Dr Yasir Hameed Dr Jaap Hamelijnck

Eastern Recovery Team

1 July 2014

THE CURIOUS CASE OF THE MAN

WHO TALKS TO HIS TEDDY BEAR

Why we chose this case?•M

ultiple and complex presentation.

•Various services supporting him and his mother.

•Diagnostic and management challenge.

Background Information•4

2 year old white Caucasian male, unemployed, lives alone in his flat but spends most of his day at his mother’s and her partner and he is totally dependent on her to organise his finances, medication and daily activities. No social contact with others.

•Referred to Eastern Recovery Team due to complex mental health problems in June 2013 and he is also under TADS for Opioid dependence.

History of Present Illness•H

as been under mental health services since 2008

•First referred by GP in late 2007 due to Opioid (codeine dependence), together with anxiety, low mood, self harm and chronic insomnia.

•Long term anger management problems since an early age, resulting in severe impairment in his life.

•In 2008, he was briefly under the Community Forensic Services due to concerns about his thoughts of following young women (teenager girls).

•Also has long history of being violent to others, especially to his mother and her partner.

•? Psychotic symptoms

Past Psychiatric History•N

o previous hospitalisation. Not known to service prior to 2008.

•April 2008: Under TADS due to Opioid (codeine) dependence and is on replacement therapy (Subutex).

•November 2011: Referred to CRHT due to• Suicidal thoughts, impulsive acts of two overdoses, and self-harm

(scratching his arms).• Violent thoughts, actions and concerns about following young women.• ? Psychotic symptoms: auditory hallucination, believing he has

different personalities (DVD shop owner, Indian Muslim).

? Psychotic symptoms (based on various psychiatric reviews)

•Single male voice, inside his head, telling him to “do things”. Some commands are harmless (buying a loaf of bread and leaving it in the kitchen), some are not (follow young women, scratch cars). He feels compelled to obey, otherwise “bad things will happen to his family”.

•Duration: has been hearing this voice for years, but was afraid to talk about it. Only got worse after his relationship with his partner broke down.

•His mother reported that he “always had imaginary friends”, and she is used to hear him in ongoing conversations while alone. He still has a teddy bear (Bradley) whom he talks with and he doesn’t finds that unusual.

• •H

e is now bothered by the voice and would like to get rid of it.

•In addition, he has certain worries, e.g., that he will be burgled and lose his possessions, that people are watching him, and that they might harm him.

•He has obsessional traits, in that he prefers to keep everything tidy and in particular order; he becomes very anxious about causing harm to his family if he does not do so. He also has checking and counting rituals.

Aggressive thoughts and actions

•Violence since the age of 16. Exaggerated by alcohol and amphetamine use but continued after abstinence.

•Amateur boxer as a young man.

•Violence in his relationships.

•He was sacked from various jobs due to his temper. In 2011 he was caught smearing the toilets at Tesco outlets with faeces.

•Obsessed with young girls.

•Obsessed with horror films (since young age) and knives. Transfixed by images of torture and violence. Gets a “buzz” from this.

Forensic History•7

convictions for ABH and GBH

•Conviction for section 18 (wounding with intent to cause grievous body harm).

•At the age of 20 he was charged and received a 6 month prison sentence after assaulting a man in his flat with his friend.

•He has also been violent towards his mother in the past and was arrested by the Police but the charges were later dropped by his mother (2008-2009)

March-April 2012

•Under CRHT. Diagnosis of Acute psychotic episode (F23.0). Quetiapine started and titrated to a dose of 450 mg nocte (effect?).

•Other medications: Venlafaxine 150 mg od, , Lorazepam 1 mg bd, Zopiclone 7.5 mg nocte.

Drug and Alcohol History•M

isused alcohol during teenager years.

•Amphetamine abuse.

•Codeine dependence.

•Cannabis briefly.

Past Medical History•E

pileptic fits

•Hypertension

•Asthma

•Eczema

•Gastritis

Pre-morbid personality•L

onely man, no friends. Avoid social gatherings. Like to live in his routines and dislikes changes. Enjoys walking the dogs, playing video games and watching TV.

Family History•N

o history of diagnosis of mental illness in family. 

Personal History•B

orn and brought up in Leicester in 1971. Only child. Normal delivery and milestones. Parents separated in 1972.

•Mother has a homosexual partner since then.

•Moved to Skegness with mother. Bullied from age 13-16. Later on he started to fight back.

•Had poor academic achievement and left school without any qualifications.

•He was an amateur junior boxer from the age of 17 years to his mid twenties, engaging in fights and suffering some significant knock-outs.

•Has done various odd jobs semi-skilled but unemployed since 2007 due to his temper.

September 2012•R

eviewed by TADS consultant. Stable. Partial response to Quetiapine, but definitely much better. Agreed to increase Quetiapine to 600 mg daily and commence a plan of Subutex reduction.

