2. Presenting complaint
35 year old female with known (mild) intellectual disability was
referred to Mental health Intellectual disability team with
complaints of:
• Agitation, no communication, poor dietary intake and
sleeplessness- 5 days.
• Bizarre behavior, suspiciousness and double incontinence- 5 days.
3. History of presenting complaint
• Ms. Gabi* 33 year old female presented to the acute psychiatric unit (Voluntary admission) with sudden
onset of restlessness, agitation, poor sleep, decreased communication and urinary incontinence.
• Family reported that she had been alright a week ago with sudden change. The mother, however noted that
she had ‘not been herself’ two days earlier. She had left the house for a walk and wandered further than
usual, but returned without any concern or information. The following day she was alright but the day
after, she went to sleep midday and then refused to get out of bed. She became quiet, restless and didn’t
sleep all night.
• Next morning, mother persuaded her to visit the G.P but she refused to sit in the car, remained irritable,
kept pacing and tried to leave the clinic. She didn’t cooperate with the doctor or nurse. She was prescribed
a Xanax but she refused to take it. At home she called her mother and sister-in-law and confessed
“Something happened…” but gave no further details.
• She visited her father over the weekend but only responded to him in nods without verbal communication.
She avoided interaction by turning away and appeared ‘fearful’. She was noticed to be ‘trembling’ and
agitated. She had poor appetite and only took sips of water or nibbled on food when urged.
• She was taken to another GP who prescribed Valium and discharged her home. She remained unsettled and
was referred for hospitalization on 5th day.
4. History of presenting complaint
• She had a light dinner and kept pacing the floor. She was disoriented to place and kept soiling
her clothes with excreta after which she had to forcefully be changed. Her blood and urine
samples were sent for investigation. She completely denied physical examination. She was
discharged from Cavan Hospital after observation.
• Mother was over-whelmed with caring for Gabi due to personal and family reasons and found it
exhausting to safeguard her from leaving the house, frequent soiling, restlessness and lack of
sleep.
• She had a review in SATU, Mullingar & then readmiited to Cavan General Hospital. She remained
mute, didn’t engage in the interviews, appeared fearful, agitated and didn’t trust anyone,
including family. She was observed to be self-talking but remained silent otherwise despite
prompts.
• She quietened the mother with “Mommy Shhh” if mother gave details to the staff. She was
anxious, suspiscious, only eating little bites and avoided company. She would not leave her
room. She collected her belongings and got angry with anyone touching even dirty laundry. Staff
usually had to insist on sanitary care and showers due to reluctance. She would not allow any
person to get physically close and got anxious around male staff.
• MHID team reviewed her on 3rd day of admission and prescribed Lorazepam. Another consultant
on day 5 suggested Olanzapine 5mg which was increased to 15mg but no improvement was
observed in 2 weeks hence was stopped.
5. History of presenting complaint
• She was overheard whispering “I shouldn’t be telling anything” with her
mouth covered. Staff reported that she screamed “Leave me alone. . . We
were never together… “. And on another occasion “I didn’t tell them
anything”
• When questioned about what was wrong, Gabi would get teary but would give
no response & was noted to be crying several times.
• She was continued on Sertraline but there was no significant recovery. She
took short phone calls from family members and used her own phone after 4
weeks . After she began tolerating company, showering and eating with
assistance, she was discharged and sent home.
• She was readmitted with initial presentation 2 days later, crying, rolling on
the floor, pacing, head-banging/headache and remaining anxious &
incontient. She was examined for vaginal soreness but without further
intervention she was discharged again & sent to the respite.
6. Hx Of Presenting complaint
• At the respite she remained unsettled with restlessness,confusion,
insomnia, suspiciousness & mutism. She hid soiled clothes in
handbag and staff found patches of pubic hair. She threw food
under the sofa and had lost significant weight.
• There was no fever, altered consciousness, neurological disorder
or trauma prior to onset. No identified stressors at home or social
setting.
7. Past Psychiatric History
• December 2106:
There was no significant mood or anxiety symptoms but Gabi had
complaints of malaise and dizziness for which the GP prescribed her
Sertraline.
8. Personal History
• Birth hx-
NVD, no complications.
Global developmental delay.
• Education:
Studied in regular school till 2nd grade then was sent to special
school where she completed her studies.
