1. What is the significance of Harvey’s suspicion of his wife having an affair?

The patient may be experiencing jealousy? But needs to be further evaluated if

pathological (othello's) through HPI and reason behind the suspicion?
 Baka makatulong ito? Delusional disorder with delusions of infidelity has been called
conjugal paranoia when it is limited to the delusion that a spouse has been unfaithful.
The delusion usually affects men, often those with no prior psychiatric illness. Marked
jealousy is thus a symptom of many disorders-including schizophrenia, epilepsy, mood
disorders, drug abuse, and alcoholism.

> Anxiety
> Overvalued idea 

2. What is a delusion? What are the different types of delusions? Give one
example for each. Differentiate delusion from overvalued idea.  Differentiate
delusion  from hallucination.

Delusions - fixed beliefs that are not amenable to change in light of conflicting
evidence. 
 Express a loss of control over mind or body are generally considered to be
bizarre 
 Persecutory delusions -  most common (DSM-V);  belief that one is going to be
harmed, harassed and so forth by an individual, organization or other group.
 Referential delusions -  belief that certain gestures, comments and environmental
cues, and so forth are directed at oneself
 Grandiose delusions - when an individual believe that he or she has exceptional
abilities, wealth or fame
 Erotomanic delusions - when an individual believes falsely that another person is
in love with him or her
 Nihilistic delusions - conviction that a major catastrophe will occur
 Somatic delusions - focus on preoccupations regarding health and organ function
 Othello’s syndrome - most common delusional disorder and more common in
men; they think their partner is cheating on them.

Delusion vs. Overvalued idea 

 Difficult to make
 Depends in part on the degree of conviction with which the belief is held despite
clear or reasonable contradictory evidence evidence regarding its veracity

Delusion vs. Hallucinations

 Hallucinations are perception-like experiences that occur without an external
stimulus; these occur in the context of a clear sensorium
 Delusions are beliefs…

3. Give four (4) common psychiatric disorders that have delusion as a prominent
symptom.
I. Delusional Disorder (0.2% lifetime prevalence)
 A. The presence of one (or more) delusions with a duration of 1 month or
longer.
B. Criterion A for schizophrenia has never been met.
1. Note: Hallucinations, if present, are not prominent and are related
to the delusional theme (e.g., the sensation of being infested with
insects associated with delusions of infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is
not markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been
brief relative to the duration of the delusional periods.
II. Schizophrenia (0.3%-0.7%)
A. Two (or more) of the following, each present for a significant portion of
time during a 1 -month period (or less if successfully treated). At least one
of these must be (i), (ii), or (iii):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
B. Level of functioning in one or more major areas, such as work,
interpersonal relations, or self-care, is markedly below the level achieved
prior to the onset
C. Continuous signs of the disturbance persist for at least 6 months. 
1. 6-month period
a. must include at least 1 month of symptoms (or less if
successfully treated) that meet Criterion A (i.e., active-phase
symptoms) 
b. may include periods of prodromal or residual symptoms.
During these prodromal or residual periods, the signs of the
disturbance may be manifested by only negative symptoms
or by two or more symptoms listed in Criterion A present in
an attenuated form (e.g., odd beliefs, unusual perceptual
experiences).
III. Brief Psychotic Disorder (9% prevalence)
A. Sudden onset
B. Presence of one (or more) of the following symptoms. At least one of
these must be (i), (ii), or (iii):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
C. Duration of an episode of the disturbance is at least 1 day but less than 1
month, with eventual full return to premorbid level of functioning.
IV. Schizophreniform Disorder (prevalence likely similar with schizophrenia in
developing countries but low incidence in US and developed countries)
 A. Two (or more) of the following, each present for a significant portion of
time during a 1-month period (or less if successfully treated). At least one
of these must be (i), (ii), or (iii):
1. Delusions.
2. Hallucinations.
3. Disorganized speech (e.g., frequent derailment or incoherence).
4. Grossly disorganized or catatonic behavior.
5. Negative symptoms (i.e., diminished emotional expression or
avolition).
B. The total duration of the illness, including prodromal, active, and residual
phases, is at least 1 month but less than 6 months
C. Lack of a criterion requiring impaired social and occupational functioning.
V. Schizoaffective Disorder (0.3% lifetime prevalence) (⅓ as common as
schizophrenia)
A. An uninterrupted period of illness during which there is a major mood
episode (major depressive or manic) concurrent with Criterion A of
schizophrenia.
1. Note: The major depressive episode must include Criterion A1 :
Depressed mood.
B. Delusions or hallucinations for 2 or more weeks in the absence of a major
mood episode (depressive or manic) during the lifetime duration of the
illness.
Medical conditions 
Alcohol-induced psychosis
4. What is the significance of the patient’s symptoms of insomnia, anorexia, and
social withdrawal?
These symptoms might not be specific manifestations or pathognomonic signs
for psychiatric disorders but these sheds light to the functional status of the patient. It
provides insight to the extent of impairment to the social or occupational functioning of
the patient.

