ABSTRACT | PDF
Case Conference
Schizophrenia with risk of suicide
Rajesh Rongpi
Postgraduate Trainee of Psychiatry
Silchar Medical College and Hospital
Twenty years old Islam female XX was admitted through outdoor patients’ department accompanied by parents. Information given was adequate and reliable. Patient had no complaint. According to parents there were reduced sleep, talking excessively and ‘out of context’, wandering behaviour and poor self-care for one and half years, repeatedly saying of ending her life and several attempts of committing suicide for four months. Gradual in onset with life event of sexual abuse in the form of rape by paternal uncle six months prior to start of illness, precipitating factor in the form of separation after one day of marriage one week before illness and perpetuating factor in the form of land dispute and noncompliance to treatment six months back.
According to parents she was apparently alright one and half years back. While she was studying in class X, she had physical relation with her uncle by force which remained unknown to family until her menstruation was irregular as noticed by mother and on enquiry she disclosed it. By then they went for abortion secretly through quack procedure and later on she developed some physical illness and was corrected by local physician. After six months, family had decided to get her married with a man of nearby village but didn’t disclose about the incidence. After a night of marriage, she started weeping and crying vigorously telling that she didn’t want to stay with the man as he was bad looking and had not matched for her. Parents brought her back home and after staying for few days, one morning she had an episode of fainting associated with clenching of teeth, twisting body movements and stiffening of the whole body. The whole episode lasted for about two to three hours. After regaining consciousness, she started complaining of burning sensation all over the body and remained fearful. These episodes repeatedly occurred for seven to ten days. So they took help of local faith healer and received some medicine and magic potion and talisman for about one and half months. Her symptoms didn’t improve, started talking ‘out of context’, at times became aggressive, also talked alone and verbally abused parents and siblings. Many a time she wanders out from home, so needed to be physically restrained or sometime locked in a room. She became less self-caring and even took off clothes in front of parents as well as others. Most of the nights, she spent sleepless and talking alone with fearful look. For that she was brought to psychiatrist and prescribed olanzapine 15mg and clonazepam 0.5mg at bedtime. Electroencephalography (EEG) showed normal recording. After four months of treatment, she talked excessively, became irritable and showed frequent change of mood. Sodium valproate 600mg daily was added along with earlier medications. She improved but not symptoms-free for the next one year. Due to financial constraints and belief, they discontinued treatment. Her symptoms exacerbated for last four months along with repeatedly talking of ending her life and made several attempts to commit suicide. She tried to hang but all the time saved by siblings. There was no history of head injury, hypertension, diabetes mellitus, tuberculosis or other infections. At present she was receiving bupropion 150mg in the morning, olanzapine 20mg in two divided doses and lorazepam 3mg daily in three divided doses. No significant past history.
Regarding family history, she lived in a nuclear one along with parents and siblings. There were positive family histories of mental illnesses in the forms of paternal aunty and grandmother suffering from acute and transient psychotic disorder and bipolar affective disorder respectively.
In personal history, she was second in order of birth among siblings and studied up to class X. She was worried on attaining menarche and needed consolation from mother. She had conceived once and aborted. She separated after one day of marriage. No history of substance use. Premorbidly she had few selected friends and was introvert.
On physical examination, both general and systemic, were within normal limits.
On mental state examination, she was of asthenic built, appropriately dressed, overt beautifying, proper hygiene and adequate eye contact. Her psychomotor activity was increased, cooperative towards examiner and rapport was established. There was no articulation defect in speech with normal prosody and pitch, poor quality, at times irrelevant and incoherent. Mood was subjectively depressed and objectively elated. Affect was inappropriate, reactivity was present, intensity was shallow and range was full with lability of affect. In form of thought, there were loosening of association and circumstantiality. In content of thought, there were delusion of reference, idea of persecution, preoccupation with poverty, suicidal ideas and guilt feeling. Perceptual disturbances in the forms of auditory hallucination of voices discussing about her and family, defaming them and visual hallucination of seeing snakes coming in front of her. No illusion.
On cognitive state, she was conscious and comprehensive. She was disoriented to time but oriented to place and person. Attention could be drawn but concentration was ill-sustained. Her immediate and recent memories were impaired with intact remote memory. Abstract thinking, judgement and reasoning were impaired. Intelligence was below average. Insight was level two (slight awareness of being sick and needing help but denying it at the same time).
She was diagnosed as a patient of paranoid schizophrenia, continuous (F20.00) and management plan was pharmacotherapy with olanzapine 20mg in two divided doses and lorazepam 3 mg in three divided doses as well as to start electroconvulsive therapy.
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