psychiatric assessment
...nd April this year, following the problems with her uncle. However, she currently does not have any suicidal thoughts and realises/concedes that her actions of the past were foolish and dangerous. Personality Assessment: Virginia described herself before the illness as a positive, happy, content individual who was close to her family and friends. She enjoyed socialising and going out, slept well and had a good appetite. Mental State Examination: General Appearance and Behaviour: Ms Malan was dressed appropriately in hospital clothing and appeared neat and well groomed. She was initially apprehensive towards being interviewed, which is understandable since she has had to go through her experience many times already. However, she soon became comfortable with the setting, sitting upright in her chair and making good eye contact. She did not appear anxious or display any abnormal, excessive or unnecessary movements. Her behaviour was normal and she was friendly, polite and respectful in her interaction. Speech: Rate and quantity were normal. She spoke spontaneously and answered questions appropriately and adequately. However, she did become hesitant and hold back when I explored certain sensitive issues. She did have mild difficulty in pronouncing/articulating some words, which she ascribed to her prior locked jaw and inability to talk (expressive aphasia). Thought: Form was normal regarding syntax and grammar, flow and continuity. She communicated clearly and language was used appropriately. Content reflected no abnormalities. She no longer experienced visual/auditory hallucinations or paranoid delusions. She did express that she was unhappy being a burden to others and wanted to become more independent. Affect: Broad; Ms Malan displayed a full range of emotions from sadness when talking about her deceased family members to happiness when reflecting on earlier times. Emotions were therefore appropriate for content. Mood: Euthymic upon both subjective and objective evaluation. However, she did express that she was unhappy being a burden and for health reasons, and appeared mildly irritable at times. Somatic Features: Appetite and bowel movements were normal. There is no diurnal variation in mood and Virginia gets along with the other patients in the ward. However, she is still not sleeping well. Perceptual Disturbances: There were no longer any abnormal experiences referred to the environment, body or self. Psychomotor Activity: No abnormalities present. Cognition: • Virginia was initially disorientated from admission to the 24 May 2004 but is now fully orientated to time, place and person. • Attention was sustained throughout the interview and concentration was good, reflected by her ability to name the days of the week in reverse order. • Immediate and short-term memory is adequate but long-term memory indicated mild impairment regarding the ability specifics about significant prior events like the passing of family members. However, this could instead be due to an unwillingness to revisit these unhappy moments. • Intelligence was average judging from the interview although no formal testing was done. This is still appropriate taking into account her education and social position. • Judgement was intact. • Insight was poor. Virginia did not display an understanding of her condition but simply accepted it that she was ill and needed medication to cure her. Physical Examination: Pulse, respiration and blood pressure were all within normal range. Pallor was noted on general examination and Ms Malan had previously been on vitamin and iron supplements. There were no abnormalities on systemic examination. Personal Reaction: I enjoyed the opportunity to talk to Virginia and appreciated her sharing information about her life, much of which was sensitive and personal, with me. Her difficult experiences certainly stirred sympathy in me and I tried to be as sensitive and understanding as possible during the interview. However, I felt that at times she resisted sharing certain details with me that would have aided in developing a clearer picture of her life and illness. Nevertheless, I believe I managed to overcome any difficulties and was able to control the direction and relevance of the interview. I also found it difficult to integrate the collateral about her attempt to drug her brother and mother, with the account Ms Malan gave me, and the character picture that I had developed from our interaction. Formulation Identifying Data: Ms Virginia Malan is a 39-year-old Coloured female who was born on 28 March 1965. She is single and currently unemployed, but receives a disability grant. She lives with her cousin’s family in Marianhill, is Christian and speaks English and Afrikaans. Principal Complaints: Ms Malan presented to the psychiatric department at Addington Hospital on 20 May 2004, brought in by her cousin, Sharmaine. She complains that she was seeing things that weren’t there and hearing lots of voices in her head. She was also feeling restless, dizzy and sick, was not eating or sleeping well and felt afraid to be alone and that people were against her. These feelings would build up to a point where she would blackout and become unaware of her surroundings and her actions. During this time it is reported from collateral that she became very aggressive, hitting out at people around her and screaming out aloud. History of Present Illness: The problem was traced back to January 2004, when she had a serious argument with her uncle with whom she was staying at the time. This caused her to become angry, upset and depressed and she subsequently attempted suicide by starvation. She also stopped taking her medication for a previously diagnosed psychiatric illness. These factors contributed to her first mental breakdown in April 2004 (she was seeing snakes and walking around aimlessly), for which she was admitted to Addington Hospital for 2-3 weeks and then discharged. A second breakdown then occurred in May 2004, with the above-mentioned features, accounting for her current admission. Past Psychiatric History: In 1996, she was taken by a friend to