normal.
Diagnostic formulation
Statement of problem

Miss Agness Chatonzwa a 34 year old single female patient who presented with a three day
history of violence, undressing in public, not sleeping and wandering around.

Differential diagnosis

1 bipolar affective disorder in the manic phase

2 seizural disorder-Temporal lobe epilepsy

3 schizophrenia

Bipolar affective disorder (current mania)

PROS

 Decreased need to sleep

 Positive family history of mental illness.
 Previous history of same symptoms.
 Second person auditory hallucinations.
 Agitated
 Elated mood congruent to affect
 Increased appetite.
 Energetic.
 Increased interest and pleasure.
 Increased libido

CONS

 She was kempt and calm

 Normal speech
 No grandiose delusion
 Good memory
 Good abstract thinking
 Good judgment

Seizural disorder

PROS

 Violent behavior
  Undressing in public
 Auditory and visual hallucinations
 Positive family history of mental illness
 Episodic presentation and normal functions between episodes
 Symptoms were preceded by drinking alcohol and stress

CONS

 Memory recollection of the events

 No history of head injury
 No history of febrile convulsions
 No depersonalization and derealisation
 No déjà vu
 No jamais vu
 No olfactory and gustatory hallucinations

Schizophrenia

PROS

 Positive family history of mental illness

 Disorganized behavior
 Agitated
 Chronic history of the condition-10 years
 Premorbid personality of being quiet and reserved

CONS

 No thought insertion
 No thought withdrawal
 No thought echo
 No passivity phenomenon
 No somatic hallucination
 No third person auditory hallucinations
 No running commentary
 Normal function between episodes
 She was kempt
 Mood and affect was congruent
 Normal speech
 Good abstract thinking and judgment.
Working diagnosis: bipolar affective disorder in the manic phase

Antilogy

Predisposing factors: - positive family history

-single and unemployed

Precipitating and perpetuating factors:-Stress

-alcohol

-defaulting treatment

INVESTIGATIONS
1 Social: collaborate history from the sister and other family members about:
 Normal function between episodes.
 Drinking habits
 Details of any illness encountered during childhood
 Details of events which occurred until the patient became ill and also a good description
of what was happening before they came to hospital.

Collateral history from Harare hospital about her first episode and the medications which she
defaulted.

2 Physical:

 Thyroid function tests, to rule out any hyperthyroidism and also a baseline to start the
patient on lithium.
 HIV test to rule out any organic cause
 Full blood count – to have a baseline for reference as lithium is associated with begnin
leucocytosis.
 Renal function test-lithium is associated with chronic renal failure.
 Liver function test-increased liver enzymes in alcohol hepatitis
 Electroencephalogram(EEG)-since temporal lobe is one of my differential diagnosis

TREATMENT
Admit in ward 12

1 Pharmacological

In the acute stage: haloperidol 5mg intramuscularly .It is less sedating and it has higher potency
also it doesn’t lower seizure threshold as compared to chlorpromazine

In the long term: give maintenance of haloperidol 5mg twice daily.

Lithium carbonate 800mg once daily.

NOTE. Strict monitoring of the patient since this drug combination is highly associated with
neuroleptic malignant syndrome

2. Psycho educations: to the patient and her sister about the condition and the importance of
taking medication .Inform the patient about the side effects of her medications. She should also
stop taking alcohol and any other form of self medication.

3. Social management: Sent a social worker for home assessment and social support building if
there is need. Sister should monitor and supervise her on the issue of medications and review.

4. Rehabilitation: Social skill training-considering her psycho-sexual history and the issue of self
medication in times of stress.

Vocational training so that she can raise her family.

PROGNOSIS

Good prognostic factors

 Good insight
 Good support from relatives

Bad prognostic factors

 Positive family history of mental illness

 History of non compliance
 Premorbid personality of being quiet and reserved
 Stressful daughter
 Single and unemployed

Overall the prognosis is poor and to improve I should counsel on need for compliance and also
to counsel the daughter
DISCUSSION

Lithium Carbonate and neuroleptic malignant syndrome

Indications for lithium carbonate

1. In mania:-treatment of acute mania

-For prophylaxes in patients with multiple relapses.

2. In depression:-Augment other drugs

-prevention of relapses.

3. Treatment of mixed affective states

4. Treatment of schizoaffective states.

5. Treatment of self mutilating behaviors.

Pharmacokinetics

Lithium is virtually completely absorbed from the gastrointestinal system within 6-8 hours.
Plasma levels peak between 30 minutes and 2 hours. It is not metabolism in the body and
excreted in urine with a half life of about 20 hours.

Pharmacodynamics

3 effects have been reported:

1.Effectys on electrolyte and ion transport-especially sodium ions

2.Effects on neurotransmitters-it enhances serotonin activity

-it decreases dopamine receptor super sensitivity when using

antipsychotics

-augment synthesis of acetylcholine.

3.Effects on second messengers-decreases intracellular levels of inositol1,4,5 triphosphate and

DAG
Adverse Effects

Lithium is well tolerated by most patients. However, careful management of lithium plasma
concentrations is required because of its narrow therapeutic window and because of the close
association between plasma levels and toxicity. Within the normal range of lithium plasma
levels, one can commonly observe persistent but benign side effects, including increased thirst
or urination, fine tremor, weight gain, and edema. Above the normal range of lithium plasma
levels, serious side effects can occur rapidly; they include (with increasing plasma
concentrations and symptom severity) nausea, vomiting, diarrhea, drowsiness and mental
dullness, slurred speech, confusion, coarse tremor and twitching, muscle weakness, and above
levels of 3.0 mmol/L, seizures, coma and death.

