2. Biodata and Chief Complaints
Zunaira 13 years old from Distt; Charsadda,
presented with
• Excessive weeping, not eating : 3 months
• Picking and smelling different things: 3-4 year
• Repetitive behaviour of touching ppls faces: 8 years
• Other repetitive and inappropriate behaviours: since
childhood
3. History of present illness
• According to the first cousin of the patient who is
reliable, married, living in Mardan for the past 3
years, and shows interest in the care of the patient.
She lived together with the patient in the same
house before her marriage and later for 3 years after
she got married, when the patient was sent to live
with her in Mardan for better schooling and as the
patient is thought to be more attached with her than
with her parents. According to her the patient was
excessively weeping with loss of appetite about three
months ago for which
4. HOPI (cont..)
her father took her to a consultant psychiatrist
who treated her with fluoxetine 20 mg and
olanzepine 5 mg, with which her mood and
appetite got improved, however the consultant
psychiatrist decided to get her admitted in
psychiatry ward for confident diagnosis after
noticing her exhibiting inappropriate behaviour of
touching her father’s face, and for her other long
lasting symptoms of repetitive behaviours since
her childhood.
5.
6.
7. HOPI (cont..)
• According to her cousin, the patient has
repetitive pattern of behaviours since she was
one and half years old. With addition of new
behavioural patterns some of her behaviours
would wax and wane with the passage of time
while other are there for several years now.
8. HOPI (cont..)
• By the time when she was about 18 months old
she would insist her mother or cousin to allow
her put her hands on their faces before going to
sleep.
• She would scratch the face of the person who
would not comply with her this demand which
would become annoying when her mother and
cousin would not be able move their heads for
significant time with the fear of getting her
disturbed. She would not get involved in playful
activities like other children at her age.
9. HOPI (cont..)
• There is stuttering is her speech since
childhood, and she has been unable to quickly
tell her name Zunaira to people without
adding miss before her name. Her stuttering
increases when she is talks to strangers.
10. HOPI (cont..)
• For Several years she is reported to have the
behaviour of touching faces of the people soon
after getting familiarized with them. She would
praise the soft cheeks of people, pinch them
gently and then kiss her fingers.
• She acts in a stubborn and impulsive way when
scolded by her mother for her this behaviour,
• On few occasions she was beaten by her father
with an attempt to change her behaviour but in
vain.
11. HOPI (cont..)
• She has no friends in school and at times she
gets involved in physical fight with other
children in school and her younger sister at
home when they feels annoyed and resist her
behaviour of touching peoples faces. There
have been complaints coming from school
about her behaviour.
12. HOPI (cont..)
• 4 years ago she used to repetitively have self
muttering for about 6 months, when she
would be looking to her right side, whispering
with herself, especially when she would be
alone, or when she would think she not being
observed. She would stop doing so when she
would notice people looking at her. There has
been no self talking in other positions and no
history of any irrelevant talking.
13. HOPI (cont..)
• She is also a reported to be picking her skin,
most commonly her face, forearms, hands and
feet. Most of the times she would pick scabs
from the ulcers of her healing wounds on
these areas.
• Its not known how did she start picking her
skin or if she also picks the normal skin areas,
but at times she is seen picking her lower lip
with her nails.
14. HOPI (cont..)
• She would not take care of the moral values
and at times say inappropriate things in social
settings. She does not properly cover herself
and does not change her previous posture in
the presence of strangers.
• There is increasing concern of her family
about her behaviour because of her entrance
into adolescence.
15. HOPI (cont..)
• She does not take care of herself, would not
change her clothes by herself, and would not ask
for meal unless she is asked to have her meal by
the family members. She has preference for
eating chips. She would not properly sit to have
meal with her family members.
• Although she is able to engage in meaningful
conversation with complete sentences when
asked, especially in her home, she doesn’t
interact with people by her own and give very
brief answers with stuttering and pauses.
16. HOPI (cont..)
• She is also reported to be picking things from
ground to eat, usually the pieces of chips
(crisps or fries), and biscuits etc.
17. HOPI (cont..)
• She was put in class 1 in the new school after formal testing
after her parents shifted to Peshawar a month ago. Apart
from her mental problem as the possible cause for her slow
learning her cousin also considers some environmental
factors to have contributed . According to her there was no
proper school in charsadda where she was put in a school
where both religious and formal education was provided.
Later at the age of 8-9 years she was sent to Mardan for
better schooling where she studied upto class 3 . She had
reportedly been able to memoriz nimaz and verses from
Holy Quran, and is able to write week days in English.
