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PBL 12


Name Age Address Marital status Sex & Race Occupation Religion Status Date of admission Date of clerking Informant Reliability : Rasida Akma Othman : 32 year-old : Pasir Puteh, Kelantan : Single : Female, Malay : Former restaurant worker : Islam : In-patient : 3rd November 2010 : 27th November 2010 : Patient herself : Reliable

B) Chief Complaint

Patient self-admitted to HUSM complaining

of uncompleted tasks and unable to sleep 1 day prior to admission.

C) History of Presenting Illness

History started back in 1996 when the patient was

diagnosed to have bipolar disorder and being warded. Starting from that, she was frequently being admitted due to similar problems. On 3rd November 2010, the patient admitted to HUSM with complaint of unfinished tasks and inability to sleep 1 day prior to admission. She worked as a restaurant worker since 1 month ago. Patient claimed that her job was so stressful that her working hour was 18 hours per day. She had to wake up at 4am everyday and the job finished at about 10pm. She felt not enough sleep during that period of working.

She also claimed that her workload was too heavy

for her that she had to do all the jobs in the restaurant except for mopping the floor. The stressful job caused her difficult to sleep. She did not find any relieving factor for her stress. She did not take her medication regularly because she was too busy with her work. Patient claimed that this cause her unease. 1 day prior to admission, patient unable to sleep for the whole night and she also noticed uncompleted house chores. For example she could not finish folding her clothes completely.

She request to be admitted to HUSM(5th time) as

she felt that the dose of medication was not enough for her symptoms at that time.
During further questioning, she also claimed that

Shahir , one of the chef in Hotel Mania(tv drama) who is her current boyfriend is falling in love with her and ask her to marry him.

Current Condition
She sang at the top of her voice, screaming and

talking something that didnt make sense. She claimed that she liked to wear bright clothes especially red when she wanted to sing. On further questioning, she mentioned that she liked to wear expensive branded clothing such as Adidas, Nike and so on. She denied hearing voices, seeing shadows, being suspicious to others and having anxiety symptoms; palpitations and sweating.

D) Past psychiatric History

1996 History started in 1996 (18 yearold), when she had high grade fever for 3 months and some episodes of seizure. She was not fully conscious and bedridden. She believed that she developed rotten teeth as complication of high

Her family doctor came to treat her at

home and medication was given to her.

Besides, during fever, patient was

depressed for about 3 days because her elder sister got married to her ex-boyfriends brother . She could not attend the wedding ceremony and she kept crying at her room. However, she claimed that her mood

In addition, she felt more

depressed when she knew most of her friends were able to further study in matriculation and university while she couldnt. She claimed that she didnt feel jealous but feel sad because she had to resit her SPM.

She worked as a factory worker in Selangor-1 day at

Sumida factory, 7 days at Hitachi factory. (Quarelling with other workers and felt irritated. She claimed that other workers bully her because she was new there.) Later, she returned to Kelantan because she was unable to cope with her stress and felt depressed. Due to this problem, she attended general practitioner and was diagnosed with bipolar disorder and prescribed with medication. She claimed that she developed limbs stiffness and drooling of saliva because of the medication given. So, she went to HUSM and being admitted to the psychiatry ward for the first time. She believed that her illness was due to drug overdose.

She said that she submitted her photo to

magazine(pen-pal). She claimed that many guys want to know her. She mentioned that she was creative and was a Malay literature experts. She claimed that there was a magazine publisher(Datos) asking her to write a poem. So, she produced a poem and submitted to the Dato but the Dato did not respond. She got depressed because of that and being admitted to HUSM again (2nd time). During admission(a day after Tsunami), she claimed that she saw the effects of Tsunami destruction in Kubang Kerian. She said that all the buildings in front of HUSM were ruined by Tsunami. In addition, she felt

She worked as a Neutrimetics(beauty product)

direct seller. She claimed that she felt depressed during her works because some of her customers did not pay their debts. Because of that, she had to pay on behalf of her customers by using her own money to the company . She claimed that she did not take her medication regularly because of her stressful job. During her depressive mood, she wrote poems in order to relieve her stress.