5. Which Schneiderian first rank symptom does Harvey exhibit?

Schneiderian first rank symptoms are a set of primary manifestations
encompassing hallucinations and delusions frequently presented by patients with
Schizophrenia. Based on the HPI, the patient is exhibiting delusional perception,
which is described as the attribution of a new meaning, usually in the sense of self-
reference to a normally perceived object.
 DELUSIONAL PERCEPTION

6. Why did it take long for Harvey to be brought to the hospital? What are the
other risk factors that delay consultation or treatment of mentally ill patients?
One of the probable reasons why the patient delayed consult is due to
unawareness of his disrupted thoughts, behavior or illness.
Other risk factors can be labelled as follows:
 Illness related: unawareness of illness, assumed physical causation of illness
and stigma associated with illness
 Patient related: underlying premorbid personality, negative symptoms at onset
of illness are likely to be neglected, poor insight or uncooperative patient
 Family related: shared societal beliefs, cultural constraints, lack of social
support
 Treatment related: poor knowledge of general physicians, poor referral,
misconceptions about medications
 Others: Financial and time constraints

7. What are positive and negative symptoms? What are the prognostic
implications of patients having predominantly positive or negative symptoms?

Positive symptoms - increase in dopamine in mesolimbic pathway; symptoms that a

schizophrenic person has that a normal person does not have 
 Hallucinations - smell of man’s cologne on wife
 Delusions 
o Persecutory - believes that the house was being invaded, newscaster was
talking about him, wife is trying to poison and kill him
o Jealousy - wife is having an affair with the neighbor
 Agitation 
 Disorganized thinking 
 Abnormal motor behavior
Negative symptoms - decrease in dopamine in mesocortical pathway; symptoms that a
normal person has that the schizophrenic person does not have 
 4As
 Avolition - stopped doing household chores and observed to be lying in bed most
of the time 
 Asociality - self isolation  
 Anhedonia - flat affect, loss of interest, alogia
 Affect

Better prognosis for patient with positive symptoms than negative symptoms 

8. How would you handle Harvey’ agitation and anxiety if he arrived for
consultation in such a state?

 Ensure safety of patient, staff, and self

 Move to a safer environment and consider factors that may cause said
symptoms 
 Verbal de-escalation -> physical restraint or pharmacological intervention ->
proceed to medical interview and examination -> diagnosis 

9. What items in the MSE were included in the assessment? For Harvey, what
were seen in the different items of the MSE?

 Appearance, Behavior and Attitude – Appropriately dressed and slightly agitated

(“slightly agitated” can be indicative of poor impulse control)
 Mood – Anxious and slightly depressed
 Affect - Constricted mood-congruent affect
 Perceptions - Denied any perceptual disturbances
 Thinking - He was jealous of their neighbor. He was convinced that his wife was
having an affair with him. (delusion of infidelity)
 Sensorium and Cognition - Oriented to three spheres (time, place, and person) ,
able to do serial 7s, intact memory and good abstract thinking 
 Insight – Poor 
o How the patient understands his condition
 Impulse control - poor

10.   What is your initial diagnostic impression based on the history, physical and
mental status examination findings at this point?

