Case Report Session

PARANOID SCHIZOPHRENIA

Oleh:

Else GempitaSari P 2126 A

Bunga Julia F.R P 2125 A

Preceptor:
dr. Taufik Ashal, Sp. KJ
Introduction
 Schizophrenia is the most common mental disorder,
which characterized by the presence of reality
distorsion, severe personality disorganization, and
disability to interact with daily activities.
 Almost 1% of global population suffered from
schizophrenia, mostly found at age 15-35.
 Riset Kesehatan Dasar (Riskesdas) in 2013
published that 0.17% of Indonesian people
suffered from schizophrenia, which as much as
400.000 people/year
 Paranoid schizophrenia as on of themost common
type of schizophrenia can endanger the patient and
the patient's family, as well as the patient's neighbors.
So schizophrenia need to be well managed so not to
pose any danger to anyone especially for the patient.

 Based on the above, we would like to raise our CRS

title under the title Paranoid Schizophrenia.
Schizophrenia
 Schizophrenia is a psychotic disorder which
characterized with main impairment of thought,
affective, and behavior.
 The symptoms are followed by blunted affect, bizzarre
motoric activities, withdrawing behavior, delusion and
hallucination
 People with schizophrenia are generally experiencing
some of the symptoms of acute episodes, between
every episode they often experience symptoms that are
less severe but still very disrupt their lives
 Bleuler (Maramis 2009) divides the symptoms -
symptoms of schizophrenia into two groups:

primary symptoms Secondary symptoms

• a) Impaired thought •a) delusions

processes •b) hallucinations
• b) Emotional disturbances •c) catatonic symptoms or
• c) Disturbance willingness other psychomotor
• d) Autism disturbances
Subtypes of schizophrenia

Paranoid Type
• often start after start 30 years
• May be subacute, but may also be
acute
• irritable, aloof, a little arrogant and
less trust in others.
Hebephrenic type
• arise in adolescence or between 15-25
years
• disorder of thought process and their
willingness depersonalization disorder or
double personality
• Psychomotor disturbance like mannerism,
neologisms or childish behavior
Catatonic type
•First onset between the ages of 15 to 30
years
•acute and often preceded by emotional
stress
•It may happen rowdy catatonic agitated
or catatonic stupor.
 Important symptom is psychomotor symptoms such
as:

a) mutism, sometimes with eyes closed, face without

expression (like a mask) stupor patient does not move
at all for a very long time, a few days, sometimes a
few months.
b) opposing position changes.
c) The food is rejected, the saliva is not swallowed and
accumulated in the mouth and melts out, urine and
feces were detained.
d) grimmace and catalepsy.
Simplex type
• Symptoms often occur first during
puberty
• Shallowness of emotion, willingness
distortion
• Impaired thought, delusions, and
hallucinations are rarely found
Residual Type
• a chronic condition with a history of at least one
psychotic episode
• Prominent negative symptoms
• Negative symptoms consist of psychomotor
delays, decreased activity, stacking affect,
passive and no initiative, poverty conversation,
nonverbal expression decreased, and poor self-
care and social function
 Clinical Manifestations

• Delusion
(+) • Hallucination
symptoms

(-) • behavioral deficit, as

avolition, alogia, anhedonia,
flat affect and asosiolitas
symptoms
 Diagnostic Criteria (PPGDJ III)
1. There should be at least one of the following symptoms which very clear (and usually
two or more symptoms when the symptoms were less sharp or less obvious):
a) - Thought echo: the thoughts themselves repeating or echoing in his head (not hard), and thought content
replay, although content is the same, but the quality is different; Thought or- insertion or withdrawal: the
contents of an alien mind from the outside into the mind (insertion) or his thoughts taken out by something
outside himself (withdrawal); and - Thought roadcasting: spread out his thoughts so that others or the
public to know.
b) - Delusion of control: delusions about himself controlled by a certain force from the outside; or - Delusion
of influence: delusions about himself be influenced by a certain force from the outside; or - Delusion of
passivity: delusions about her helplessness and surrender to something outside forces. - Delusional
perception: sensory experience that is not fair, meaningful very typical for him, usually mystical or
miraculous.
c) Auditory hallucinations:
 Voice continually commented on the behavior of the patient
 Discuss about patients among themselves (among the various voices to speak).
 another hallucinatory voices coming from one body
d) delusions
• Persistent delusion which according to the local culture is considered unnatural and impossible, for example, concerning
religious beliefs or political, or power dam above capabilities ordinary human being (eg being able to control the
weather, or communication with aliens from the world other).
2. Or at least two of the following symptoms should always be clearly found
a) persistent hallucinations of ANY five-senses, if accompanied either by
floating delusions or half-shaped without clear affective content, or
with ideas of excessive (over-valued ideas) that persist, or if it
happens every day during weeks or months repeated.
b) Disconnected the current thinking (break) or an insertion
(interpolation), resulting in incoherence or irrelevant speech, or
neologisms
c) Conduct catatonic, like agitated state (excitement), certain body
positions (Posturing), or flexibility cherea, negativism, mutism, and
stupor
d) Negative symptoms; very apathetic attitude, rarely spoke, and
blunted or unnatural emotional responses, usually resulting in
withdrawal from social interaction and decreased social performance;
but it should be clear that all this is not caused by depression or
neuroleptic medication
3. The presence of typical symptoms of the above
has lasted over a period of one month or more.
4. here must be a consistent and meaningful change
in the overall quality (overall quality) of some
aspects of personal behavior (personal behavior),
manifest as loss of interest, life is not intended, does
nothing, self absorbed attitude, and social
withdrawal.
 Treatment of Schizophrenia
 Antipsychotics are used to treat schizophrenia.
 Antipsychotics work in controlling hallucinations, delusions and

