FACULTY OF MEDICINE

PSYCHOLOGICAL &
BEHAVIOURAL MEDICINE
POSTING

1st ROTATION

CASE WRITE UP

YEAR 5 2017/2018

NAME : NOR MASLINA BINTI NOR AZAINI

MATRICS NUMBER : 2013895214

SUPERVISOR : AP DR EIZWAN HAMDIE YUSOFF

GROUP :D
DEMOGRAPHIC DETAILS

Patients initial Mr NMP

Age 44 years old
Sex Male
Race Chinese
Occupation Helper in brothers restaurant
Marital status Single
religion Buddha
Source of history Patient, case note
Language spoken Chinese, malay
Date of admission 16th august 2017
Date of clerking 6th september 2017

CHIEF COMPLAIN

Mr N, 44 years old, Chinese gentleman, single, helper in his borthers restaurant, with known case of
bipolar II disorder for 13 years, was referred from clinic due to suicidal ideation and worsening
depressed mood for 2 weeks prior to admission.

HISTORY OF PRESENTING ILLNESS

He was brought by his brother for regular clinic follow up 2 weekly. Upon reviewing him in the clinic,
he complaints of having suicidal thought on and off for 2 weeks. He said that he wanted to kill
himself by ingesting his psychiatric medication in a large amount because he felt hopeless with his
life and felt unmotivated to continue his life. However he hesitated to fulfill the suicidal ideation due
to his concern with his work. He was able to dismiss his suicidal thought by doing something like
watching television or doing house chores. He did not have any specific plan to end his life.

He also has depressed mood which occur throughout the day and became worsen 2 weeks prior to
admission. Sometimes he feels irritable and scold people without any reason. His brother noticed
that he cannot concentrate at work as he describe him as daydreaming with slow movement, so his
brother gave him a simple task for work. He has difficulty in initiating sleep where he went to sleep at
10 pm, only able to sleep around 12pm. It is because he has a lot of thinking in his mind. He had been
thinking of his work, his future life time, his debt and also worried that his illness would not get
better. He woke up in the middle of sleep because he felt hungry and took his supper before going
back to sleep again. He will force himself to wake up at 6 am and going to work. Due to the lack of
sleep, he always felt drowsy and tired during daytime especially in the morning but still force himself
to go to work everyday.

He also has loss of interest lately. Usually he likes to play badminton and hangout with his friends,
however he does not feel pleasure to do it anymore and refused to see his friends although the
friends called him and invited him to go out with them.

Otherwise, he did not have any other symptoms of depression such as excessive guilty, no feeling of
worthlessness, no psychotic symptoms such as hearing voices, no visual hallucination, no delusion,
no manic symptoms for instance elated mood, no grandiosity, no disorganised speech, no violence
behaviour, no increase in energy and increase in goal directed activity.

He was not compliance to his medication for 2 weeks since the last clinic follow as he did not take the
night medication as sometimes he forget to take it after coming back from work. He has increase in
appetite and weight where he gained 2-3 kg in a month since he started taking the psychiatric
medication, however he was unsure of the duration. There were no stressful situation occuring
lately, no recent conflicts or arguments with his family or friends. He was worried that his illness
would not get better, so he wanted to to do electroconvulsive therapy as he said he felt better after
the last electroconvulsive therapy which was on June 2017.

Besides all of the above symptoms, he did not have other hypothyroid symptoms such as cold
intolerance, constipation, dry skin, or muscle ache.

PAST PSYCHIATRIC HISTORY

He had first psychiatric contact in 2004 at the age of 31 years old in private brain clinic where at that
time,he was diagnosed with schizoaffective disorder. However he was not able to recall what
happened during this episode. Since then, he was prescribed with T.lithium 300mg OM and 600 mg
ON, T. Risperidone 1 mg ON. T. Sertraline 50mg ON and T. Diazepam 5 mg PRN.

He was referred to psychiatry department HS in 2011, the diagnosis was revised to Bipolar II disorder
in hypomanic phase where at that time he presented with elated mood, spending spree, and flight of
ideas with no psychotic symptoms.

He has multiple relapse and admission due to suicidal attempt:-

First attempt was in May 2012 where he overdosed himself with T. Lithium. He was on T.
Lithium 600mg BD, so the medication was change to sodium valproate 400mg OM/600 mg
ON. After discharge from the ward, he defaulted follow up.
He was admitted again for second suicide attempt which occur in August 2013 where he
overdosed himself with his anti-hypertensive medication. At this time, he required ICU
admission.
Third suicidal attempt was in March 2016 where he overdosed himself with multiple
medications that he has. Others include two times in April 2017 and lastly in May 2017.