Primary Impression: Delusional disorder, Jealousy Type

A. The presence of one (or more) delusions with a duration of 1 month or

longer.
 B. Criterion A for schizophrenia has never been met. Note: Hallucinations, if
present, are not prominent and are related to the delusional theme (e.g.,
the sensation of being infested with insects associated with delusions of
infestation).
C. Apart from the impact of the delusion(s) or its ramifications, functioning is
not markedly impaired, and behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been
brief relative to the duration of the delusional periods.
E. The disturbance is not attributable to the physiological effects of a
substance or another medical condition and is not better explained by
another mental disorder, such as body dysmorphic disorder or obsessive-
compulsive disorder.

History

  3 months PTC
o  Patient thought he smelled a man’s cologne on her (Olfactory
Hallucination) - once lang nangyari though; connected to his
delusion - delusional perception
 2 month PTC
o Patient became hypervigilant and had difficulty sleeping
o Patient started to suspect that his wife was having an affair
(Delusion of Jealousy)
 1 month PTC
o Patient became depressed
o Patient’s insomnia worsened
o Patient became withdrawn (Social Withdrawal)
  2 weeks PTC
o Patient stopped doing chores and was observed lying on the bed
most of the time (Avolition) less than 1 month
o Patient tore green clothing because he associated them with
surgical gowns (Bizarre delusion)
  1 week PTC
o Patient got very angry because he felt the newscaster was making
snide remarks about his manhood, implying he was deceived
(Referential delusion)
o Patient became further isolated
o Patient refused to eat because he believed his wife was going to
poison his food and kill him so that she could marry the neighbor
(Persecutory Delusion) caused by the jealousy
 1 day PTC
o Patient still believed his wife is cheating despite wife’s denial

Physical Examination

 Anxious and slightly depressed

 Constricted mood-congruent affect
  He was jealous of their neighbor. He was convinced that his wife was
having an affair with him

11. What other diagnostic procedures would you request for to confirm your
impression?

CBC, serum electrolytes, urinalysis

Laboratory Findings

CBC, CXR, EKG, urinalysis, fecalysis were all normal. WAIS showed an above average
IQ. Thematic Apperception Test responses centered on a dark, hooded male figure
involving themes of violence and death.

12. What are projective tests? What is their value in psychiatric disorders? What
is the significance of the results in the TAT?

Projective tests are commonly used in the measurement of personality. In a projective

test, respondents must interpret or describe an ambiguous stimulus (as in a Rorschach
inkblot or a Thematic Apperception Test photo), or come up with a drawing in response
to a minimal prompt (“Draw a person”), or say a word in response to a stimulus word (as
in Jung's Word Association Test). 

-Psychological Testing, Overview. Miriam W. Schustack, Howard S. Friedman, in

Encyclopedia of Social Measurement, 2005

The Thematic Apperception Test (adult and children's versions) includes a series of
scenes from which the patient is to make up a story about what is taking place. The
pictures elicit information about interpersonal dynamics and reactions to classic human
situations. This test can be useful in discovering more about family issues and
attachment, relationship issues, mood variables, and body image.

-Psychological Evaluation and Treatment of the Patient with Headache. Randall E.

Weeks, Steven M. Baskin, in Office Practice of Neurology (Second Edition), 2003

The stories that the patient makes up concerning the pictures, according to the
projective hypothesis, reflect the patient's own needs, thoughts, feelings, stresses,
wishes, desires, and view of the future. According to the theory underlying the test, a
patient identifies with a particular individual in the picture. This individual is called the
hero. The hero is usually close to the age of the patient and frequently of the
same sex, although not necessarily so. Theoretically, the patient would attribute his or
her own needs, thoughts, and feelings to this hero. The forces present in the hero's
environment represent the press of the story, and the outcome is the resolution of the
interaction between the hero's needs and desires and the press ofthe environment.

