SCHIZOPHRENIA (A CASE STUDY)

Ken (not is his real name) is a 26 year old male who was diagnosed with schizophrenia about 7 years ago. He had his first psychotic episode at the age of nineteen years(19) after a prodromal period of thinking classmates were out to hurt him and using Kuber(tobacco) to treat his stress. He decided to repeat his o-level education because he was dissatisfied with the grades he had gotten and the stress of wanting to get excellent results started putting him down. He was treated as an outpatient with ant-psychotics. The school and the parents thought that he was abusing drugs but they were not aware that a urine toxicology screen would have helped on determining whether Ken was on drugs or not.

Subsequently he was transferred to another school where the parents hoped he wouldn’t be able to access drugs of abuse. He however developed another psychotic episode (had paranoid delusions, auditory hallucinations and disorganized behavior) and was hospitalized for three weeks. During this admission toxicology screen for cannabis and other drugs of abuse was negative. He stabilized on olanzapine gave up on re-sitting his high school examination and enrolled for a diploma at a University.

Eight months later, he suffered from chicken pox and when he was recovering from it he suffered another psychotic episode. He was admitted at a general hospital. This time he had paranoid delusions (thinking that some people wanted to kill him.) and auditory hallucinations. In response to the hallucinations and delusions, he escaped from the hospital through a window, jumped the fence, crossed a river and went into the bush running from these people who wanted to kill him. After 5 days he was found immobile and unresponsive. He was transferred to a more specialised hospital and he was investigated for physical illnesses, poisoning and no physical abnormality was discovered. He was diagnosed to have scizophrenia, catatonic subtype. He was referred for Electroconvulsive therapy (ECT) in addition to ant-psychotics, benzodiazepines and appropriate nursing care. He recovered from the stupor on the fourth E.C.T. and had two more E.C.T.S. He was discharged on Risperidone and flupenthixol decanoate 40 mg. The flupenthixol depo was stopped after two months and he continued on risperidone. After about nine months he discontinued the risperidone because he believed he was well and the risperidone was giving him extrapyramidal side effects.

Two months later he developed another psychotic episode which ended up in a catatonic stupor. At this time Electroconvulsive therapy, intramuscular ant-psychotics and benzodiazepines were started sooner than the first episode and he was out of the stupor on the third E.C.T. session. He received an extra ECT session and was discharged on Risperidone and flupenthixol decanoate 40 mg. He continued on the two medications for two months and the flupenthixol depot was stopped. He continued taking risperidone until he complained of extrapyramidal side effects of risperidone and he was put on olanzapine 10mg nocte. (At this time in Kenya there was a wide variety of olanzapine preparations) Together with his family he was educated on what symptoms to watch out for and advised to consult the psychiatrist even if an appointment wasn’t due if the symptoms recurred.

Ken has been followed up as an outpatient and has not had a relapse since 2009. His Family has been very supportive. He is currently on olanzapine 5mg p.o. nocte. He enrolled for a diploma and graduated and thereafter enrolled for a degree course and finally graduated.

Ken has a family history of schizophrenia in both the maternal family and the paternal family . He is the first born in a family of four. His siblings are well and two have graduated from the university. His childhood was normal and he is reported to have been very obedient boy. It is reported that when he was sixteen years he was treated for peptic ulcer disease.

CATATONIC SCHIZOPHRENIA IN THE ERA OF DSM 5 AND MORE ACCESS TO ATYPICAL ANTPSYCHOTICS IN KENYA

Dr. Catherine Munanie Syengo-Mutisya

BACKGROUND TO THE STUDY

      Several reasons made me choose to write on this topic.                                  

         The first reason was that schizophrenia is widely considered to be one of the most serious mental illness necessitating high levels of care and sometimes hospital admission. The second reason was that psychiatry is a very dynamic medical speciality and there has been a lot of hullabaloo on the shift from DSM 4 to DSM 5 with notable changes in the diagnosis of schizophrenia. My last but not least reason was that there is a patient I have been managing for the five years with one of the rare subtypes of schizophrenia (catatonia) and I wanted to reexamine this case with the readers and see whether the management would change in this era of DSM 5 in which schizophrenia subtypes were removed because they didn’t appear to help with providing better targeted treatment, or predicting treatment response. Is catatonic schizophrenia rare in Kenya as it is in the developed countries?

 

Kenya

1.       Kenya has seen a major shift of treatment from the era of limited choice of atypical antipsychotics to that of amble choice of atypical ant psychotics.

2.       To examine how this change has affected the management of my patient whose chronological age changed from late adolescence to young adult. Did age and availability of drugs contribute to the good control of the illness?

