ABSTRACT | PDF
Case Conference II
Schizoaffective disorder, manic type
Ajit Kumar Kakati
Postgraduate Trainee of Psychiatry, Silchar Medical College and Hospital
P, female patient, 46 years of age, Hindu by religion coming from a lower socioeconomic group and admitted in psychiatry ward through outdoor patients’ department (OPD). She was brought by her son who was a reliable and adequate informant.
According to patient, she had no complaint. According to informant, muttering, occasional laughing and crying due to no apparent reason for three years, excessive and irrelevant talk, and aggressive behaviour for three months, talking of supernatural power, hearing voices not heard by others, and decreased need for sleep for two months. Mode of onset was gradual and course was continuous. There was neither precipitating factor nor life event.
Patient was apparently alright three years back. She gradually developed excessive talking while interacting with people. She also used to entertain each and every guest who visited her home. She would sing in front of the guests and sometimes queried about the quality of her song. At times, she sang alone. She also started spending money unnecessarily by buying things which are not useful.
After six months, she became less talkative and her sleep was also reduced. There was delay in initiation and interrupted in between. She had lack of interest in her work and avoided all her pleasurable activities. Her appetite was also reduced and after repeated request by family members, sometime she took little. She continued to mutter and sometimes laughed and cried due to no apparent reason. She could maintain her hygiene and take care of herself. Seeing her behaviour, she was then treated by a medicine specialist.
Two years back, her son found patient unconscious at bed with froth coming from mouth. She was admitted in hospital and diagnosed of poisoning. Later she confessed that she consumed insecticides. After discharge, her low mood persisted. She remained aloof and didn’t interact much with the people. She was then treated by a cardiologist. She gradually started to improve.
Last year again she developed reduced interaction with people and most of the time she used to see snakes passing by her side. She also dreamed God and Goddess at night and described to the family members that God and Goddess talked to her. Sometimes she used to hide under the bed but family members could not find out reason even after repeated query.
Two months later, one morning she suddenly woke up and started saying that last year’s Durga puja celebration was not satisfactory (they celebrate it at their home every year). So this time it should be celebrated in formal procedures. Family members accepted her suggestion.
After three months in the afternoon at three o’clock, she was invited by a neighbour to her home and she spent few minutes there. As all family members were busy in work in their paddy field, she then attempted suicide by hanging with her sari in the bathroom. At 5:15 p.m. when all the family members returned home and searched for her, she was found in the bathroom. After rescuing she was breathing with difficulty. She was admitted in psychiatry ward following consultation with otorhinolaryngology and medicine departments.
After discharge she was on regular follow up till six months back. Her muttering as well as laughing and crying remained as before. She became nonadherent to treatment subsequently and started talking excessively which was mostly ‘out of context’. At times she showed aggressive behaviour to those people who had conflict with her in the past.
Last month, she went out of home promising that she wouldn’t be back again. She then started visiting her different relatives. She observed Basanti puja where she saw the sacrifice of different animals. After returning, she started saying that Ma Durga had given her a sword and the snake of Lord Shiva. The snake always slept with her at night. According to her, she had been endowed with supernatural power by Goddess Durga Ma and she would ruin those people who didn’t listen or obey her directions. She gradually became more aggressive and was brought back home. At home, she used to say that she heard the voices of God and Goddess and They direct her to control the people. She kept a large knife and started scolding people who passed by showing the knife. Her sleep was reduced but never complained it. She hardly slept for one to two hours. There were delay in initiation and also woke up early. After getting up she sat in the courtyard and would start talking at self. If any family member forbade she became aggressive. She said family members didn’t understand that Ma had given her power and it was her advantage to take revenge on those disobedient people. Whatever she was doing was according to Ma’s direction. She refused to visit doctor. She was restrained and brought to Silchar Medical College and Hospital for treatment.
Mental state examination revealed athletic built, proper dress, maintained hygiene, hair combed, adequate eye to eye contact, crying and laughing spells at times. Psychomotor activity was overactive, partially cooperative attitude toward interviewer and rapport could not be established. In speech, no articulation defect, normal tone, reaction time, and flow, increased quantity, and quality was irrelevant at times but coherent. Mood was dysphoric. Affect was inappropriate, reactive, moderate intensity, full range and lability. Form of thought exhibited loosening of association and tangentiality. Content of thought showed mood incongruent ideas of grandeur. There was no perceptual disturbance. In cognitive function, patient was conscious, comprehensive, oriented to time, place and person, attention can be drawn but concentration was poor, immediate memory was impaired, recent and remote memories were intact, abstract thinking was impaired, intelligence was below average, and insight was level 1.
Summary A 46 years old female, Hindu by religion from lower socioeconomic group coming from a rural area and was admitted in psychiatry ward with complaints of muttering and occasional laughing and crying due to no apparent reason for three years, excessive and irrelevant talk and aggressive behaviour for three months and talking of supernatural power, hearing voices and decreased need for sleep for two months with gradual onset and continuous course with positive family history of psychiatric illness with educational history up to IV standard with normal psychosexual history and good marital history with history of use of tobacco and betel nut for 25 years with good coping skill and extrovert type of premorbid personality. On general examination, pulse is 84/minute, blood pressure is 110/70 mm of Hg and with normal systemic function. On mental state examination, she is athletic built with adequate eye to eye contact with laughing and crying spells at times with increased psychomotor activity with partially cooperative without establishing good rapport. In speech, there is increased quantity with irrelevancy at times with dysphoric mood with appropriate and labile affect with full range with loosening of association and tangentiality in formal thought disorder with ideas of grandeur which is mood incongruent in thought content with poor concentration and impaired immediate memory with impaired abstract thinking and test and personal judgement with below average intelligence with insight level 1. Provisional diagnosis is schizoaffective disorder, manic type (F25.0) and differential diagnosis is bipolar affective disorder, current episode manic with psychotic symptoms (F31.2).
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