Long Case Presentation

Dr Aziz Mohammad

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

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

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Personal HistoryWanted 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.

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

Systemic Ex

• Resp : Clear LF, vesicular breathing.• CVS: s1+s2, no added sounds.• Abd: soft, non tender, no visceromegally• CNS: no focal neurological signsGait: normalCoordination: normalsensory/motor systems: intactDeep Tendon Reflexes: normalPower, 5/5 in all 4 limbsNo sings of meningism.

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

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.

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.

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: ?

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

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.

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.

THANK YOU