Definition

Schizophrenia is a psychiatric illnesses that presents with psychosis. I will therefore define psychosis before I move on to define schizophrenia. Psychosis is a complex medical condition affecting the brain and it refers to a loss of contact with reality, in which people have difficulty distinguishing between real and imagined experiences. Thought and emotions are impaired and characterized by radical changes in personality, impaired functioning, and a distorted or nonexistent sense of objective reality. When this occurs, it is called a psychotic episode. Schizophrenia is therefore a severe chronic brain disorder presenting with psychosis. It may result in hallucinations, delusions, and disordered thinking and behavior. It isn't split personality or multiple personality.

 Risk factors

Although the exact cause of schizophrenia isn't known, certain factors seem to increase the risk of developing or triggering schizophrenia. These factors include; having a family history of schizophrenia, exposure to viruses, toxins or malnutrition while in the womb particularly in the first and second trimesters, stressful life circumstances, older paternal age, Taking psychoactive drugs during adolescence and young adulthood and many more.

Causes

Researchers believe that a combination of genetics and environment contributes to development of the disease. Imbalances in the neurotransmitters dopamine and glutamate, also may contribute to schizophrenia. Neuroimaging studies show differences in the brain structure and central nervous system of people with schizophrenia. While researchers aren't certain about the significance of these changes, they support evidence that schizophrenia is a brain disease.

 

Diagnosis

Diagnosis involves a thorough physical examination to rule out a physical illness.  Laboratory tests may include all tests to exclude all possible causes of psychosis.  Psychological evaluation includes evaluation of thoughts, feelings and behavior patterns. Enquiry into the symptoms, including when they started, how severe they are, how they affect ones daily life and whether the patient has had a similar episodes in the past. The clinician should also enquire about suicidal ideations and self-harm or tendency to harm others. Collaborative history from family or friends is very important because the patient most of the time has no insight into his illness. If the patient is unresponsive or the behavior seems inappropriate, the doctor should check for catatonic symptoms.

Possible causes of catatonia are many and  include;  Mental illnesses like Depression –( in severe cases), Schizophrenia, Delirium, Emotional trauma,  Certain medications, Brain disorders, Carbon monoxide poisoning, Viral encephalitis, Multiple sclerosis, Malaria, Meningitis, Tuberous sclerosis, Tetanus, Medications, Electrolyte imbalances, Subarachnoid hemorrhage, Addison's disease, Tay Sachs disease, Heat stroke, conversion, Parkinson's disease, Huntington's disease, Frontal lobotomy, Stroke, Neuroleptic Malignant Syndrome, Seizure, Drug withdrawal, CNS bleed , Tuberculosis, Substance intoxication, Brain cyst, Status epilepticus, Anorexia, Neuro-syphilis, Brain trauma, Frontal lobe brain damage, Encephalitis, Strychnine poisoning, Malignant hyperthermia, Mood disorders, Acute stress disorder, AIDS, Wilson's disease, Seizures,

Diagnosis is primarily based on observing individual’s behavior for the clinical symptoms he /she exhibits. One has to rule out any other medical illness that may result in behavioral changes. Brain imaging techniques include; C.T Scan of the brain and

Magnetic resonance imaging (MRI)

For many mental health professionals, familiarity with the diagnostic system described in the American Psychiatric Association’s “Diagnostic and Statistical Manual of Mental Disorders” (DSM) is a fundamental competency because it provides a common language and standard criteria almost all over the world for classification of mental disorders. The current version was published on May 18, 2013, and it is the fifth edition (DSM-5). I will therefore keep referring to it.

The D.S.M. criteria for diagnosis of schizophrenia is stratified into 5 clusters (A-E)

 CLUSTER A: Two (or more) of the following symptoms, each present for a significant portion of time during a 1-month period (or less if successfully treated):

(1)        Delusions

(2)        Hallucinations

(3)        Disorganized speech (e.g., frequent derailment or incoherence

(4)        Grossly disorganized or catatonic behavior

(5)        Negative symptoms, i.e., affective flattening, alogia (poverty of speech), or avolition (lack of motivation)

The DSM-IV currently requires the presence of two Criterion A symptoms (“Characteristic Symptoms”), which include delusions, hallucinations, disorganized speech, catatonic behavior, and negative symptoms. If delusions are bizarre or hallucinations consist of running commentary, the DSM-IV allows that a single Characteristic Symptom to count for two symptoms in Criterion A. In DSM-5, however, that special treatment is eliminated.