changes in thought patterns that occur in schizophrenia.

 Patients may want to try several types of antipsychotics before

getting a drug or combination of antipsychotic drugs really

suitable for the patient.
 Examples of antipsychotic drugs:

1. Haldol (haloperidol) 5. Stelazine (trifluoperazine)

2. Mellaril (thioridazine) 6. Thorazine (chlorpromazine)
3. Navane (thiothixene) 7. Trilafon (perphenazine)
4. Prolixin (fluphenazine)
Case Report
Patient’s Identity
 Name (initial) : Tn.M/ Muslim
 Sex : Male
 Age : 55 yo
 Religion : Islam
 Tribe : Minangneese
 Last Educational : Elementary School
 Occupation :-
 Marital status : Married
 Address : Pariaman Tengah
Chief Complaint
Patient had raged and destroy glass in Regina Eyes
Center Hospital.
Current Desease History
The patients had brought by “Satpol PP” Padang
city because he was rage and break glass in Regina
Eyes Center Hospital. Patients often felt suspicious with
people around him. Patients also hear whispering to kill
people and see the shadow of his wife(dead).
He said that he lives alone without anyone and he
ever met Muhammad SAW and gave him rosary.
The patients have good appetiate and enough sleep
this recent. Sad History (+), hopeless history (+), excited
history (+), new idea history (-), a lot of speak (+).
 Past Disease History

Psychiartry Desease History

• This is the first time patients got
treatment in RSJ HB. Saanin Padang
Medical Desease History
• DM type 2, tinea corporis+capities,
food alergic (tuna fish).
 Past Disease History

NAPZA History

• Smoker
 Family History
 Pedegree Scheme
 Family History
 Patient House’s History
No House House’s Condition

1.
Parent’s in law Less calm, less suitable,
House less comfortable
 Premorbid Patient Mental Condition

Previous Personality Disruption

Personality Clinical Condition

Skizoid Cold Emotion, No indifferent, Less Friend, Always Daydreaming

Paranoid Over vigilance, Less Critism, Hypersensitive

Skizotipial Mind unseen, Abnormal conversation

Siklotimik Hopeless, easy to be sad and cry

Histrionik None
 Universitas Andalas

Premorbid Patient Mental Condition

Previous Personality Disruption
Personality Clinical Condition

Narsistik None

Dissocial None

Threshold None

Dodge None
Anankastik None
Dependen None
 Premorbid Patient Mental Condition

Psychological Stressor (Axis IV)

• Problem in family

No desire to commit suicide

No Law Violate

Patient is a Moeslem
Do not know
Patient hope is to come back home and meet with his children
 Illustration Chart of Disease

Year : july 2016

Old : 55 yo

July 2016
• Patient had raged wihout a
reason and destroy glass in
Regina Eyes Center Hospital
INTERNUS AND NEUROLOGICAL STATUS
- Within normal Limits
MENTAL STATUS
GENERAL CONDITIONS

1. Awareness : Composmentis
2. Apperarance
posture : ordinary
dressing : ordinary
physical health : healthy
3. Physical contact : can be done, natural way,
long enough
4. Attitude : cooperative, pay attention, honest
5. Behaviour
Walking: ordinary
VERBALIZATIONS AND SPEAKING
 Speaking flow : ordinary
 Speaking productivity : a lot
 Vocabulary : a lot
 Volume of speaking : ordinary
 Content of speaking : suitable
 Emphasis of speaking : present
 Spontaneity : spontaneous
EMOTIONS
1. Affective : Appropriate
2. Mood : eutime
3. Other emotions : anxiety
4. Physical conditions that connected with mood : none
EMOTIONS
 Stability : Not stable
 Control : adequate
 Echt/unecht : Echt
 Deep / Shallow : Deep

 Difference scale : Narrow

 Emotional flow : ordinary

THINKING PROCESS
 Speed of thinking process : ordinary
 Quality of thinking process : clear

- General disturbance in the form of mind : none

- Specific disturbance in the form of mind : loose
association
- Specific disturbance in mind content : greatness
dellution
PERCEPTION
 Hallusinations : Auditoric, visual
 Illusions : None
 Depersonalization : None