He had done ECT three times which were in 2013, March 2016 and the latest ECT was in April 2017.

His last admission was in 25/5/2017 until 21/6/2017, where he stayed for about one month in the
ward, for bipolar in depressive phase, anxious distress and suicidal ideation. No ECT was done during
the last admission. He was discharged with T. Olanzepine 20mg ON, T. Quertiapine 100mg ON,
Lamotrigine 175 mg ON and clonazepam 1 mg ON. He was planned to come again 1 week after
discharged.

2 weeks after discharged (25/6/2017), during the clinic review, he still has depressed mood, so he
was prescribed with increased dose of T. Quertiapine to 200mg ON, and T clonazepam 2 mg ON.
Other medication was maintained.
His last clinic follow up was on 26/7/2017 where at that time he was started back with lithium 150mg
BD. He was relatively well at that time until this current episode.

MEDICATION SUMARY

Anti-depressant:

in 2011, he was on sertraline up to 75 mg OD, unable to tolerate the side effect. change to T.
Mirtazapine in 2013-2016.
In Feb 2016, T.mirtazapine was off due to overdosing himself with multiple meds.
Feb 2016 july 2016 : T. Fluvoxamine up tp 125mg ON, however had dry mouth.
July 2016 may 2017: T.mirtazapine but was off due to in may 2017 due to side effect.

Mood stabilisers :

2011-2012: on T. lithium 600mg BD, was off due to overdosed himself with it.
2012-2013: on sodium valproate 400mg OM/ 600mg ON, was off due to overdosing himself with
anti-hpt.
2013-now ; on lamotrigine

Anti-psychotic:

2011: t. chlorpromazine up to 75mg ON

2012: t. airiprazole 10mg OD started in ward
2013 may 2017: T. quetiapine but was off in May 2017 due to dry mouth.
may 2017- now: T. olanzapine up to 20mg ON.

PAST MEDICAL/SURGICAL/HISTORY

He was diagnosed with hypertension 4 years ago (2013) at the age of 41 years old. However, the
medication was stop in review of his controlled blood pressure. The history cannot be further illicited
as the patient was unsure of the details. He has never undergo any surgery before.

FAMILY HISTORY

His father passed away at the age of 50 due to heart attack while he was 13 years old. After the
death of his father, his mother had to raise her children alone while all of them are studying in
school. Her mother had gone through a lot of hardship that eventually she develop psychiatric
problem as well. He was unsure of the exact diagnosis and unable to tell the duration of her illness.
The patient was closed to his mother as he shared his problems with his mother and also he was the
one that accompanied her for follow up in the clinic for her illness. However, his mother passed away
5 years ago at the age of 60. He was unsure of the cause of death of his mother.
He is the 5th out of 6 siblings. He has 4 brothers and a younger sister. After the death of her mother,
he keeps his problems himself as he did not closed with his siblings. Now, all of his siblings have their
own family, no one can really look after him. They did their own business. However, if he had any
financial issues, he will get help from his first brother who owned a restaurant, and hired him to work
in his restaurant.

PERSONAL HISTORY

Birth history

Patient was unsure about the pregnancy and birth.

Childhood history

Developmental milestones were normal

No physical, emotional, mental abuse

Education history

Primary: SRJK(C) Jinjang

Secondary: SMK Jinjang
SRP: He passed some subjects
SPM: failed however he cannot recall the grades
never further his study after SPM.
Extra curricular involvement: He took part in badminton and football games in school but
only for the team for school annual sports day.
He claimed to had a lot of friends back in the school, has 2 best friends. There were always
going to school together. No disciplinary problems such as truancy, bullying or being bullied.

Occupational history:

He helped in his first brothers restaurant

Job scope: washing dishes, help in food preparation, cashier. His income is Rm1800 per
month received by his brother. He claimed to be satisfied with his works and salary. He
claimed that he works with his brother since finish SPM.

Sexual & marital history:

He is heterosexual, he has many friends of different gender, but never had any special
relationship as he said there was no one suitable for him. He is not sexually active.

Substance history:
Ex-smoker, stop 5 years ago. He used to smoke 4-5 sticks per day since 20 years old. He is a social
drinker, only consumed alcohol during weekends or celebration when he hangout with his
friends. He took 1-2 cans of beer each time. Never took illicit drugs.

Social condition:

He lives in his 4th brothers house together with his sister in law, and 5 his brothers child. They live
in a single storey terrace house in Jinjang. He has his own room. He said that he borrowed
some money from his friend for about RM 1000 to RM2000 a long time ago, but he was
unable to pay the money till now.