9. Pre-morbid personality
• Gabi was generally a shy but a friendly person. She would enjoy
engaging & telling about herself and her family.
• She was able to dress and shower independently & loved dressing
up.
• She was updated about sports -Football and soccer. Watched
cartoons on TV and listened to music.
• Enjoyed shopping and attended social activities under supervision.
• Stress coping: Verbalization with occassional regression noted.
10. Family History
• Gabi belonged to an Irish family. She had 3 brothers and was 3rd in
birth order.
• Parents had separation in 2004.
• Father lived separately-she visited him over the weekend.
• Her elder brother had Down’s syndrome and Diabetes.
• The eldest brother was married and lived separately.
• She resided with her mother and two brothers.
• Grandfather died a year ago- met frequently.
11. Medical History
• Frequent issues with Low Blood pressure.
• Mild anemia- 2011
• Hypothyroidism diagnosed- 2011
15. Mental State examination
• A petite lady in her 20s, nearly 5.3 ft tall. Underweight with pale
complexion. She appeared anxious, frightened and perplexed. She
attempted to hide herself within her arms and turned body away.
She had no eye contact and rapport was not established.
• Mood: (S)-X
• Mood:(O)- Anxious.
• Affect: Anxious- Congruent.
• No Speech
• Thoughts/perception/cognition/insight could not be evaluated.
17. Vulnerabillity Assesment
Clinical symptoms Behavioral symptoms Treatment Support
Problems with sleep Wandering Failure to
engage/uncooperative
Recent
stress/Impending crisis
Cognitive impairment No self/other injury Admission to secure
setting
Lack of structured daily
acitivity
Hallucinations?? No risk taking behavior Concern expressed by
relatives
Poor insight Inability to
communicate
effectively with others.
20. Course of Illness
• The patient was referred to MHID on June 27th, June 2017- 5 days after
discharge from the Hospital with complaints of restlessness, mutism, double
incontinence, anorexia and insomnia. She had day-care admissions for
dehydration in acute unit twice. She refused to change soiled clothes and
accepted assistance only from brother. There were reports of bizarre behavior
(screaming for the devil/ shouting/ inappropriate undressing/ phone use with it
switched off etc).
• She was prescribed Olanzapine with dose optimization within 2 weeks. Recovery
was noticed within a week with incomplete remission & 2 relapses in the course
of 12 weeks.
• There was a query of Tinnitus.
• There was an addition of Haloperidol & Serc.
• Complete recovery by 16th week of onset.
21. Provisional Diagnosis
• Axis I
• Mild Intellectual disability
• Axis II
• Hypothyroidism
• Axis III
• Acute Psychotic disorder
• Axis IV
• GAF- 31 to 40 (major impairment in several
areas)
• Axis I
Severity of retardation and problem behaviors
• Axis II
Associated medical conditions
• Axis III
Associated psychiatric disorders
• Axis IV
Global assessment of psychosocial disability
• Axis V
Associated abnormal psychosocial situations.
24. Acute Stress reaction-ICD 10
• Acute Stress Reaction refers to the development of transient emotional,
cognitive and behavioural symptoms in response to an exceptional
stressor such as an overwhelming traumatic experience involving serious
threat to the security or physical integrity of the individual or of a
loved person(s) (e.g. natural catastrophe, criminal assault, rape), or an
unusually sudden and threatening change in the social position and/or
network of the individual.
• The symptoms usually appear within hours to days of the impact of the
stressful stimulus or event, and typically begin to subside within a week
after the event or following removal from the threatening situation.
25. Acute stress disorder-DSM 5
• A. Exposure to actual or threatened death,
serious injury, or sexual violation in one (or
more) of the following ways: Directly
experiencing or witnessing the traumatic
event(s).
• B. Presence of nine (or more) of the following
symptoms from any of the five categories,
beginning or worsening after the traumatic
event(s) occurred:
• Intrusion symptoms Recurrent, involuntary, and
intrusive distressing memories of the traumatic
event(s).
• Negative Mood Persistent inability to
experience positive emotions.
• Dissociative Symptoms An altered sense of the
reality of one's surroundings or oneself.
• Avoidance symptoms: Efforts to avoid distressing
memories, thoughts, or feelings about or closely associated
with the traumatic event(s).