She worked as a AVON direct seller which was

one of multilevel marketing company. She had similar problems as in 2006 She went to HUSM for 4th admission because of her stressful job and she did not compliance to her medication

Cardiovascular System No shortness of breath No chest pain No ankle swelling No palpation No syncope No intermittent claudication. Central Nervous System No numbness or increasing sensation, No blurring of vision No hearing problem No muscle weakness No symptom of sphincter disturbance No loss of consciousness Musculoskeletal System No pain, stiffness or swelling of the joint Respiratory System No cough No purulent sputum No haemoptysis No night sweat. Genitourinary System No pain and difficulty in passing urine No abnormal changes in urine color No urinary incontinence No frequency Endocrine System No swelling in the neck. Hematological System No bruises No lumps under the arms, neck or groin.

Prenatal history Patient was delivered via spontaneous vaginal delivery. Early childhood (through age 3) According to the patient, there was no abnormalities in the development. Middle childhood (age 3-11) She went to primary school and was one of the 5 top students. She was an active students and took part in many competitions. She did not have any problems making friends.

Adolesence She was active in debate competition. Her social life at school was normal and she was able to make friends. She started having relationship with her boyfriend when she was13years old but it lasted for 4 months only. She claimed that she got depressed and became tearfulness for about 2-3 days only, then she recovers. Early Adulthood She kept changing her jobs as she was unable to cope with the stress at work.


She had prolonged fever for about 3 months

on year 1996. She had home-visit treatment due to her bed-ridden condition. There was no previous surgical history.

H) Pre-morbid Personality
She claimed that she is a cheerful, energetic and

positive thinking person. She claimed that she is responsible to her work and family. Intellectually intact. She claimed that she is talented in Malay literature. She joined various competitions and won most of the time.

She is the 6th among her sibling (total of 9). She

claimed that she does not have any past major illnesses (eg. hypertension, diabetes mellitus, heart disease etc) There was no known medical and psychiatric illness run in her family.

J) Social History
She lives with her parents in Pasir Puteh,

Kelantan. She claimed that she is the apple in his fathers eye. She is financially supported by her father and siblings. She write poems in her free time. She enjoys Malay literature. She claimed that she is friendly to everyone and she prefer to befriend with male compare to female friend. She claimed that she is not a drug abuser nor alcoholic.

K) Drug History
She was prescribed with Epilim Chrono (sodium

valproate),1000mg and Seroquel (quetiapineatypical antipsychotic), which has been increased the dose from 600mg to 800mg. She admitted that previously, she was careless with her medication intake because she was too busy with her works. She also mentioned of gaining weight since she started to consume the medicine. She claimed that she had no allergy towards any known medication.

My patient, a 32 year old Malay lady, complained

of uncompleted task and unable to sleep 1 day prior to admission. She had depressed mood, easily irritated and tearfulness. Despite that, she also had manic symptoms like insomnia, grandiose delusion and engaged in buying sprees. She presented with some psychotic symptoms as well such as visual hallucination and amorous delusion.

Mental Status Examinations

Appearance and Behaviour

Mood and Affect Perceptual Thought Cognitive Abstract Reasoning Judgement Insight

Appearance and Behaviour

My patient was overweight, appearing at her age,

sitting comfortable on a chair. She dressed well with a green scarf and green baju kurung. She claimed that she liked to wear colour-matched clothes. She had rotten teeth on her left anterior maxillary teeth. She had an overall neat appearance and adequate hygiene. She was being over-friendly and approached us on the day of interview. She was polite and had appropriate manners. She looked cheerful and was cooperative throughout the interview. However, she was easily distracted by noises and movements. She remained good eye contact and rapport was easily established.

She spoke in Malay language fluently. Her

speech was normal in tone, volume and speed but increased in quantity/ amount. The speech was coherent and relevant. Patient reaction time towards the question asked was normal.

Emotional Expression
Mood Affect
Nature = Happy Appropriateness = Normal Range = Normal Depth = Normal Lability = Sudden unexpected emotional outburst
= Normal

No illusion Presence of functional hallucination

*Functional hallucination = Normal perception of a stimulus and a hallucination in the same modality are experienced simultaneously.

Form/ Structural Circumstantialit y Flight of ideas Tangentiality Stream/ Flow Pressure of speech

Content Grandiosity Amorous delusion Possesion No thought insertion, thought withdrawal and thought broadcasting


Patient awared and orientated to time, place and person.

Attention/ Concentration

Patient was not co-operative and refused to answer.

Memory a) Immediate

Patient was not co-operative and refused to answer.

b) Short term

c) Remote


Information and Intelligent Comprehension General knowledge Intact Vocabulary

* Calculation
Patient was not co-operative and refused to answer.