18. HOPI (cont..)
• When enquired about her behaviours she is
unable to tell whether the behaviours she
engages in are the results of absurd intrusive
thoughts in her mind or if they are logical to
be carried out.
19. Past History
• Although her symptoms are there since her childhood,
she was brought to Psychiatry OPD by her father in
june 2012 and treated with Fluoxetine (syp; Depricap,
1TSF OD), and later with Fluoxetine and Risperidone
(sol: Peridal 2.5 cc OD) with which she showed some
improvement with reduction in her symptoms but did
not get completely well. For that reason her treatment
was stopped by her father after a couple of month.
• History of febrile illness at one year of age when she
was treated with injectables for a wk. after which she
recovered. No record available
• No past history of any admission or other treatments.
20.
21. Family History
• Parents Alive
• Father : Lab Technician, currently working in a
maternity hospital in dabgari garden for the last 5
months. Previously was an employee in KTH.
• Mother is a house wife with no formal education.
• Has one sister who is 7 years old. No other siblings.
• (2 reported still births and 2 third trimester
miscarriages).
• One maternal aunt had history suggestive of mental
retardation.
• No other significant psychiatric or medical History in 1st
and 2nd degree relatives.
22. Personal History
Wanted pregnancy, NVD, no prenantal, natal or post natal
complications.
She has never shown to have developed secure attachment
behaviour with her mother. Repetitive behaviours at the age of 2
years.
With delayed speech, she could never tell complete sentences at 4
years of age. She has difficulty to interact with ppl appropriately
since her childhood.
Uneventful early childhood. No history of any kind of abuse during
early childhood.
Started going to school at age 6 years. Reported to have difficulty
in learning and adjusting in new or unfamiliar environment.
Currently student of class 1. Her behavioural symptoms got worse
with the change of her school.
No history of conduct disorder symptoms.
23. GPE
• Small ulcers at different stages of healing on
hands, forearms, face and legs.
• No JACKL
• BP=110/70
• Pulse= 74/min
• Temp: 98 F
24. Systemic Ex
• Resp : Clear LF, vesicular breathing.
• CVS: s1+s2, no added sounds.
• Abd: soft, non tender, no visceromegally
• CNS: no focal neurological signs
Gait: normal
Coordination: normal
sensory/motor systems: intact
Deep Tendon Reflexes: normal
Power, 5/5 in all 4 limbs
No sings of meningism.
25. Investigations
• baseline Biochemical Investigations were in
normal range.
• Psychological investigations revealed
intellectual impairment on CPM, although she
could not complete the test.
• HFD showed gross abnormalities, with
interpretation suggestive of intellectual
impairment, dependency and immaturity
26.
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30. MSE
• A/B: girl of apparently 12 years, sitting on chair,
dressed traditionally. She did not respond to
questions about her basic information and was shy
to communicate so she was provided with a pen
and pencil to draw anything she wanted in order to
build rapport with her. She wrote the week days in
english, with urdu translation, and sketched pictures
of apples, banana, grapes and mango with their
english names. Some of the spellings were wrong,
although her drawing was ok.
31. MSE (cont..)
Limited rapport was established, as she would give
very brief answers to questions with fleeting eye
contact.
• Mood: subjectively and objectively low.
No death wishes, hopelessness, worthlessness
could be elicited from the patient.
Speech: Very brief answers after repeated
questioning. Relevant, coherent, with long pauses,
and stuttering. Of low volume and motonous. No
formal thoughts disorder were noted.
32. MSE (cont..)
Thought/Perception: no hallucinations, and
delusions could be elicited. Patient gave ambivalent
answers to direct closed ended questions about
obsessions, as if she would not understand the
questions. She would say yes to some of the
questions but could not elaborate on it.
Cognition: well oriented in place and person, reg:
2/3, could not understand the command properly.
could tell wk days in fwd but not in backward
direction. Could not do serial 3.
Insight: ?
33. DDx
According to DSM-V
• Autism Spectrum Disorder (299.00) with
accompanying intellectual and language
impairment (stuttering)
• Obsessive Compulsive disorder with
co morbid intellectual impairment.
• Schizophrenia
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39. Management
• No medications are known to be helpful for
the treatment of the disorder itself
• but atypical antipsychotics for behavioural
problems, and antidepressants for comorbid
depression usually are needed.
• Patient has been put on fluoxetine 25 mg and
Olanzapine 6.
40. Management (cont..)
• Non Pharmacological Treatment for the
abnormal behaviour (Contingency
management).
• Apart from medications, management has two
other aspects
1. Educational and social support and services.
2. Help for the family.