Crimical history: never been arrested

PREMORBID PERSONALITY

He described himself as friendly, brave and determined person. He likes to help other people. He
was closed to his mother and shared problems with her. After she passed away, he kept the
problems himself and only got helped for his financial issue from his 1st brother. He is
devoted to his religion, go to temple 3 times in a month.

CONTRIBUTING FACTORS

Predisposing factors:

Genetic predispositions his mother has psychiatric illness

Precipitating factors :

Not compliance to medication

Financial problems he has debt from his friends.

Loss of his mother

Perpetuating factors :

Not compliance to medication

MENTAL STATE EXAMINATION

1. Appearance and behavior

Medium body built for Chinese man. He was wearing hospital attire. He was well groomed,
good hygiene, cut nails. He was sitting in a slouch posture. He was alert and cooperative
during the interview. The eye contact was present but not sustained. He had slow
movement.

2. Speech
 The speech was slow in rate, monotonous, decrease in amount. He has poverty of speech,
sometimes he suddenly stop speaking in the middle of the speech. The speech was relevant
and coherence.

3. Mood and Affect

Have claimed to have an euthymic mood. The affect was restricted. The affect was stable and
appropriate to the mood.

4. Thought disturbance
He has a slow thought and poverty of thought.
No suicidal ideation, no delusion, no possession of thought.

5. Perceptual disturbances
He has no hallucination or illusion.

CONGNITIVE FUNCTION

Orientation: He is oriented to time place and person

Memory: immediate recall: he was able to recall 3 things (rumah, kucing, bola)
-short term memory: unable to recall (only able to recall one thing which is rumah)
-long term memory: unable to recall IC number

Attention and Concentration: he was unable to do serial 7-s and unable to spell WORLD
backward.

Intelligence and general knowledge: unable to give the current Prime Ministers name

Abstract thinking: unable to interpret bagai anjing dengan kucing and unable to interpret
ulat buku, however able to identify similarity between apple and orange- (fruit)

Judgment: good judgment when asked about what he will do if there is fire in the building
call firefighter
Insight: partial
-he is aware that he has mental illness but not knowing the diagnosis.
-aware the symptoms he experiencing is not normal.
-aware that he needs treatment and felt better after doing ECT.
-does not aware non-compliance to medication leads to relapse to his disease.

CASE SUMMARY
Mr N, a 44 years old Chinese man, single, a helper in his brothers restaurant, a known
case of bipolar II disorder for 13 years and strong family history of psychiatric illness. He has a
total of 7 admissions due to suicidal attempts with overdosing himself with his medications
and had received 3 times of electroconculsive therapy. Apparently he was not compliance to
his medication for 2 weeks since the last clinic follow up, currently presented with depressed
 mood and recurrent suicidal thought of overdosing himself just like before. He also has other
symptoms of depression which include lethargy throughout the day, insomnia, loss of
interest, anhedonia, and feeling hopeless 2 weeks prior to admission. No symptoms of mania
and psychosis.

MSE: He had slouched posture and psychomotor retardation. His speech was in slow rate,
monotonous and has poverty of speech. He had restricted affect with slow thought process.
He was oriented to time, place and person, had poor concentration, poor memory, poor
abstract thinking and partial insight. He still has a good judgment.

Management (biopsychosocial)

The main aim to manage this patient includes treating the acute symptoms of depression,
investigate biologically, psychologicallyand socially, put the patient on long-term treatment
to prevet relapse.

Biologically, this patient was given anti-psychotic, T. Quetiapine IR 100mg ON and T.

Olanzapine 20mg ON. He was also on anxiolytics to help with his insomnia with T.
clonazepam 2mg ON. He has received mood stabilizer, T. Lamotrigine 200mg ON and T.
lithium 450 mg ON.

Since, he has a lot of side effect toward the medication and somehow the medication did not
help him much, electroconvulsive therapy can be used. It is used when the symptoms of
depression are severe and there is poor response to other therapies, or when a rapid
response is needed, such as when the patient is actively suicidal. This patient was aimed for 6
times ECT for current admission, and was planned for maintenance of ECT weekly.