Abstract Reasoning
Similarity and Difference Testing

Patient was not co-operative and refused to answer.

She was able to answer the meanings of the

proverbs that were given to her. Eg. Bagai aur dengan tebing

Bagai isi dengan kuku

Social judgement Patient was not co-operative and Test judgement refused to answer. Personal judgement
Q = Apakah rancangan kamu selepas keluar dari sini? A = Saya nak kahwin.



On MSE, her appearance, behavior, speech,

mood & affect, and cognition were good, except

perceptual disturbance = Hallucination (Once only) thinking

= Grandiosity = Amorous delusion

Moderate Mental Status.

Physical Examination

General Examination
My patient was sitting comfortably on a chair.

She looked well and not in pain. She was not in respiratory distress. Her hydrational and nutritional statuses were clinically adequate. No abnormal movements and no attachments were noted.

Vital Signs

= 37 C Pulse rate = 78 b.p.m Respiratory rate = 18 b.p.m. Blood pressure = 120/ 70 mm Hg

Hand Her hands were warm, moist and pink. There is no peripheral cyanosis and clubbing. Capillary refilling time was normal. Eye There was no yellow discolouration on the sclera and the conjunctiva was pink.

Nose and Ears No discharge was noted.

Mouth The tongue was not coated. There was no central cyanosis and the oral hygiene was poor.

Leg Absence of pitting oedema. Peripheral pulses was detected.

Specific Examination
Nervous System
All 12 cranial nerves were intact.


Mood Disorder
Mood is defined as pervasive emotional tone That profoundly influences ones outlook and

perception of self, others and the environment.

DSM categories of Mood Disorders A. Depressive Disorders 1.Major Depressive Disorder, MDD 2.DysthymicDisorder 3.Depressive Disorder Not Otherwise Specified B. Bipolar Disorders 1.Bipolar I Disorder 2.Bipolar II Disorder 3.CyclothymicDisorder 4.Bipolar Disorder NOS C. Other Mood Disorders 1.Mood Disorder d/tGMC 2.Substance induced Mood Disorder 3.Mood Disorder NOS Other causes of Depresive and Manic Symptomss 1.Schizoaffective Disorder 2.Cognitive Disorder with Depressed mood 3.Adjustment Disorder with depressed mood 4.Personality Disorder Borderline, Avoidant, Dependent, and Histrionic PD 5.Bereavement-sadness at the death of relative or friend 6.Other Disorders schizophrenia, eating Disorders, Sexual Dis, Gender Identity DisandAnxiety Disorders

Bipolar Disorder
Also known as Bipolar affective disorder Manic depressive disorder

Diagnostic Overview (DSM-IV-TR)

Bipolar I 1. At least onemanicor mixed episode. 2. Major depressive orhypomanice pisode may occur Bipolar II 1. At least one major depressive episode. 2. At least one hypomanicepi sode, NOmanic episode Cyclothymic Bipolar NOS 1.At least one A disorder with hypomanic bipolar episode features, but 2.Mood states does not meet do not meet specific full criteria for criteria for any depressive, specific manic, or bipolar mixed disorder episode. DSM-IV-TR 2000: Diagnostic and Statistical Manual of Mental Disorders, 4th ed. Text Revision. 2000.

Bipolar disorder affects both sexes equally Usually first occurs between the ages of 20 and 30, starting with a manic episode


A. A distinct period of abnormally and persistently elevated, expansive, or irritable mood lasting at least 1 week(any duration if hospitalization is necessary) B. During the period of mood disturbance, 3 or more following symptoms persisted (4 if the mood is only irritable) and have been present to significant degree : i. Inflated self esteem or grandiosity ii. Reduced need for sleep (feel rested after only 3 hours of sleep) iii. More talkative than usual/ pressure to keep talking iv. Flight of ideas or subjective experience that thoughts are racing v. Distractibility ( attention to easily drawn to irrelevant external stimuli) vi. Increased in goal directed activity (either socially, at work or school / sexually) or psychomotor agitation vii. Excessive involvement in pleasurable activities that have high potential for painful consequence (eg: engaging in unrestrained buying sprees, sexual indiscretion/ foolish business investment) C. The symptoms do not meet criteria for mixed episode

D. The mood disturbance is sufficiently severe to cause marked impairment in occupational functioning or in usual social activities or relationships with others, or to necessitate hospitalization to prevent harm to self or others, or there are psychotic features

E. The symptoms are not due to the direct physiological effects of a substance(eg: drug abuse, medication or other treatment) / general medical condition: hyperthyroidism

Major Depression Disorder

Epidemiology Twice as common in females than in males. Symptoms must be present for at least 2 weeks and represent a change for previous functioning.

