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Case Presentation Physical and Mental Illness. Case. 50yr old Asian Gentleman Brought in by AMHP under section 2 Little English 7pm Can you clerk him in?. Histroy. Patient states he is perfectly well and no idea why he is here. Wants to go home? AMPH
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Case • 50yr old Asian Gentleman • Brought in by AMHP under section 2 • Little English • 7pm Can you clerk him in?
Histroy • Patient states he is perfectly well and no idea why he is here. Wants to go home? • AMPH • Been closing all the curtains and not left the house for 4 weeks • Locked all the doors, refused to let anyone in • Refusing to let wife out
History • Thinks he is being poisoned by people injecting his food, fumes coming through his letter box and washing machine • People are spying on him through the curtains • His wife is in danger too • Can hear voices through the TV and they tell him to stop his medication. • Denied any thought interference
Past History • Grew up in Pakistan, lost one eye as a boy and therefore struggled at school • Moved to England – 18yrs old • Married twice, no children • Worked in plastics factory – he lost his job due to being a diligent worker • Currently unemployed • Lives with wife • PMHx – diabetes and hypertension • No alcohol, no drugs, no forensic hx • Previous section 2 and admissions.
O/E • Asian clothing well dressed and polite • Calm until asked about his delusions • Speech – normal rate and volume • Mood – objectively and subjectively euthymic • Appetite and sleep normal • Paranoid thoughts, Pt can read our thoughts, no thought broadcasting or insertion • Perceptions – no visual hallucinations. Can hear voices through the TV • Orientated in time, place and person. • Insight - none
Differential Diagnosis • Paranoid schizophrenia • Persistant Delusional Disorder • Mood Disorder • Bipolar – manic presentation • Organic • Drug induced psychosis
Schizophrenia • Life time risk 1% of population • Risk increased if relative with schizophernia • M=F • Increased in those born Feb-May (NH), June-Oct (SH) • Onset • Male 15-25yrs • Female 25-35yrs • Increased prevelance – urban populations, low SEC, prison populations • 10% life time suicide risk
Schneider’s first rank symptoms • Thought insertion • Thought broadcasting • Thought withdrawal • Thought Echo • Delusional perception • Running commentary (3rd person hallucination) • Voices arguing (3rd person allucination) • Made feelings, impulses or actions • Somatic passivity
Affective disorders Persistent delusional disorders Personality Disorders Autism / Aspergers Drug induced psychosis Cerebral tumours Huntingtons disease Demetia HIV Neurosyphilis Hyper/hypothyroisim SLE Cushings Wilsons disease Head injury Schizophrenia mimicks
Treatment of schizophrenia • Antipsychotics treat acute episodes and prevent relapse. • Benzodiazepines – agitation or anxiety • Lithium – if affective symptoms • ECT – post-schizophrenic depression • Clozapine – for treatment resistant (10%)
Prognosis • 20% – single episode, recover fully • 35% - recurrent episodes, but slight impairment • 8% significant impairment, but non-progressive • 35% significant progressive impairment
Plan? • Admit to psychiatry ward • Start Risperidone quicklets BUT......
Physical exam • Asked about his diabetes... • Patient throws his medicine boxes on the table, says he is cured and takes coconut to keep him well • AMPH – district nurses not been in for 4 months to give inuslin • Wife states drinking and pu’ing +++ • Patient states he has not got diabetes and the machienes are lying, we are also fake doctors.
A – clear • B – Chest clear • C – HS1+2+0, BP170/100, 118bpm (sinus tachy) • D – BM= unreadable, refusing to PU for urinalysis What would you do next?
Medics! • Blood gas • Urine dip for ketones • IV fluids • Stat dose of metformin • No acidosis, no ketones • Blood sugars decreased to 23 then 17.
NICE - Diagnosing Diabetes Diabetes is diagnosed on the basis of history (ie polyuria, polydipsia and unexplained weight loss) PLUS • random glucose >= 11.1 mmol/l • OR a fasting glucose >= 7.0 mmol/l • OR 2 hour plasma glucose concentration >= 11.1 mmol/l 2 hours after 75g OGTT HbA1c >= 6.5% (48 mmol/mol) = diagnosis of diabetes
NICE - Glucose Control • Discuss individual HbA1c target level, • Encourage maintaining target unless side effects • Discuss how any reduction benefits future health. • Monitor 2–6 monthly until stable • Monitor 6-monthly once stable. • Self-monitoring of plasma glucose should be available: • to those on insulin treatment • to provide information on hypoglycaemia • to assess changes from medications and lifestyle • to monitor changes during intercurrent illness • to ensure safety during activities, including driving. • Discuss urine glucose monitoring if plasma monitoring is found to be unacceptable.
Dilemma of treatment Hyperglycaemia and hypertension risks V Distress to patient by treating V Risk of being able to report a hypo What would you do?
Diabetic review 1/ Janumet (Metformin and sitagliptin) 2/ Pioglitazone 3/ Gliclazide MR
Progress? • Patient distressed by all the tablets. Reporting numerous symptoms and side effects • No change in delusions or insight • No change in blood sugars Idea’s for further management
Started depot Risperidone (later changed to clopixol as no response) • Started Ramipril • Started Insulin • Patient refusing insulin • Can you treat?
“Specifically, the laws in Part IV of the Mental Health Act on treating people without consent, only apply to treatment for mental disorder. They do not apply to the treatment of physical disorders unless it can reasonably be said that the physical disorder is a symptom or underlying cause of a mental disorder”
Conclusion • Complex and interesting case due to overlap of physical and mental illness • Lessons learnt • 1 step at a time • Can’t treat one without the other • Doesn’t always fit NICE – do what you can • We rely a lot on patient co-operation!