Hostility towards the neighbour 

Fear (threatening their relationship and his masculinity)

13. What are your main differential diagnoses? List each one and explain how you
are able to rule it in and rule it out based on DSM Diagnostic Criteria.  Not quite
sure yet if tama :(

DDx Rule in Rule out

Schizophreniform B. An episode of the disorder A. Two (or more) of the

disorder lasts at least 1 month but less
than 6 months. When the
diagnosis must be made
without waiting for recovery, it
should be qualified as
“provisional.”
following, each present for a
significant portion of time
during a
1-month period (or less if
successfully treated). At least
one of these must be (1), (2),

C. Schizoaffective disorder and or (3):

depressive or bipolar disorder
with psychotic features have 1. Delusions.= PRESENT

been ruled out because either 2. Hallucinations. - patient first

1 ) no major depressive or
manic episodes have occurred
concurrently with the active-
phase symptoms, or 2) if mood
episodes have occurred during
active-phase symptoms, they
have been present for a
minority of the total duration
of the active and residual
periods of the illness.
exhibited signs of
hallucination of the olfactory
sense “smelled another man’s
cologne”
And then auditory
hallucinations - TV
newscaster
3. Disorganized speech (e.g.,
frequent derailment or
incoherence).
4. Grossly disorganized or
 D. The disturbance is not catatonic behavior.
attributable to the physiological
effects of a substance (e.g., a 5. Negative symptoms (i.e.,
diminished emotional
drug of abuse, a medication) or expression or avolition). -
another medical condition. patient exhibited avolition -
apathy, lack of motivation
“stopped doing household
chores, lay in bed all day”
NOT YET 1 MONTH PTC
JUST 2 WEEKS 

 *does this mean 3 are met?

But it does say significant
portion of time during 1 month
period :( halp *

Delusional A. The presence of one (or  

disorder - jealous more) delusions with a duration
type of 1 month or longer.  

B. Criterion A for schizophrenia

has never been met.

Note: Hallucinations, if present,

are not prominent and are
related to the delusional

theme (e.g., the sensation of

being infested with insects
associated with delusions of
infestation).

C. Apart from the impact of the

delusion(s) or its ramifications,
functioning is not markedly

impaired, and behavior is not

obviously bizarre or odd.

D. If manic or major depressive

episodes have occurred, these
have been brief relative to the
duration of the delusional
 periods.

E. The disturbance is not

attributable to the physiological
effects of a substance or
another medical condition and
is not better explained by
another mental disorder, such
as body dysmorphic disorder
or obsessive-compulsive
disorder.

14. Discuss the diagnostic criteria of your primary diagnosis.

The diagnosis of delusional disorders require fulfillment of the DSM-5 criteria.

DSM-5 diagnostic criteria

A.  Presence of one delusional disorder - subtype jealousy. 

B. Criterion A for schizophrenia has never been met.
C. Apart from the impact of the delusions, functioning of the patient is not markedly
impaired, behavior is not obviously bizarre or odd.
D. If manic or major depressive episodes have occurred, these have been brief
relative to the duration of the delusional periods.
E. The disturbance is not attributable to the psychological effects of a substance or
another medical condition and is not better explained by another mental disorder,
such as body dysmorphic disorder or obsessive-compulsive disorder. 

15. What are the biological (anatomical and physiological) bases of this disorder?
What is the neurochemical hypothesis for this disorder?

Genetic predisposition- predisposition to a selective D2 receptor-related

hyperdopaminergia

Brain abnormality in medial frontal/anterior cingulate cortex

Dopamine Theory- release of mesolimbic dopamine neurons from inhibitory control

causes delusions

16. Formulate an acute and long-term pharmacologic treatment plan for this
patient. Based on the ESSC criteria, choose the most appropriate drug for this
patient.
 Drug class E S S C
*first- and second-
generation
antipsychotics are
similarly effective
in the acute
treatment of
psychotic
symptoms

First generation Postsynaptic extrapyramidal symptoms, Oral

antipsychotic blockade of brain tardive dyskinesia, dosing
dopamine D2 hyperprolactinemia, neuroleptic Usually
receptors. malignant syndrome, QT once a
Strong antagonism prolongation, sudden death, day
of D2 receptors in and an increased risk of
both cortical and mortality when used to treat
striatal areas. psychiatric symptoms
associated with dementia in
older adult patients