her local clinic after behaving strangely, and was placed on medication for her illness. She then attempted suicide in October 1996 by overdosing on her medication. However, according to collateral information, she had actually attempted to poison her mother’s and brother’s food with her medication, rendering them unconscious. They both recovered and Ms Malan was sent to Town Hill for evaluation, but discharged shortly afterwards. She then suffered a mental breakdown in May 1997, following four months of depression after the death of her mother. She was subsequently taken to her general practitioner and her illness was well managed on medication. Family History: Virginia is the only surviving member of her family. She is the youngest of six siblings, and had four older brothers and an older sister. They were all very close to each other, but she had an especially close relationship with her mother, whom she regarded as a close friend. Her father died from liver and kidney failure following chronic alcoholism. Her mother died from Parkinson’s disease. Her oldest two brothers were both murdered, one of them being a cannabis abuser and the other having an affair with a married woman. Her youngest brother died from TB and also suffered a mental breakdown, similar to those she experiences, at the funeral of their oldest brother. A brother and sister immediately preceding her passed away at birth from complications. Following the death of her mother, she moved from Wentworth to Marianhill to stay with her uncle. She moved in with her cousin’s family in Marianhill in January 2004, after being thrown out by her uncle. Personal History: Birth and early development were uneventful apart from initial breathing difficulties. She repeated standards one and six and left school in standard nine, feeling she was too old. She then tried to gain her matric through correspondence but was unable to pass. Ms Malan later did a child day-care course but did not complete it because of the passing of her father. She got a job with Spar as a cashier in 1993 and then as a sales assistant in Mr Price. However, she had to leave both jobs to take care of her ailing mother. She has had three significant relationships in the past but is currently single. She is still a virgin and has never been married. She is of Christian faith and prays regularly even though she does not attend church. She finds strength in God and in herself. She has no history of note regarding previous diseases, surgery, medication or allergies. She has never previously consumed alcohol, smoked tobacco or taken drugs and there is no forensic history. Virginia described herself before the illness as a positive, happy, content individual who was close to her family and friends. She enjoyed socialising and going out, slept well and had a good appetite. Mental State Examination: Ms Malan appeared neat, well groomed and appropriately dressed. Her behaviour was normal and she was friendly, polite and respectful in her interaction. Rate and quantity of speech were normal and she spoke spontaneously and answered questions appropriately and adequately. Thought was normal regarding both form and content and she no longer experienced visual/auditory hallucinations or paranoid delusions. She displayed a broad affect and mood was euthymic. No abnormalities were present regarding psychomotor activity, perceptual disturbances or somatic function, apart from some difficulty with sleeping. Regarding cognition, Virginia was well orientated, displaying good attention and concentration; Immediate and short-term memory was adequate, but long-term memory was inadequate; Intelligence was average, judgement intact and insight was poor. Physical Examination: There were no abnormalities on general/systemic examination apart from mild pallor. Critical Influencing Factors: Biological: There is no history of trauma, abuse or genetic disorders as possible predisposing factors. Regarding medical conditions, her father suffered from hypertension, her mother from Parkinson’s disease and her youngest brother died from TB. However, there is no confirmed familial occurrence of these conditions. Her defaulting on medication between January and April 2004 can also be regarded as a precipitating factor, and indicates a predisposition to non-adherence. Psychological: Family history indicates a possible addictive personality type, with both her father and oldest brother abusing substances. This may be due to poor familial coping mechanisms predisposing to, in these cases, substance abuse as an escape strategy. However, in Virginia’s case poor coping mechanisms may have predisposed to her mental breakdowns, especially in response to any precipitating factors. These included the initial diagnosis of her mental illness in 1996, the death of her mother in 1997, and the problems with her uncle in 2004. In each instance, the precipitating factor was followed by a psychiatric event. Her youngest brother also displayed a similar occurrence when he suffered a mental breakdown precipitated by the loss of their oldest brother, strengthening the prediction of a familial predisposition. Social: Ms Malan’s low socio-economic status, poor level of education, unemployment (leaving jobs to take care of her ailing mother), single status and dependence on others can all be regarded as perpetuating factors influencing her illness. She is the last living member of her family and past experiences regarding the manner of loss of her family members, to whom she was very close, through homicide and disease may also play a role in her illness. However, protective factors are also in place in the form of her faith in God and her inner strength, having a positive influence on her life. Differential Diagnosis: The symptomology of the “mental breakdowns” that Ms Malan presented with reflects a disturbance in reality, in keeping with a diagnosis of psychosis. She showed disturbances in thinking regarding both form (incomprehensible shouting/screaming) and content (paranoid/persecutory non-bizarre delusions, believing that people were against her, which were mood congruent as she felt restless, anxious and sick). There were also perceptual disturbances in the form of visual and auditory hallucinations; of even greater significance is the fact that the auditory hallucinations were of the commentary-type. These manifestations also impacted on her behaviour, which had become strange since 1996, especially evident during her “blackouts”, when she became very aggressive, hitting out at people around her and screaming out aloud. She was also unaware of her actions (lacking insight and judgement) or surroundings (losing touch with reality) and was unable to give an account of herself during these events. 