DSM-5 diagnosis of schizophrenia will also require that at least one of the Characteristic Symptoms must be delusions, hallucinations, or disorganized thinking. (Referred to as “positive” symptoms)

CLUSTER B: Social/occupational dysfunction: For a significant portion of the time since the onset of the disturbance, one or more major areas of functioning such as work, interpersonal relations, or self-care are markedly below the level achieved prior to the onset (or when the onset is in childhood or adolescence, failure to achieve expected level of interpersonal, academic, or occupational achievement).

CLUSTER C: Duration: Continuous signs of the disturbance persist for at least 6 months. This 6-month period must include at least 1 month of symptoms (or less if successfully treated) that meet Criterion A (i.e., active-phase symptoms) and may include periods of prodromal (symptomatic of the onset) or residual symptoms. During these prodromal or residual periods, the signs of the disturbance may be manifested by only negative symptoms or two or more symptoms listed in Criterion A present in an attenuated form (e.g., odd beliefs, unusual perceptual experiences).

CLUSTER D: Schizoaffective and Mood Disorder exclusion: Schizoaffective Disorder and Mood Disorder with Psychotic Features have been ruled out because either

(1) no Major Depressive Episode, Manic Episode, or Mixed Episode have occurred concurrently with the active-phase symptoms; or

(2) if mood episodes have occurred during active-phase symptoms, their total duration has been brief relative to the duration of the active and residual periods.

CLUSTER E: Substance/general medical condition exclusion: The disturbance is not due to the direct physiological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition. F. Relationship to a Pervasive Developmental Disorder: If there is a history of Autistic Disorder or another Pervasive Developmental Disorder, the additional diagnosis of Schizophrenia is made only if prominent delusions or hallucinations are also present for at least a month (or less if successfully treated).

Elimination of schizophrenia subtypes

Paranoid type, Dis-organized type, Catatonic type, Undifferentiated type, and Residual type—all the classic subtypes of schizophrenia are eliminated in DSM-5.

THE DSM-V FORMULATION OF CATATONIA

The DSM-V recommendations for catatonia proposed by the DSM-V Psychosis Work Group were posted on the website www.dsm5.orgon January 18, 2011. Four principal changes are recommended.

1. “Schizophrenia, catatonic type (295.2)” is to be eliminated, ending the direct tie of catatonia with schizophrenia.
2. Catatonia is recognized as a specifier across the 10 principal primary diagnoses of the system, including schizophrenia, major depression and bipolar disorder and their related subtypes. Recognition of the catatonia specifier is to be coded by using a fifth digit (xxx.x5).
3. Catatonia in a general medical condition (293.89) is to be maintained.
4. A new class of catatonia NOS (298.99) is recommended for those cases that exhibit the motor, mood and systemic signs of catatonia, but in whom the underlying pathology cannot be confirmed.

What is the anticipated impact of these proposed changes? Specifiers, including catatonia, were adopted in DSM-IV without numeric codes, discouraging their use in the clinic and in research. Physicians find a single diagnosis sufficient to support the care that they select for each patient. The DSM-V consideration of a fifth digit for the catatonia specifier would be an improvement, but the concept of specifiers for at least 10 principal diagnoses concept serves no clinical purpose and confuses treatment options.

Catatonia secondary to a medical disorder and catatonia NOS will justify the testing and treatment of catatonia as a principal intervention. Because all forms of catatonia are of systemic origin, it is probable that the code 293.89 will have limited use, and the less restrictive “Catatonia NOS” will be applied for all forms of catatonia.

Conclusion

If Ken were to present for the first time to a Kenyan psychiatrist today, he will still be diagnosed to have schizophrenia. However the catatonic episode will not be referred to as “schizophrenia-catatonic sub-type” but catatonia will be a specifier. His diagnosis would therefore read “catatonia in patient known to have schizophrenia.” The catatonia would still be managed with ECT, intramuscular ant-psychotics and benzodiazepines but he would probably be maintained on aripiprazole because it has fewer side effects as opposed to risperidone and it is now readily available in Kenya. Psychotherapy for the patient and his family would still be the same. It is therefore true that the subtypes of schizophrenia in DSM 1V do not help in providing better targeted treatment, or predicting treatment response. The continued psychotherapy and availability of a variety of anti- psychotics in Kenya has helped in the prognosis and actually the patient is living a productive normal life.

Dr. Catherine Munanie Syengo-Mutisya

M.B.Ch.B, M.med (Psychiatry), U.O.N

Consultant psychiatrist

The author’s private office is located at K.M.A Center 3^rd floor on the junction of Mara Road and Chyulu road Ajacent to the Nairobi Club, Upper Hill