December 2012•H

e would like to stop medication. He is gaining weight, the voice is getting more derogatory because of his weight.

•Reported second and third person auditory hallucination, derogatory. Ideas of reference.

•He also described recurrent absences of consciousness for 30 seconds – 5 minutes during which he becomes unaware of his surroundings, inaccessible and discontinues whatever he was doing.

•Repeated head injury.

Plan•R

educe and stop Venlafaxine.•S

tart Carbamazepine.•K

eep a diary of absences and tonic/clonic convulsions.•N

o change to Quetiapine yet: to be considered at later stage.•T

o postpone Subutex reduction

•Later on..

•EEG reported as 'Normal with occasional G waves in temporal region”. Not conclusive but lends to diagnosis of temporal lobe epilepsy. EEG with sleep deprivation reported as 'Normal without epileptic features.

•and CT normal.

ERT assessment (June 2013)•I

mpression•C

omplex combination of different types of symptoms.•

Obsessions, compulsions and anxiety.•P

ossibility of organic psychotic illness in relation to his epilepsy as well as the psychological trauma which occurred following the breakdown of his relationship.

•Plan:

•Switch Quetiapine to Aripiprazole (due to significant weight gain)

•Start Clomipramine

November 2013•W

orsening of his anxiety symptoms since the switching. Talking more to himself, and to objects (tree).

•Getting very irritable and even confused. Drank a bottle of whisky he bought as a gift for a relative. He was found wandering in the street by police afterwards.

•Also reporting visual hallucinations (he sees dark shadows, a tiger, a snake in the shower) and has been having these experiences for the last 3 weeks.

•No improvement noted in his obsessions and compulsions.

•Plan:

•Restart Quetiapine. Stop Aripiprazole.

January 2014•E

xplored the life long nature of his symptoms with his difficulties in in socialization, communication and repetitive, stereotyped behaviour.

•Life long problems with attention, hyperactivity and impulsivity.

March 2014•R

e-referred for forensic community services.

•Recommendation on reducing risk:

•Optimise antipsychotic (clozapine)

•Change to valproate

•Increasing his social contact (currently only with mother)

March-May 2014•T

he assessment confirmed the diagnosis of Asperger’s syndrome and Attention Deficit Hyperactivity Disorder (ADHD).

•Screening Questionnaire Scores for Asperger’s Syndrome

•We used the Autism Spectrum Quotient AQ the Empathy Quotient EQ and the relative’s questionnaire RQ (ARC, Cambridge University)

• AQ score was 36 out of 50 (any score above 32 is significant)• EQ score was 13 out of 80(any score below 30 is significant)• RQ score was 18 out of 31 (any score above 15 is significant)

interview for the diagnosis of Adults with Autism Spectrum Disorder ASD which is (RCPsych)

•Area 1 – Reciprocal Social Interaction:

 •G

rew up and continued to be lonely.

•Always had imaginary friends and used to talk to toys and to himself.

•Lives in fantasy world and sometimes can not differentiate between what is real and what is not real.

•Unable to comfort anyone.

•Area 2 – Communication

•No language delay but difficulties in pronouncing certain words, like thirsty or kettle.

•Literal Interpretation

•Do not understand implied meaning and not understand verbal humour

•N

ot good at holding conversations and avoid chatting to people

•Area 3 – Rigidity and Repetitive Interests

•You must do things your own way the same every day and in the same order and not missing out anything.

•You said you liked to collect DVD’s.

•Like watching violent films.

ADHD Assessment•C

urrent symptoms scale- self report form:•9

/9 Inattentive (IA) 8/9 Hyperactive/Impulsive (HI)

•Childhood symptoms scale- self report form:

•9/9 IA 8/9 HI. All areas. ODD 8/8. CD 4/15.

•Current Symptoms Scale-other:

•9/9 IA 8/9 HI. All areas were affected.

•Childhood Symptoms Scale-other:

•9/9 IA 8/9 HI. All areas.

•ASRS-v1.1

•Part A 6/6

•Part B; 10/12

Clinical Interview (DIVA®)

•Scored 7 out of 9 on the inattentive symptoms (both as an adult and in childhood)

•Scored 9 out of 9 on the hyperactive/impulsive (both as an adult and in childhood)

•Life long pattern of symptoms and limitations in at least 2 domains of functioning

May 2014•S

witched carbamazepine to valproate

•Switched Lorazepam to Diazepam

•Failed to respond to Methylphenidate. Changed to Atomoxetine.

