Questions on two separate cases (psychiatry resident)

[phantasmagoric]

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Questions on two separate cases (psychiatry resident)

Our supervision is "questionable", to say the least, so looking for any insights that you may have.

First case: A 32 yo male patient who was previously given diagnoses of Schizoaffective, Schizophrenia, Bipolar Disorder. Although he was somewhat tangential, digressive, what I could gather was that he first experienced possible prodromal symptoms in his early 20s with avolition, social isolation, cognitive difficulties. Few years later, he experienced significant syptoms of psychosis (e.g. AVH, delusions, negative sxs) which apparently involved agitation and aggression, which would recur episodically. Currently, he seemed to be in a better place but presented in the interview with obvious residual symptoms encompassing cognition, social isolation, some disorganization of speech/thought.

When I tried to probe into possibility of any mood episodes, he expressed a lot of guilt, intermittent passive SI along with periods in which he feels "irritable" with risk-tasking behaviors. When asked to provide an estimate for length of his depression/mania, he stated few months to 1 year - although he did not sound confident and history taking was rather challenging. He also declined that I reach out to his family for collateral information.

So, either diagnosis of Schizophrenia vs Schizoaffective appears to be likely, but I am uncertain between the two. There are certainly inherent challenges due to lack of collateral information and limited interview.

Here's where I need help. I am somewhat leaning toward the diagnosis of Schizophrenia 1) because of the progressive history and presence of clear residual symptoms/continued impairment. 2) fact that negative symptoms and agitation can be easily mistaken for depressive/manic symptoms - which further cast doubt of the past Schizoaffective dx. 3) Schizoaffective tends to be rarer and with medium prognosis between Schizophrenia and Mood disorder.

Is my line of thinking correct? Any insights into differentiating the diagnoses? I will continue to explore this question in subsequent sessions and also see how he responds to an Invega trial (hoping to transition into LAI)

Second case: A young female patient with major complaint of obsessions/compulsions about cleanliness. She has to make sure her bed is clean, has rituals when taking a shower (e.g. towels having to be placed in a certain way). While these tasks do not occupy significant amount of time, she does experiences significant emotional distress when she is not able to perform these compulsions. It does have some impacts to her daily life and relationships, such as not being able to sleep outside her home if she is not able to take a shower and not being able to work out in the morning (because she would no longer be “clean”). What is interesting is that, she truly believes that “everyone should do it this way” and “for me, this way of life is perfect,” although she does recognize that it does create some issues for her and her acquaintances. She does not experience distress about these rituals/obsessions UNLESS she is unable to perform them.

Since the ego-syntonic nature seemed less typical for an OCD patient, I tried to explore whether she had OCPD traits. It was not a home-run but she did have certain things: being pre-occupied with details; finding it hard to delegate tasks unless others agree to do things exactly her way; and finding it difficult to make changes once a plan has been set.

Can be case be conceptualized as OCD with comorbid OCPD traits (not full diagnosis) – which can explain the ego-syntonic nature? Or could be it be considered as OCD with poor insight? (Also, can we count significant distress if not being able to perform the compulsions as meeting criterion B of OCD?)

In general, I have some difficulty conceptualizing the core symptomology of OCD just based on the DSM 5 criteria, and I would appreciate any guidance on this.

Sorry for the wall of text – but I would appreciate any insights.

 

[Merovinge]

First case - I think this is a classic presentation where the diagnostic concerns are largely irrelevant. Treatment for schizophrenia and schizoaffective bipolar type are essentially the same pharmacologically, with CBT for psychosis, and from a social work perspective etc. I would agree with schizophrenia if all I had was what you had, but I also tell people the diagnosis is on the schizophrenia spectrum and leave it at that.

Second case - Are there obsessive thoughts? Does she otherwise worry about cleanliness at other times of the days and have other obsessions while she is out of the house or in other places beyond the morning? OCD sx should be pervasive though different settings/time of day etc.

 

[aim-agm]

Mood symptoms are common in schizophrenia - such as grandiosity manifested by believing they are a famous figure (e.g. Napoleon, Jesus). It is important to draw a distinction between these and major mood episodes (i.e. major depressive episodes or mania).

Perfectionism is OCPD is pathologic because it is excessive and disproportionate, but is usually not seen as such by the patient. Perfectionism can often include cleanliness, organization, and other factors.

 

[clausewitz2]

Questions on two separate cases (psychiatry resident)

Our supervision is "questionable", to say the least, so looking for any insights that you may have.

First case: A 32 yo male patient who was previously given diagnoses of Schizoaffective, Schizophrenia, Bipolar Disorder. Although he was somewhat tangential, digressive, what I could gather was that he first experienced possible prodromal symptoms in his early 20s with avolition, social isolation, cognitive difficulties. Few years later, he experienced significant syptoms of psychosis (e.g. AVH, delusions, negative sxs) which apparently involved agitation and aggression, which would recur episodically. Currently, he seemed to be in a better place but presented in the interview with obvious residual symptoms encompassing cognition, social isolation, some disorganization of speech/thought.

When I tried to probe into possibility of any mood episodes, he expressed a lot of guilt, intermittent passive SI along with periods in which he feels "irritable" with risk-tasking behaviors. When asked to provide an estimate for length of his depression/mania, he stated few months to 1 year - although he did not sound confident and history taking was rather challenging. He also declined that I reach out to his family for collateral information.