 Derealization : None
DREAM AND FANTASY
 Dream : None
 Fantasy : None
COGNITIVE AND INTELECTUAL FUNCTION

1. Orientation : time (disturbed), place (no

problem), personal (no problem), situation (no
problem)
2. Attention : Good
3. Concentration : Disturbed
4. Calculation : Disturbed
5. Memory : Impairment in remote memory,
recent past memory, and
immediate memory
6. General knowledge : Good
COGNITIVE AND INTELECTUAL FUNCTION

7. Concrete thought : Good

8. Abstract thought : Disturbed
9. Intelectual decline : None
Mental retardation : None
Dementia : None
DISCRIMINATIVE INSIGHT

Level 1 : denial
Level 2 : ambiguous
Level 3 : aware, but blame someone else
 Level 4 : aware, but don’t know the reason
Level 5 : intelectual insight
Level 6 : true emotional insight
AN OVERVIEW OF SIGNIFICANT DISCOVERIES

 The patient came to the Saanin Hospital in July

2016 and got treatment since that time.
 Patient often feel suspicious with the people
around him talking about him.
 Patient have desire to do suicide.
 Patinet often day dreaming
 Patient had raged and destroy glass in Regina
Eyes Center Hospital .
 Patient hear whispering and see his wife(dead)
AN OVERVIEW OF SIGNIFICANT DISCOVERIES

From mental status:

General apprearance : neat apprearance
Physical contact : can be done
Willingnes to cooperate : yes
Psychomotor : normoactive
Mood : eutim
Affective : appropriate
Verbalization : clear
AN OVERVIEW OF SIGNIFICANT DISCOVERIES
From mental status:

Hallucinations : auditoric, visual

Dellutions : Yes
Thought process : incoherent
Orientation : Disturbed
Memory impairment : Disturbed
MULTIPLE AXIS DIAGNOSIS

Axis I : Paranoid Schizophrenia (F 20)

Axis II : Paranoid personality disorder
Axis III : DM type 2, tinea capities and corporis
Axis IV : family problem
Axis V : GAF 20-11
LISTS OF PROBLEMS

A. Organobiologic : none
B. Psychology :
 Mood : eutim
 Affective : Appropriate
 Hallucinations : Auditoric (+), visual (+)

 Delusions : Present
c. Surroundings and psychosocial : None
DIFFERENTIAL DIAGNOSIS
-Schizoaffective disorder depression type
-Episode of Major depression with Psychotic symptoms.

THERAPY
 Risperidon 2 x 2 mg po

 Lorazepam 1x1 mg po

PROGNOSIS
 Clinical : bonam
 Functional : bonam
 Social : dubia at bonam
DISCUSSIONS
 A 55-year-old male came to RSJ HB. Saanin Padang on July
15, 2016 with diagnosis of paranoid schizophrenia. Diagnosis
was made based on anamnesis, physical examination and
psychiatric examination.
 Based on history of disease, psychotic symptoms were found in
this patient in the form of delusion and hallucinations. The type
of delusion was suspicion to people around the patient. While
the type of hallucination were auditory and visual
hallucinatiom.
 This patients also in rage when he is in Regina Eyes Center and
potentially harm others
 There is no history of alcohol usage or other psychoactive substances
that cause physiological changes in the brain. So the possibility of
mental disorders and behavior and feelings due to the use of
psychoactive substances can be removed (F10 - F19).
 The patient's complaints do not meet the criteria for major
depression with psychotic symptoms so that the diagnosis can be
excluded (F 32.3).
 The presence of affective disorders and psychotic symptoms of the
patient does not occur simultaneously and not equally prominent so
that the diagnosis of schizoaffective depression type can be
removed (F 25.1)
 Based on PPDGJ III can be concluded that this patient's axis wass
paranoid schizophrenia (F 20).
 From the patient's personality history there was a sense of being cheated
or harmed, excessive vigilance and refusing to accept criticism. In the
patient there was no history of mental retardation. Thus the diagnosis of
the axis II in this patient is a paranoid personality disorder.
 In this patient there was signifiant general medical, so in this patient there
is axis III diagnosis with DM type 2, tinea capities and corporis.
 In this patient there is a history of unharmonious relationships in the
family so that for the diagnosis for IV axis is a family problem.
 The diagnosis of the axis V in the patient was found to be moderate
disability so that based on the assessment of GAF (Global Assessment of
Functional Scale), the patient is currently at a value of 20-11 because
the patient is potentially harmful to the surrounding community's friends.
 Management given to this patient is 2x2 mg of risperidone
and lorazepam 1x1 mg.
 Risperidone is an atypical drug of atypical antipsychotics
selected as a treatment because of minimal side effects and
better medication work than typical groups.
 Lorazepam is a benzodiazepine class of drugs selected as a
sedative effect in patients.
Thank You