Second Postsynaptic weight gain and related Oral

generation blockade of brain metabolic effects, dosing
antipsychotic dopamine D2 hypotension, sedation, Usually
or atypical receptors. anticholinergic symptoms, once
antipsychotic Strong antagonism hyperprolactinemia, daily
of D2 receptors in extrapyramidal symptoms
both cortical and (EPS), cardiac effects,
striatal areas. cardiomyopathies, cataracts,
and sexual dysfunction

According to WHO, first generation antipsychotics are the essential medicine for acute
psychotic symptoms because they are safer but in our case second gen was prescribed
 Phenothiazines
Ex. chlorpromazine
 Butyrophenones
Ex. haloperidol
 Injectable long-acting antipsychotics
Ex. fluphenazine

According to the American Psychiatric Association, second-generation (atypical)

antipsychotics (SGAs)—with the exception of clozapine—are the agents of choice
for first-line treatment of schizophrenia.

Drug E S S C
Risperidone Risperidone is a more common side 2 mg tablet 25
benzisoxazole effects of risperidone OD pesos/2m
atypical can include: g tablet
antipsychotic w/ parkinsonism (trouble
moving)
mixed serotonin
akathisia
dopamine (restlessness and
antagonist activity urge to move)
that binds to 5- dystonia (muscle
HT2-receptors in contractions that
the CNS and in the cause twisting and
periphery w/ a very repetitive movements
high affinity; binds that you can’t control)
to dopamine-D2 tremors
receptors w/ less (uncontrollable
affinity. rhythmic movement in
one part of your body)
Pharmacokinetics:
sleepiness and
Absorption: Readily fatigue, dizziness,
absorbed from the anxiety, blurred
GI tract. Time to vision, abdominal
peak plasma pain or discomfort ,
concentration: W/in drooling, dry mouth,
1-2 hr. increased appetite
Distribution: or weight gain, rash,
Distributed into stuffy nose, upper
breast milk. respiratory tract
Volume of infections, and
inflammation of your
distribution: 1-2
nose and throat
L/kg. Plasma
protein binding:
Approx 90%
(risperidone), 77%
(9-
hydroxyrisperidone
).
Metabolism:
Extensively hepatic
via hydroxylation
mediated by
CYP2D6
isoenzyme to 9-
hydroxyrisperidone
(main active
metabolite);
oxidative N-
dealkylation is a
minor metabolic
 pathway.
Excretion: Via urine
(70%) and to a
lesser extent in the
faeces (14%).
Elimination half-life:
20 hr (oral); 3-6
days (IM).

Aripiprazole Aripiprazole is a Common: Initial: 10 mg 140 per

quinolinone GI disorders (e.g. or 15 mg tab
derivative constipation, once daily. 10 mg or
antipsychotic agent dyspepsia, nausea, Maintenance 15mg
which acts as a vomiting); : 15 mg
partial agonist at headache, anxiety, once daily
D2 and 5-HT1A insomnia,
receptors and as lightheadedness,
an antagonist at 5- drowsiness, wt gain;
HT2A receptors. agranulocytosis,
Pharmacokinetics: leucopenia,
Absorption: Well neutropenia,
absorbed from the thrombocytopenia;
GI tract. akathisia, tardive
Bioavailability: 87% dyskinesia,
(oral); 100% (IM). pathological
Time to peak gambling.
plasma Potentially Fatal:
concentration: Neuroleptic
Approx 3-5 hr malignant
(oral); 1-3 hr (IM). syndrome.
Distribution: Enters
breast milk.
Volume of
distribution: 4.9
L/kg. Plasma
protein binding:
Approx 99%
(mainly to
albumin).
Metabolism: Mainly
in the liver via
dehydrogenation
and hydroxylation
by CYP3A4 and
CYP2D6
isoenzymes, and
 N-dealkylation by
CYP3A4
isoenzyme.
Excretion: Via
faeces (approx
55%); urine
(approx 25%)
mainly as
metabolites.
Elimination half-life:
Approx 75 hr
(aripiprazole);
approx 95 hr
(dehydro-
aripiprazole).

