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.

 

[calvnandhobbs68]

For the second case, I'd be surprised if there are a significant amount of behaviors around cleanliness (ex. showers, towels, clean bed you described above) and truly minimal cognitions around contamination if it's risen to the level that this person is being seen by psychiatry. Your line about distress if being unable to perform them is probably a big key....why? What's the cognition there? What prompted the referral? she might have SOME insight or else why is she presenting? Did someone else bring her to you or suggest she see you?

Anyway, the statements you're describing are fairly common to the peds side because it's often the parents who are bringing the kids to us and from the kids standpoint, especially with cleanliness/contamination fears, there's often the cognition that "everyone else is just being dirty" or "if everyone else did it that way or was more clean things would be fine" or "if everyone else would just follow my routines or let me do what I want everything would be good".

I've had a kid who would literally undress himself completely down to changing his underwear every single day when he came home from school because he was so concerned he was "contaminated" with something from school and would deny this even happened unless you really pressed him on this directly. We'd generally have to measure if we were making progress when the heaps of clothes his parents had to wash went down in volume.

 

[phantasmagoric]

Thank you everyone for your comments. I perused each post thoroughly. For the second case, as suggested, I will be digging into it more in the following ways:

a) Exploring further obsessive thoughts/cognition about contamination
b) Asking whether she has these issues in other settings/time of day
c) Evaluating whether for her the rituals are enjoyable or "under aversive control"

I will hopefully update the thread with what I find out.

@calvnandhobbs68

The patient has been seeing a therapist for these issues (not sure what prompted that in the first place) and was recently referred to me for "medication management" since the therapist was reportedly planning to start more "heavy-hitting" therapy like ERP, at least so I have been told.

 

[phantasmagoric]

I recently had a follow-up appointment with the patient and explored some of the questions that were brought up on this thread.

When asked about her obsessions in more depth, the patient reports that her concerns about getting her objects/space dirty is most closely linked to her fear that she will not have "safe place" where she can sleep clean. She denies specific concerns about "germs" or contamination. She is able to tolerate going to sleep "dirty" for one night if she knows that she will be able to clean herself in subsequent days. She wonders if that her obsession about having a clean, safe place might root from past experiences of severe car sickness in the truck camper which was associated with different smells and her dog with "a lot of fur."

Beyond her routine/rituals at home prior to sleep, she also has problems (although less severe) with her roommate's dog getting on her blanket and also brushing up against surfaces in public spaces, especially if she knows that she will not be able to wash herself afterwards - both of which similarly root from the possibility of "dirtying" or defiling the clean place that she needs for the night.

She notes that she finds her rituals/compulsions to be generally "relaxing" because they are generally not overly time-consuming (indeed, they occupy less than 1 hour a day) unless something goes astray which makes her very anxious.

So, in some ways, this interview brought up more questions than it answered them. It does not appear to be a "classic" case of contamination OCD. Also, the patient seems to find her compulsions/rituals "relaxing" - perhaps because it assuages her fears and anxiety - and maybe not to the extent that it is "enjoyable."

Any further insights would be appreciated!

 

[Transistor]

I'm reading a lot of what she said to you but I don't have a full picture of who she is. (Maybe it's my lack of sleep)

Who referred the patient to your care? Was it her decision or someone else's? Why does she want help, was there a certain index event? What was her morning routine like before coming to the appointment? How was her mental status in your appointments? In a vacuum, in any diagnostic evaluation there's a ton of value itself in understanding why did they come to you now including when ego-dystonic vs syntonic features are involved

BTW get collateral.

 

[esob]

2nd case, I would explore developmental concerns. I have a couple pts with OCD + comorbid ASD (level 1 support) that have similar presentations. Inflexible adherence to routines, ritualized behavior, and distress at changes can be part of insistence on sameness or RRBs in ASD.

 

[FlowRate]

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 generally think of OCPD patients as having extremely strong preferences for how things are done or arranged. They're often very high neuroticism and very high conscientiousness and prefer cleanliness/orderliness. That's how the brief description we were given sounds to me: the patient has ways she likes things done/arranged/separated at home but doesn't obsess over them, limited fear expression, and sounds like there's no repetition /hyper-specific-perfectionistic components (e.g. needs to be done X number of times, towel folded with ends absolutely precisely aligned, etc.), which is generally what leads to the functionally impairing time spent in behaviors, involved. In other words, I'm not clear that these are "compulsions" per se. But I'm also not an expert in this like you are, so very open to feedback if you disagree.

Related, I see a lot of patients who fit this description but don't meet all of the OCPD formal criteria. I usually conceptualize them best as just "very high/pathological neuroticism" (I guess could call it other OCRD) and still start with an SRI and refer for CBT (regular CBT more than ERP although often recommend NOCD since their therapists can do both.)

 

[FlowRate]

For the first case, I basically agree with everyone else. One thing I'd add that I don't think I saw explicitly is that treatment of Schizoaffective roughly covers treatment of Schizophrenia but doesn't always cover the potential BPAD or MDD components. So your task may be longitudinally meeting with the patient to monitor for concrete evidence of mood episodes, which might indicate a change (e.g. additional classes of medication) in management.

 

[phantasmagoric]

Thank you very much for your responses. I am continously learning new things from these insights.

@FlowRate Yes, I didn't get a sense that there was much of a repetitive component, if at all, to her behaviors. All of her "rituals" are directly related to her concerns of disrupting a clean place to rest at bedtime, and the tasks generally do not occupy more than a few minutes of her time.

@Transistor As mentioned above, therapist began seeing her first for symptoms and the therapist referred her to me because she felt that the patient might benefit from medications before starting exposure therapy. I looked over the therapist's intake to get a sense of why she sought care in the first place. It is not entirely clear from the notes, but her great distress when things go awry is mentioned. I will delve into this more in my next meeting.

Her MSE was generally unremarkable - well-groomed young Caucasian female who was cooperative, euthymic, appropriate affect, logical and linear. She appears to be fairly intelligent (attends college with good grades), perhaps somewhat shy and reserved but no overly awkward (or appearing to lack "theory of mind").

It is interesting to think about though. How would you formulate the case differently if she came of her accord - as opposed to being "brought in" by a third person - especially when certain ego-syntonic vs dystonic features are involved?