The major side effects of lithium affect the endocrine, renal, hematologic, cardiovascular,
cutaneous, gastrointestinal, ocular, and nervous systems . Side effects are usually dosage
dependent and transient in nature. Lithium has teratogenic effects, particularly when taken
during the first trimester of pregnancy. The risk factors predisposing to lithium side effects and
toxicity include renal disease or reduced renal clearance with age; organic brain disorder;
dehydration after vomiting, diarrhea, increased perspiration, and strenuous exercise; low
sodium intake or high sodium excretion; prolonged dieting, especially salt-restriction diets; and
early pregnancy .

Management of Lithium Side Effects

Because most side effects are dosage dependent, reduction of lithium intake will quickly
ameliorate the acute symptoms, but this may increase the risk of relapse. Nausea, vomiting, and
diarrhea can be reduced in some patients by switching from the carbonate to the citrate salt of
lithium. Polydipsia and polyuria can be managed by giving the entire daily dosage of lithium at
bedtime.

Tremor is often responsive to beta-blockers such as atenolol or propranolol. These and other
common side effects (i.e., memory problems, weight gain, and tremor)—although not
immediately harmful and dangerous—can be quite troublesome, may be intolerable to patients,
and often negatively affect compliance. Goodwin and Jamison (1990), pooling percentages from
12 studies including 1094 patients, showed that subjective complaints were common. Among
the most frequent were thirst (36%), polyuria (30%), memory problems (28%), tremor (27%),
weight gain (19%), drowsiness (12%), and diarrhea (9%). Only 26% of patients had no
complaints. Memory problems were most likely to cause noncompliance, followed by weight
gain, tremor, polyuria, and drowsiness.

Thyroid dysfunction can be associated with lithium treatment. A small proportion of patients
receiving chronic lithium treatment will develop thyroid enlargement with elevations in plasma
TSH concentrations. Few patients, however, develop frank hypothyroidism. When this occurs,
lithium may be discontinued, if possible, or thyroxine supplementation may be initiated.
Serious cardiac side effects are uncommon . T-wave flattening or inversion occur often and are
not associated with negative treatment outcome. Some patients taking lithium over the long-
term may experience sudden death of presumed cardiac origin. In particular, sinoatrial node
dysfunction (sick sinus syndrome) can occur with increased frequency in these patients. Routine
monitoring of the patient's electrocardiogram and pulse is necessary in order to minimize
cardiac risk.

The use of lithium during pregnancy is controversial . Mild transient hypothyroidism and
somnolence are common in newborns exposed in utero. The concentration of lithium in breast
milk may also adversely affect nursing infants. The possibility of cardiovascular
abnormalities(Ebstein’s anormally) in some infants exposed to lithium during the first trimester
in utero necessitates both a careful initial risk-benefit analysis and close monitoring.

Contraindications to Lithium

Relative or absolute contraindications to lithium are severe renal disease, acute myocardial
infarction (in which complications may occur owing to arrhythmias, use of diuretics and digoxin,
reduced fluid or salt intake, cardiac failure, and reduced renal function), myasthenia gravis (in
which lithium interferes with the release of acetylcholine and the depolarization and
repolarization of the motor endplate), first trimester of pregnancy, and breast-feeding mothers.

Management of Lithium Treatment Failure

About 60% of bipolar patients respond to lithium treatment alone. If patients do not respond to
lithium treatment, the clinician has several alternative options. The first is to change the
medication schedule to one of two anticonvulsants, carbamazepine or sodium valproate. These
can be administered with or without continuing lithium, and the majority of patients will
respond to one or the other.

Neuroleptic malignant syndrome

This is an idiosyncratic side effect of anti psychotic and the risk is increased in patients on
lithium.Symptoms usually starts after about 5-28 days on treatment and resolve after about10
days if the medications were taken orally. Symptoms are:

1.motor-hypertonicity/rigidity which may present as dysphagia or dyspnoea.

2.mental-akinetic mutism,stupor and decreased level of consciousness

3.autonomic-unstable blood pressure,tarchcardia,increased sweating,salivation,urinary

incontinence and pallor.
Secondary features include pneumonia, thromboembolism, cardiovascular collapse and renal
failure.

The patient has increased creatinine phosphokinase,potassium ions and neutrophilia

The differential diagnosis are encephalitis and heat stroke.

Treatment

Stop the drug.

Manage the symptoms.

REFERENCES

 Michael H Ebert, Peter T Lossen , Barry Nurcombe (2007). Current Diagnosis and
Treatment in Psychiatry, McGraw Hills Access medicine, chapter 21
 New Oxford Textbook of Psychiatry (September 2003): by Michael G. Gelder (Editor),
Juan J. Lopez-Ibor (Editor), Nancy Andreasen (Editor), Jaun J. Lopez-Idor
By Oxford University Press
 Emedicine @http//emedicine/specialities/ psychiatry/bipolar affective disorder
 Oxford handbook of clinical specialties, Collier Longmore and Duncan Brown; 5th edition,
Oxford University press, (1999).
 Bipolar disorder, vol 5. Edited by Mario Maj, Hagop S, Akiskal,Juan Jose Lopez-lbor and
Norman Sartorious, Copyright 2002, John Wikely and Sons limited.