Current Medication (June 2014)Quetiapine 350mg twice daily

Clomipramine 100mg nocte

Zopiclone 7.5mg nocte

Subutex 16mg once daily, prescribed by NRP/TADS

Diazepam 2mg twice daily for anxiety

Lansoprazole 30mg once daily

Bendroflumethiazide 2.5mg tablets OD

Hydroxyzine 5mg tablet used as advised

Chlorphenamine 4mg tablet TDS

Sodium Valproate 500 mg twice daily

Discussion•D

ifferential Diagnosis of Asperger’s syndrome

•In 1944 Hans Asperger described a condition he termed autistic psychopathy, characterised by:

•Problems in social integration

•Non-verbal communication

•Egocentric preoccupation with unusual and circumscribed interests

•Difficulties with empathy and intuition. They were also clumsy (50–90% had motor coordination problems), found it hard to take part in team sports and exhibited behavioural difficulties including aggression and being victims of bullying.

•Asperger did not provide diagnostic criteria for this condition and it remained obscure until a review article by Lorna Wing in 1981.

Diagnosis and differential diagnosis of Asperger syndromeFitzgerald M and Corvin A. Advances in Psychiatric Treatment (2001)

•Schizophrenia spectrum disorders vs AS

•Major differences in age at onset, developmental history and mental state examination. In DSM–IV, PDD is an exclusion condition for schizophrenia and it should be suspected in atypical or non-responsive cases.

•People with AS may say they hear voices but refer to actual voices (auditory hypersensitivity)

•Deficiencies in concrete thinking and in understanding how other minds think may cause patients with AS to misinterpret what is said to them, and they might as a result be labelled paranoid.

Schizophrenia vs autism: (cont’d)

•Persons with AS sometimes speak their thoughts out loud, which again can be misinterpreted by a psychiatrist.

•Language abnormalities associated with ASD include substitutions, literalness, problems with prosody, staccato speech and monotonous speech that is excessively pedantic and focused on details or obsessive questions.

•A tendency to direct the conversation towards obsessions could easily be mistaken for evidence of associative loosening.

Schizophrenia vs autism: (cont’d)

•A comparison of thought disorder and affective flattening in patients with autism and with schizophrenia found that they did not differ in terms of affective flattening, and that adult patients with autism showed poverty of speech, poverty of content and perseveration (Ramsey et al, 1986).

•The autism group showed significantly less derailment and illogicality, suggesting that they would be unlikely to meet DSM or ICD criteria for thought disorder in schizophrenia.

Schizophrenia vs autism: (cont’d)

•Schizophrenia can co-occur in ASD, but the additional diagnosis is made only if prominent delusions or hallucinations are present for at least 1 month (less with treatment).

•Despite an absence of epidemiological studies of psychiatric co morbidity in ASD, it has been suggested that delusions or auditory hallucinations may be more common than in the general population, but the prevalence of schizophrenia (at 0.6 %) is comparable to general population levels.

4 “A”s•‘

affect’: Inappropriate or flattened affect-emotions in-congruent to circumstances/situation.

•‘autism’: social withdrawal- preferring to live in a fantasy world rather than interact with social world appropriately.

•‘ambivalence’ : holding of conflicting attitudes and emotions towards others and self; lack of motivation and depersonalization.

•‘associations’ : loosening of thought associations leading to word salad/ flight of ideas/ thought disorder.

Schizotypal and Schizoid Personality Disorder

•The conditions do differ in at least three important respects.

1- An increased rate of development of schizophrenia in schizotypal personality disorder (not in ASD)

2- Schizotypal personality disorder and schizophrenia co-occur in families and appear genetically related.

3- Prospective research of children at high risk of schizophrenia (Erlenmeyer-Kimling et al, 2000) suggests that some individuals later diagnosed with schizotypal personality disorder developed without impairments in reciprocal social interaction and communication.

Attention-deficit hyperactivity disorder

•Gillberg & Ehlers (1998) point out that children who meet criteria for ADHD may also meet the full criteria for Asperger syndrome. They mention one study, in which 21% of children with severe ADHD met the full criteria for Asperger syndrome and 36% showed autistic traits.

•It is important to consider that impulsivity can interfere with social relationships, making children appear unempathic.

•Indeed, children with ADHD can be so easily distracted that they appear to be in a world of their own and therefore seem socially disconnected.

Obsessive compulsive disorders•P

ersons with AS have obsessive interests that are not experienced as ego-dystonic and, indeed, are often enjoyed.

•Baron-Cohen (1989) was critical of the use of the term obsession in persons with autism because the subjective phenomena of resistance to repetitive activities could not be discerned in autism. He suggested instead the phrase ‘repetitive activities'.

•OCD generally has a much later onset and lacks the poor social emotional reciprocity, empathy problems and social skills difficulties of people with Asperger syndrome (Szatmari, 1998).

•Detailed analysis of current symptoms and an early developmental history are the key to making a correct diagnosis.

Was reaching a diagnosis helpful?•T

he importance of formulation?

•How do we decide on treatment?

•How do we prescribe?

Take home message•N

eurodevelopmental disorders are not more difficult to diagnose than any other psychiatric disorder

•Life long symptoms trait like behavioural and emotional problems are big clues

•The importance of developmental history and structured assessments

Thank you..