• Arousal symptoms Sleep disturbance (e.g., difficulty falling
or staying asleep, restless sleep)
• Irritable behavior and angry outbursts (with little or no
provocation) typically expressed as verbal or physical
aggression toward people or objects.
• Hypervigilance: Problems with concentration Exaggerated
startle response
• C. The duration of the disturbance (symptoms in Criterion
B) is 3 days to 1 month after trauma exposure.
Note: Symptoms typically begin immediately after the trauma,
but persistence for at least 3 days and up to a month is
needed to meet disorder criteria.
• D. The disturbance causes clinically significant distress or
impairment in social, occupational, or other important areas
of functioning.
29. AUTOIMMUNE ENCEPHALITIS
• Anti-NMDA receptor encephalitis — Anti-NMDA receptor encephalitis is the
best characterized of the autoimmune encephalitis syndromes and is associated
with a predictable set of symptoms that combine to make up a characteristic
syndrome.
• Clinical features — Many patients present with prodromal headache, fever, or a
viral-like process, followed in a few days by a multistage progression of
symptoms that include:
• Prominent psychiatric manifestations (anxiety, agitation, bizarre behavior,
hallucinations, delusions, disorganized thinking); isolated psychiatric episodes
may rarely occur at initial onset or at relapse
• Insomnia
• Language dysfunction: diminished language output, mutism, echolalia
• Decreased level of consciousness, stupor with catatonic features
• Memory deficits/ Seizures
• Frequent dyskinesias: orofacial, choreoathetoid movements, dystonia, rigidity,
opisthotonic postures
• Autonomic instability: hyperthermia, fluctuations of blood pressure, tachycardia,
bradycardia, cardiac pauses, and sometimes hypoventilation.
Clinical spectrum
The autoimmune
encephalitis syndromes
have a wide clinical
spectrum that ranges from
typical limbic encephalitis
to syndromes with complex
neuropsychiatric symptoms
such as deficits of memory,
cognition, psychosis,
seizures, abnormal
movements, or coma.
30. Acute and transient psychotic disorders-
ICD 10
• A heterogeneous group of disorders
characterized by the acute onset of
psychotic symptoms such as delusions,
hallucinations, and perceptual
disturbances, and by the severe
disruption of ordinary behaviour.
• Acute onset is defined as a crescendo
development of a clearly abnormal
clinical picture in about two weeks or
less.
• For these disorders there is no
evidence of organic causation.
Perplexity and puzzlement are often
present but disorientation for time,
place and person does not justify a
diagnosis of delirium.
• Complete recovery usually occurs
within a few months, often within a
few weeks or even days.
• The disorder may or may not be
associated with acute stress, defined
as usually stressful events preceding
the onset by one to two weeks.
33. • The aetiology of schizophrenia in intellectual
disability is probably similar to that of the general
population, but the higher prevalence suggests
that this population have an increased risk due to
obstetric complications (O’Dwyer, 1997) and
genetic risk factors.
34.
35. Dissociative disorder
• Dissociative disorders are characterized by a disruption of and/or
discontinuity in the normal integration of consciousness, memory,
identity, emotion, perception, body representation, motor
control, and behavior.
• Dissociative symptoms can potentially disrupt every area of
psychological functioning.
• Includes dissociative identity disorder, dissociative
amnesia, depersonalization/derealization disorder, other specified
dissociative disorder, and unspecified dissociative disorder.
36. Lujan-Fryns syndrome
• Lujan-Fryns syndrome (LFS) is an extremely rare, X-linked
disorder, for which the full clinical spectrum is still unknown.
Usually, it presents with neuropsychiatric problems such as
learning disabilities, Marfanoid features, and behavioral issues.
• It is frequently associated with psychotic or other psychiatric
symptoms. In all patients with symptoms of schizophrenia and
mental retardation Lujan-Fryns syndrome should be considered in
the differential diagnosis.
Editor's Notes
Byrne P. Managing the acute psychotic episode. BMJ : British Medical Journal. 2007;334(7595):686-692. doi:10.1136/bmj.39148.668160.80.
14.6% of first-episode psychosis patients had primary negative symptoms (PNS).
Premorbid, clinical and cognitive correlates of primary negative symptoms in first-episode psychosis- 30 August 2016,
