Interesting C/L Case

[DO-Riz]

Hey had an interesting case today:

Cardiology consulted on a 21 y.o. male for Behavioural change:
Patient is a 21 y.o. AA male with a hx. of mild MR who was admitted to Cards as he presented with CP/Tachycardia. Apparently his behaviour had been worsening and had been acting bizarre. When I went to see patient, he was AAO x 3 but a poor historian. He did endorse AH starting a few months ago, and also some paranoid ideation. He was proccupied with his physical health and on 2 occasions asked me to check his heart. Denied any recent EtOh or drugs but stated he quite EtOH, THC and cocaine about 2 weeks ago.
When I spoke to Mom, she reported that he had an episode where his whole body was "shaking", eyes rolled backed, lasted about 20 min and was confused afterwards about a week ago. Apparently he had a previous episode when he was 15. She states that they took him to hospital and they attributed it to dehydration. She says that he has become more withdrawn, is constantly worried people are out to get him. SHe also notes it appeared he was respondng to VH last night and she has not seen that before.
Denies any family hx. of mental illness or seizures. Reports no previous psych. diagnosis. States his birth was complicated by C-section and some doctor told her "he may have problems when he is older".

ON MSE: Patient was thin, somehwat guarded. Moderate psychomotor ******aion. Poverty of speech. Ruminated on bodily sensations. Hyperreligosity. +Ah/PAranoia. Mood Anxious. Flat Affect


- CT of Head was negative
- Labs WNL
- UDS not done ( as usual)


- ANyways I thought he would benefit from Inpatient hospitalization to further w/u the Psychosis, but Mom stated she would prefer outpatient referral. SInce we are a voluntary unit and he did not meet any criteria for involuntary commitment...I made an appointment,

- But i was dissapointed, as it was an intriguing case

- Just wanted to know what your guys experience has been with MR assoc. with Schizophrenia and TLE with Psychosis. Also how about experiences with Schizophrenics beng preoccupied with things wrong in their body,This guy was sure something was wrong with his heart, although all w/u negative.
This guy had a complicated picture as there was some questions of whether these were truly seizures and also some issue of substance use. Neuro had seen the guy and they were not entirely convinced it was seizures, but since he was being discharged no further w/u could be done.


- Sorry my post was soo long......just some food for thought

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[Doc Samson]

Would be interested to know if his MR was due to a structural lesion. Had a very similar case with a guy with congenital hydrocephalus and distant h/o seizure - presented with new onset AH/VH, had some weird episodes of shaking/staring. Neuro insisted it wasn't seizure, but his symptoms completely resolved with Depakote. Either way, from the sound of it, I would certainly leave partial complex seizures in the differential.

 

[Anasazi23]

UDS is critical in this case, as is ruling out causes for delirium.

It sounds like you're going toward the first-break route. If this were the case, it would certainly not be uncommon to misinterpret his cenesthesias or for him to lack the ability to separate external bodily influences from his own.

 

[whopper]

Sounds to me like a first break or drug induced psychosis. The guy had cardio problems & several (+) sx of psychosis implying stimulant use-amphetamines or cocaine.

As Anasazi mentioned, UDS was critical. Its a shame it wasn't done.

Only way to tell now if it was drug induced or actual non-drug induced is to not treat the pt's sx of psychosis and see if the pt improves which might not be possible if he's dangerous or too out of control.

I'd be thinking its probably drug induced more so than not only because of the odds. A pt that young without previous cardiac hx with no family hx of mental illness puts a shift against non-drug induced, but you can't base your treatment based on those odds.

As for MR & psychotic illness, I only had 2 cases so far with that. From what little I do understand, you need to interview the patient very carefully because their sx may not be due to psychosis but their MR. You need to understand how profound the MR is.

Also, in MR patients who have behavioral problems, antipsychotics are sometimes used even if they are nonpsychotic.

You'll also have to factor if the patient truly is having psychosis. Several times family or caretakers try to have a psychiatrist solve problems a MR pt has that are purely behavioral such as being a bit out of control. You really need to look into this carefully before you dx the patient as having a psychotic illness such as schizophrenia.

Just a little rant: this one outpt facility sends their "hard to control" MR patients to one of my outpatient offices. They don't seem to get that medications in keeping them under control is controversial at best. They seem to think that we psychaitrists will be able to solve the problem and that they have no responsibility in controlling the pt.

 

[Dramkinola]

I agree with the last poster...
I wouldn't be surprised if some of his paranoia was secondary to his MR.
If he's been worked up in the past for his heart, and told he has cardio problems, then he may be fixating on that issue.
It would have been nice to have a drug screen, but hospitalization and monitoring of his hallucinations would have been nice, because depending on the extent of his MR, they may or may not actually be there...
But I have seen mild MR patients with Schizophrenia... it's often hard to elicit true symptomology due to poor insight...
regardless, I think starting low dose antipsychotics and see if there is a resolution of symptoms is a safe course of actions.

on a somewhat tangential note, we got this patient with a long standing cocaine problem and "history" of schizophrenia, who happens to be homeless and on dialysis, complaining of auditory hallucinations and suicidality, with documented diagnosis of antisocial PD, who we felt was totally malingering, but good enough to warrant admission, and we started him on Haldol and developed EPS the next day, unable to control his tongue. We promptly stopped his Haldol and the symptoms resolved, and we kept him off antipsychotics. He still complains of auditory hallucinations, but has never been observed responding to internal stimuli. The point of the tangent was, I wish there was an objective method to test for (and document) auditory hallucinations.

 

[worriedwell]

velo-cardio-facial syndrome is commonly predisposing to schizophrenia.

Best,
Worriedwell