Clozapine Used only if all the Agranulocytosis

*not other medications (life-threatening)
recommende are not working
d

Haloperidol Haloperidol is a Extrapyramidal 0.5-5 mg 2-3 4.31

(1st gen)- butyrophenone. It syndrome (e.g. times/day. pesos per
just for nonselectively pseudoparkinsonis Maintenance 5 mg tab
comparison inhibits m, akathisia, tardive : 3-10
postsynaptic dyskinesia, mg/day 25 pesos
dopaminergic D2 dystonia), CNS per 20 mg
receptors in the depression, tab 
brain. anticholinergic
Pharmacokinetics: effects (e.g.
Absorption: Readily constipation,
absorbed from the xerostomia, blurred
gastrointestinal vision, urinary
tract. retention),
Bioavailability: esophageal
Approx 60-70% dysmotility and
(oral). Time to peak aspiration,
plasma somnolence,
concentration: 2-6 orthostatic
hours (oral); 20 hypotension, motor
minutes (IM). or sensory
Distribution: instability,
Crosses the blood- hyperprolactinaemia
brain barrier; .
enters breast milk.
Plasma protein
 binding: Approx
92%.
Metabolism:
Extensively
metabolised in the
liver via oxidative
dealkylation and
ultimately
conjugated with
glycine.
Excretion: Via urine
(30%, 1% as
unchanged drug).
Elimination half-life:
Approx 12-38
hours (oral).

Acute 

It is generally suggested to use one antipsychotic at a time. The concurrent use of two
or more antipsychotics do not provide additional benefit, while it produces additional
adverse reactions and may interfere with treatment adherence. It is generally suggested
to start with low doses, and to increase gradually. The minimum effective dosage should
be prescribed.

Initially 0.25 to 0.5 mg/day; typical maintenance 1 mg/day; maximum 2 mg/day.

Risperidone can be started on 2 mg administered as a single daily dose or 1 mg twice a

day. If this dose is well tolerated (ie, minimal sedation, hypotension, or akathisia) the
dose can be increased to 3 mg on the second day and 4 mg on the third day. Since 4
mg is in the therapeutic range for most patients, the clinician may then choose to
continue this dose for an additional two weeks before considering an increase. If the
patient shows only minimal or no improvement, the dose can be increased up to 8 mg
daily with careful monitoring for clinical response and side effects. Doses of risperidone
above 8 mg daily are associated with substantial risk of EPS.

Treatment effectiveness should be assessed after 6-8 weeks

Long-term

After the acute episode has resolved, health care providers should generally prolong
treatment for at least one year to avoid relapse.

17. Would you agree with the length of time Risperidone was going to be given?
Why?
  No, the length of time is too long especially that the drug is given at a high dose
per day (4 mg instead of 2 mg). This may increase the risk of having
extrapyramidal symptoms, gynecomastia, or hyperprolactinemia.  
 According to Kaplan, Risperidone is given 2 mg per day and is increased slowly. 
This is given in a 6-week trial to determine if the chosen medication is suitable for
the patient. If the patient is responsive to the treatment, medication can be given
in low dose as maintenance to prevent relapses. However, if the patient is not
responsive to the initial drug, the drug should be replaced with antipsychotic
drugs from other classes.
 Doc’s answer: Yes, to ensure remission.

18. When a mentally ill patient becomes agitated or violent, what steps can be
taken to deal with the situation?

o Immediate Physical separation may be needed if a patient is in contact with

another patient/staff member 
o Crowds may exacerbate the patient’s sense of threat, therefore the scene
needs to be clear so as to prevent the agitation of the patient
o De-escalation needs to be observed all the time, and reassuring the patient
and negotiating can help make the agitated patient make negotiations as well
as compromises. 
o Chemical restraints
o Physical restraint (last line)
 Clonazepam as needed
 Bring the patient to the ER immediately

19. What are the guidelines in the management of drug-induced side effects?

1st reduce the dosage.. If side effects are still manifested → switch to another
medication.