For psychologically,
psychoeducation (to the patient and family members)

Eventhough this patient has suffered from bipolar II disorder for quite a long time ago, he
and his family seem not to understand the mental illness itself since they did not aware
about bipolar disorder. In this situation, we have to explain again regarding:
o the nature of the bipolar disorder,
o Explain about the medications and the side effects that the patient might get
o Stressed on the importantce of compliance to his medication to prevent relapse and
mood discturbance
o Also stressed out on the importance of regular follow up, not to defaulted treatment.
o Also ask the caretaker to remind the patient to take the medications everyday on the
right time. Since this patient lived with his 4th brother, we have to make sure that his
brothers know the importance of the medication as well.
o Teach them to recognise early signs of relapse in bipolar disorder
o If the symptoms persist or notice any change in behaviour, quickly bring the patient
to the hospital
 o Explain about high expressed emotion to the family members : do not over-
protecting, over-criticism, over-involvement to the patients life, otherwise the
patient can get relapse of the disease
o Ask the patient to get help quickly if he has suicidal thought again, not to keep the
problems to himself

Cognitive behavioural therapy

As this patient had depression, he is suitable for cognitive behavioural therapy. Basically this therapy
can change the way of patients thinking towards his surroundings and how to act their thinking in a
positive way. Refer this patient to clinical psychologist for CBT session.

Socially, we should encourage on the activity that this patient loves to do. As he likes to play
badminton, we should encourage him playing badminton in order to release stress, and not to thinks
too much of his problems.

DISCUSSION

This patient currently presented with depression as he has more than 5 symptoms of depression
includes depressed mood, anhedonia, insomnia, psychomotr retardation, feeling of hopelessness and
recurrent thought of suicide for 2 weeks. These symptoms fit the criteria of major depressive
disorder, however, as he had hypomanic phase in 2011, and has been diagnosed with bipolar
disorder before, so the best diagnosis for him currently is bipolar II disorder in depressive phase.

For his suicide thought, assessment of suicidal risk must be performed to decide wether he needs to
be managed as an outpatient or in the hospital. Based on SAD PERSON Scale:

S: sex (male) = 1
A: Age <20 years, >45 years = 1
D: depression major = 2
P: prev attemps = 1
E: ethanol abuse = 1
R: rasional thinking loss (psychosis) = 1
S: Separated / single = 1
O: Organised plan = 1
N: No support system = 1
S: sickness (chronic illness) = 1

In this patient, he is male, has major depression, had previous attmeps and single make the total of
his score of 5. He can be managed as inpatient and must be monitored closedly in the ward.

Admission criteria for admission of bipolar disorder is based on Malaysian Mental Health Act 2001
(Act 615) and Regulations which are

o Risk of harm to self or others

o Treatment is not suitable to be started as outpatient
As this patient has medium risk of suicide and he requested to do ECT, the best way to manage him is
as an inpatient.

For managing him, it is quite chalenging as he has multiple episodes of relapse due to non-
compliance to medicatio, he has history of overdosing himself with his medication, also he has a lot
of side effects with the medications. The choice to manage him with medication has been narrrowed
due to these factors.

The factors that can be identified which probably be the reason of his frequent relapse, he is not
compliance to his medication. He claimed that he forgot to take it especially the night medication,
because of tiredness. Here, the importance of family support takes place. The brother should always
serve the medication for him so that he can go to remission state. However, due to his lack of
support system, which his brothers had been busy with their own matters, this patient has been left
behind. He also has lost his mother 5 years ago which was the starter of his suicidal thought. After his
mother passed away, he has frequent relapse with suicidal attempts. Moreover, he has borrowed
some money from his friend which indirectly act as an addition to the current problems.

Ideally, according to guidelines, treatment of acute bipolar depression includes combination of mood
stabilliser and antipsychotics has showed to be significantly efficacious. Mood stabilisers such as
lithium and lamotrigine is effective for acute depression. Anti[sychotic such as Quetiapine,
olanzapine is also effective in acute depression. Pertaining to this case, this patient had received
lithium before, however had been off due to overdosing himself. So he had received lamotrigine up
to 200mg. He has develop rash with lamotrigine if the dose is higher than 200 mg. So this current
admission, doctor has planned to restarted him back with lithium as an add on the lamotrigine.
Currently he was not on any anti-depressants as he has develop side effects. He had tried
fluvoxamine but has side effects of nausea and vomiting. He also had been on Mirtazapine but was
off also due to side effects. However, lamotrigine has an antidepressive effect also. He was currently
on 2 anti-psychotic which are Olanzapine and Quetiapine. These medications have sedative effect
which can help with his insomnia.

REFERENCES

1. Kaplan and Sadockss synopsis of psychiatry, 11th edition

2. CPG management of Bipolar Disorder in adult, July 2014
3. Howland RH, Journal of Psychosocial Nurs Mental Health Service, 2010, Potential adverse
effects of discontinuing psychotropic drugs. Part 3: Antipsychotic, dopaminergic, and mood-
stabilizing drugs.