DSM-IV-TR Criteria for Major Depressive Episode A.Five (or more) of the following symptoms have been present during the same two-week period and represent a change from previous functioning; at least one of the symptoms is either (1) depress mood or (2) loss of interest or pleasure. NOTE: Do not include symptoms that are clearly due to a general medical condition, or mood-incongruent delusions or hallucinations. i. depress mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad or empty) or observation made by other (e.g., appears tearful). NOTE: in children and adolescents, can be irritable mood. ii. markedly diminished interest or pleasure in all, or almost all, activities most of the day, nearly every day (as indicated by either subjective account or observation made by others). iii. significant weight loss when not dieting or weight gain (e.g., a change of more than 5% of body weight in a month) or decrease or increase in appetite nearly every day. NOTE: in children, consider failure to make expected weight gains. iv. insomnia or hypersomnia nearly every day.

v. psychomotor agitation or retardation nearly every day (observable by other, not merely subjective feelings of restlessness or being slowed down vi. fatigue or loss of energy nearly every day. vii. feeling of worthlessness or excessive or inappropriate guilt (which may be delusion) nearly every day (not merely selfreproach or guilt about being sick). viii. diminished ability to think or concentrate, or indecisiveness, nearly every day (either by subjective account or as observed by others). ix. recurrent though of death (not just fear of dying), recurrent B.The symptoms do not meetspecific criteria plan, for a mixed episode . suicidal ideation without or a suicidal attempt or a C.The symptoms cause clinically significant distress or impairment in specific plan for committing suicide. social, occupation, or other important areas of functioning. D.The symptoms are not due to the direct psychological effects of a substance (e.g., a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism). E.The symptoms are not better accounted for by bereavement, i.e., after the loss of a loved one, the symptoms persist for longer than two months or are characterized by marked functional impairment, morbid preoccupation with worthlessness, suicidal ideation, psychotic symptoms, or psychomotor retardation.

Dysthymic Disorder
is a long-term, mild depression that lasts for a minimum of two years. There must be persistent depressed mood continuously for at least two years.

This disorder often begins in adolescence and crosses the lifespan.

By definition the symptoms are mild and not as severe as MDD, although those with Dysthymia are vulnerable to co-occurring episodes of MDD. People who are diagnosed with Major depressive episodes and Dysthymic disorder are diagnosed with double depression.


SA is likely to be either A subtype of schizophrenia A subtype of affective disorder A heterogenousdisorder (intermediate between schizophrenia and affective disorder)-Continuum model (schizomanicand schizodepressivesubtype)

Differential Diagnosis



Manic episode Depressive episode Depressive episode Manic episode



Depressive episode

Manic episode


Hallucination Delusion Mood disorder Hallucination Delusion

No prominent perceptual and thought disturbance No prominent perceptual and thought disturbance Mood disorder


Management and Treatment

Pharmacology : Mood Stabilisers

MOOD STABILIZERS : agents used to stabilise the mood swings of depression and mania 1. Lithium (priadle or camcolit) 2. Anticonvulsants: a) sodium valproate (epilim) b) carbamazepine (tegretol c) lamotrigine (lamictal)
* For acute and prophylaxis

typical and atypical antipsychotics (eg; olanzapine and risperidone) used to treat the manic episodes Antidepressants (eg; fluoxetine , venlafaxine and bupropion) sometimes used to treat depressive episodes

Cognitive behavioral therapy

Helps people with bipolar disorder learn to change inappropriate or negative thought patterns and behaviors associated with the illness. Teach about the illness and its treatment and how to recognize signs of relapse so that any intervention can be sought before full-blown illness episodes occur To reduce level of distress within the family that may either contribute to or result from the ill persons symptoms Improve interpersonal relationships and regularize their daily routines. Regular daily routines and sleep schedules may help protect against manic episodes


Family therapy

Interpersonal and social rhythm therapy

may be considered when medication,

psychosocial treatment and combination of these interventions were ineffective or work too slowly to relieve severe symptoms such as psychosis and suicidality Used when medications are too risky ( pregnancy) Highly effective treatment for severe depressive, manic or mixed episodes

Thank you