1. Schizophrenia: The psychosis was of slow onset and long duration, beginning in 1996 and progressing over time, indicating a chronic illness. Ms Malan was 31 years old at the time of onset, with the disorder showing a peak age of incidence amongst females of 25-35 yrs old. She is also of low socio-economic status, a group that has been shown to have a higher prevalence of the condition. A. Characteristic psychotic symptoms of delusions, visual and auditory (commentary-type, multiple voices) hallucinations and grossly disorganised behaviour were present, each for a significant portion of time during a one-month period. B. The illness has caused significant occupational and social dysfunction since its onset. It has been present for 9 years but has been well managed on medication since May 1997 until she defaulted in 2004. C. Manifestations of the illness included active-phase symptoms as described in the “mental breakdowns”, each of about a month in duration, as well as prodromal and residual symptoms of marked social isolation and withdrawal, impairment in role function, peculiar behaviour, unusual perceptual disturbances, odd beliefs/thinking and a marked lack of interest for prolonged periods of time preceding and following the “mental breakdowns”. D. Although she was depressed for four months prior to her first breakdown, following the death of her mother, and between January and April this year, prior to her second and third breakdowns, due to the fallout with her uncle, these episodes did not occur concurrently with the active-phase symptoms. E. No history of any substance abuse or other medication (except that for the psychiatric illness) was given and no general medical conditions were present on history or examination, which could directly account for the psychotic disturbance. However, this may not be adequate to exclude substance-induced or organic psychosis and further investigations may be required. F. There is no relationship to a pervasive developmental disorder. 2. Mood Disorder (Major Depression) with Psychotic Features: a. Depressed mood, markedly diminished interest/pleasure in activities, decrease in appetite, insomnia, psychomotor agitation and feelings of worthlessness were present most of the day, nearly everyday during the same period (>2 weeks), and represented a change from previous functioning. These occurred twice, the first time following the death of Ms Malan’s mother, and the second following the fallout with her uncle. b. The symptoms do not meet criteria for a mixed episode. c. They caused clinically significant impairment in social and occupational areas of functioning. d. They aren’t due to the direct physiological effect of a substance or a general medical condition. e. The symptoms are not better accounted for by bereavement. However, the mood disorder was responsible for causing less distress and dysfunction than the psychotic disorder, and only occurred during the prodromal phases preceding the first and second breakdowns. It was otherwise absent in the early part of the illness in 1996 and prior to the third breakdown, although psychotic features were present at these times. This makes regarding the mood disorder as the major feature of the illness unlikely. It rather occurred as a co-feature on the background of the major disorder being the psychosis, precipitated by significant events in Ms Malan’s life, as mentioned above. 3. Substance-Induced Psychosis: No history was given regarding the use of alcohol, tobacco, recreational drugs or medication for other conditions. However, this is not sufficient for exclusion, and collateral information and further investigations would be beneficial to try to identify or eliminate potential causes. 4. Psychosis due to a General Medical Condition: No general medical condition was identified on history or examination. However, collateral information and further investigations would be beneficial to try to identify or eliminate potential causes. Of particular relevance are excluding temporal lobe epilepsy (especially because of her age group and the reported “blackouts”), infections (neurosyphilis, HIV), endocrine/metabolic disorders, vitamin (B12) and iron deficiency, auto-immune diseases (SLE) and poisoning (toxins). 5. Schizoaffective Disorder: Although Criterion A has been met, the mood symptoms of depression did not occur concurrently with the active phase of the psychosis, but rather preceded it, occurring only during the prodromal phase. 6. Schizophreniform Disorder or Brief Psychotic Disorder: Criteria A, D and E have been met as above. However, each of the three episodes (including prodromal, active and residual features) occurred when the patient was not on medication but the illness was well managed in between on medication, displaying no features of a psychotic disorder. This indicates that the condition has been present since initial presentation in 1996 (duration >6 months) and manifestations have only been absent between May 1997 and January 2004 because of appropriate and effective medical management. 7. Cultural Psychosis: She does not belong to a cultural group in which these phenomena have been identified, making this highly unlikely. 8. Delusional Disorder Of later onset in life. Function is retained outside the content of the delusions, unlike in this case where there are also other manifestations of psychiatric illness. 9. Psychotic Disorder Not Otherwise Specified: Adequate information is available to the contrary. Additional Information: Collateral in...