Case Presentation

Dr. Hawari team

Presented by:
Dr. Ali mohammed Bahathig
Aim:
 This case was presented for:

management purposes
HISTORY
 35 year old saudi male, single, major, lived in
Riyadh with his Family.
 Informants were patient’s Father & brother.
 Brought by his family & policeman.
 Chief complaints:
 Abnormal believes.
 Isolation.
 These symptoms started 2 months ago.
History of present illness:
 Patient was in his usual state of health till 2
months ago when his family observed that:
Isolated.
Easily provoked.
Preoccupied.
Having idea that his colleagues are detectors, especially
one of his close friends.
(they want to recruit him)
Later on, he said that his father also works as a detector.
Talking non sense with his father about this issue.
 Accordingly, he started to react with this idea:
Not drinking or eating with them.
Excessive checking of TV, radio….etc
 He left his home and stayed in a flat.

 His family discovered incidentally that he was

Abusing cannabis and
absent from his work
 When he felt that his family knew his location, and
his brother confronted him regarding cannabis abuse.
 He threatened his family.
 Then he left his flat and stayed in a hotel.
 The family went to check the flat and found that he
covered the TV and all mirrors, disassembled the
receiver.
 finally, he escaped from Riyadh.
 He went to Jaddah & Taif & lived in hotel their.
 His family brought him to Riyadh by police & he was
arrested for 24 hours.
 There was no hx of depressive symptoms.
 There was no hx of manic or hypomanic
symptoms.
 No other psychotic symptoms.
 No death wishes or suicidal ideas.
 Past Psychiatric history:
 There was no psychiatric illness before
 Medical& Surgical history:
 Patient not known to have any medical illness.
 No surgical history
Family history:
 Father 69 year old hypertensive, retired from
ministry of higher education.
 Mother 65 year old Hypertensive, diabetic,
housewife.
 He had 6 brothers& 2 sisters, he is the 5th
among them.
 Older brother has a psychiatric illness.
 Personal history:
 Attended school at 6 years of age.
 Excellent performance.
 Good relationships with his teachers and siblings.
 Graduated from Air forces school.
 Premorbid personality assessment:
 Introverted, sociable
 Stable relationships with his friends.
Mental state examination:
 Appearance:
 Young male, around his stated age,
accepted grooming & hygiene. Guarded,
not cooperative.
 Talk:
 relevant ,↑ tone &volume.

 Mood:
 irritable.
 Though:
 No formal though disorder
 Denied any abnormal thought or perception.
 Denied any substance abuse.
 Denied death wishes, suicidal idea or homicidal
tendency.
 Cognitive function: intact.
 Insight: poor insight.
Impression:
 Axis 1: DDx: Substance induced psychosis
Schizophreniaform
Delusional disorder
 Axis 2: deferred.
 Axis 3: nil.
 Axis 4: no obvious stressor.
Plan:
 Admit this patient:
clarify the diagnosis
stabilize this patient
 Basic investigation + urine toxicology
 start olanzapine 10 mg Po Nocte
 Provisional diagnosis:

Delusional disorder
Hospital course:
 First month:
aggressive, guarded, argumentative, isolated
poorly insighted.
denied any drug abuse
asked to be discharged or transfered to RKH
he refused : to take his medication.
to be visited by his family.
to talk about his problem.
He claimed that his family want to control his
life, they are forcing him to do things against
his well and they admitted him as a
punishment.
He claimed that the treating team is against
him and they are not real doctors.
Also he claimed that there was conspiracy
between his family and treating team.
 Urine sample was +ve for cannabis
 Plan:
Olanzapine ↑ to 20 mg PO Nocte.
Clopixol accuphase 100 mg IM Q3/7 as PRN
 Second month:
Patient still the same
Still refusing any visitor
Started to take his medication easily.
 Plan:
personality assessment → He Refused
D/C Olanzapine
strated Risperdal
 Third month:
 At beginning : patient show some improvement:
More sociable
Interacting well
Taking his medication easily
 But, still refusing any visitor.
To be transfer to RKH.
 Patient deteriorated again.
He started again to be uncooperative
He refused to be seen by any doctor
Refused to attend ground round
Started to be suspicious toward treating
team, nursing staff and some patients????
Not interacting with other patients and
Praying alone.
 Plan:
continue on Risperdal 6mg Po Nocte
start Risperdal consta 25 mg IM Q2/52
 Forth month:
 Patient still the same
uncooperative, argumentative
refuse to see us or his family
 He claimed that he had a wife & 1 baby
( his family wanted him to be separated from
his wife & to get married with another
woman)
 He wandered how could we brake the rules,
and keep him for this long period without any
obvious reason.
 He is not satisfied with our treatment.
 Still want to be transferred to RKH.
Thank you