So, either diagnosis of Schizophrenia vs Schizoaffective appears to be likely, but I am uncertain between the two. There are certainly inherent challenges due to lack of collateral information and limited interview.

Here's where I need help. I am somewhat leaning toward the diagnosis of Schizophrenia 1) because of the progressive history and presence of clear residual symptoms/continued impairment. 2) fact that negative symptoms and agitation can be easily mistaken for depressive/manic symptoms - which further cast doubt of the past Schizoaffective dx. 3) Schizoaffective tends to be rarer and with medium prognosis between Schizophrenia and Mood disorder.

Is my line of thinking correct? Any insights into differentiating the diagnoses? I will continue to explore this question in subsequent sessions and also see how he responds to an Invega trial (hoping to transition into LAI)

Agree with @Merovinge substantially. I'd be curious as to the agitation and aggression (against who, what did he do, what were the circumstances, was he obviously responding to internal stimuli at the time) but yes, this sounds like fairly typical young-ish schizophrenia spectrum patient. I would push back against the assumption that schizoaffective disorder is a "medium" prognosis, the studies that have looked at this longitudinally don't really seem to find that people who get that diagnosis actually have better outcomes. But at the end of the day schizophrenia/schizoaffective/bipolar I with psychotic features tend to all cluster together and are more related than not.

Second case: A young female patient with major complaint of obsessions/compulsions about cleanliness. She has to make sure her bed is clean, has rituals when taking a shower (e.g. towels having to be placed in a certain way). While these tasks do not occupy significant amount of time, she does experiences significant emotional distress when she is not able to perform these compulsions. It does have some impacts to her daily life and relationships, such as not being able to sleep outside her home if she is not able to take a shower and not being able to work out in the morning (because she would no longer be “clean”). What is interesting is that, she truly believes that “everyone should do it this way” and “for me, this way of life is perfect,” although she does recognize that it does create some issues for her and her acquaintances. She does not experience distress about these rituals/obsessions UNLESS she is unable to perform them.

This is actually not uncommon in cleanliness/contamination OCD in particular. OCD is not always based on fear and anxiety and when disgust is the driving emotion you're much more likely to get people saying some version of "it takes a lot of time and is burdensome but all those other people are just being grossly irresponsible/filthy". Provided she doesn't enjoy the rituals/obsessions (still under aversive control), this could totally be OCD.

Since the ego-syntonic nature seemed less typical for an OCD patient, I tried to explore whether she had OCPD traits. It was not a home-run but she did have certain things: being pre-occupied with details; finding it hard to delegate tasks unless others agree to do things exactly her way; and finding it difficult to make changes once a plan has been set.

OCPD has more overlap with OCD than you find by chance despite repeated assertions in generalist texts that they're not related. They are definitely not the same thing but the naming similarity is not only an historical accident.

Can be case be conceptualized as OCD with comorbid OCPD traits (not full diagnosis) – which can explain the ego-syntonic nature? Or could be it be considered as OCD with poor insight? (Also, can we count significant distress if not being able to perform the compulsions as meeting criterion B of OCD?)

I'd be inclined towards OCD with poor insight for lack of the more distinctively OCPD v, OCD phenomenology (miserliness, excessive devotion to work, rigid ideas about morality) and also because most of the personality disorders have terrible psychometric properties as psychological constructs per se. I would definitely count that distress if it is happening because she is not able to perform elaborate and socially unusual cleaning precautions and rituals that are difficult to understand as a proportionate response to the threats involved.

In general, I have some difficulty conceptualizing the core symptomology of OCD just based on the DSM 5 criteria, and I would appreciate any guidance on this.

Sorry for the wall of text – but I would appreciate any insights.

 

[clausewitz2]

Second case - Are there obsessive thoughts? Does she otherwise worry about cleanliness at other times of the days and have other obsessions while she is out of the house or in other places beyond the morning? OCD sx should be pervasive though different settings/time of day etc.

In terms of minor nitpicking, they absolutely can be limited to particular times or places way more than others, though I agree that you should probably be looking for more than just one setting/situation. You might not see explicit thought type obsessions in a case like this so much as overwhelming feeling that something is disgusting/dirty/filthy/contaminated and has to be avoided/cleansed. It's a bit like just right OCD where there's often not much of a cognition there, more of an urge.

 

[brosa]

I barely believe schizoaffective as a real diagnosis, and mostly see it being used as a lazy diagnosis. Just theoretical discussion, since LAI will be great for first patient. It wouldn't change treatment options either way.

 

[Merovinge]

In terms of minor nitpicking, they absolutely can be limited to particular times or places way more than others, though I agree that you should probably be looking for more than just one setting/situation. You might not see explicit thought type obsessions in a case like this so much as overwhelming feeling that something is disgusting/dirty/filthy/contaminated and has to be avoided/cleansed. It's a bit like just right OCD where there's often not much of a cognition there, more of an urge.

I didn't fully flesh it out in my comment, but 100% on board that compulsion only OCD is still OCD (I actually see this not infrequently). I am not an OCD specialist, but I have just yet to run into someone with contamination concerns that were only in their bedroom/bathroom but no where else. I do see people with OCPD tendencies that are dramatically more obsessive in these specific places. I bet there is more going on and it could very well be OCD, we'ill see what phantasmagoric says.