SORRY NOT SURE, WALA BOOKS NOR TRANSES

 Weight Gain: 
o Metformin: Facilitate weight loss
 Tardive Dyskinesia (TD)
o S/s:involuntary and irregular choreoathetoid movements
o Altering Treatment
 Using lowest effective dose of antipsychotic
 Prescribing cautiously with children, elderly and patients with mood
disorders
 Examining on a regular basis for evidence of TD
 Considering alternatives to the antipsychotics being used and
considering dosage reduction
 If worsens, discontinuing or switching to a different drug
 Neuroleptic malignant syndrome
 o S/s: muscular rigidity,and dystonia, akinesia, mutism, obtundation and
agitation.
o Tx:
 Supportive medical treatment
 Dantrolene
 Bromocriptine
 Amantadine
 ECT: for antipsychotic drugs with anticholinergic effects
 Neuroleptic-induced parkinsonism
o S/s: muscle stiffness, cogwheel rigidity, shuffling gait, stooped posture and
drooling
o Tx: Anticholinergic agents, benztropine, amantadine, diphenhydramine
 Medication Induced Acute Dystonia
o s/s: Abnormal contraction of muscle
 Oculogyric crises, tongue protrusion, trismus, torticollis, laryngeal-
pharyngeal dystonias and dystonic postures
 Opisthotonus, scoliosis, lordosis, writhing movements
o Tx: Anticholinergics, Diphenhydramine, diazepam, amobarbital, caffeine
sodium benzoate
 Change antipsychotic
 Medication-induced acute akathisia
o s/s: feelings of restlessness, objective signs or restlessness
o Tx: reducing  medication dosage
 B-adrenergic
 Benzo
 Extrapyramidal Side Effects (EPS)
o Altering treatment
 Reduce the dose of the antipsychotic drug
 Adding an anti-parkinson medication
 Changing present antipsychotic medication to an SDA that is less
likely to cause extrapyramidal side effects
o Anticholinergic antiparkinson drugs: most effective anti-parkinson
medications
o B-blockers: For akathisia
o Prophylactic anti-parkinson medications are given if: 
 If considering conventional antipsychotics are being prescribed
 Experienced disturbing EPS
 History of EPS sensitivity
 Being treated with high doses of high-potency drugs
 Young men with an increase vulnerability for developing dystonias

20. What are the common problems of patients with stable condition of this
disorder?

NOT SURE RIN :(((

  Violence such as suicide, homicide and other destructive behavior
 Depression
 Poor judgement and insight
 Anxiety
 Compliance to medications (ex. d/t side effects)
 Medication induced movement disorders

21. What are the psychosocial factors associated with this condition ?

(still not sure ano yung psychosocial factors but these are the psychodynamic factors
enumerated sa kaplan)

Practitioners have a strong clinical impression that many patients with delusional
disorder are socially isolated and have attained less than expected levels of
achievement.

  Paranoid pseudocommunity: an increased expectation of receiving sadistic

treatment, situations that increase distrust and suspicion, social isolation,
situations that increase envy and jealousy, situations that lower self-esteem,
situations that cause persons to see their own defects in others, and situations
that increase the potential for rumination over probable meanings and
motivations
 Psychodynamic  factors:  paranoid patients experience a lack of trust in
relationships. A hypothesis relates this distrust to a consistently hostile family
environment, often with an overcontrolling mother and a distant or sadistic
father. 
 Erik Erikson's concept of trust versus mistrust in early development is a
useful model to explain the general distrust of their environment.
  Defense mechanism:  
 denial to avoid awareness of painful reality
 Projection of their resentment and anger onto others and use projection to
protect themselves from recognizing unacceptable impulses in
themselves.
 Reaction formation as a defense against aggression.

 Other relevant factors: social and sensory isolation, socioeconomic deprivation,

and personality disturbance.

22. What  is  the  value  of  a  biopsychosocial  approach  in  this  disorder?     
What psychosocial  approaches  would  be  appropriate  for  this  disorder?     In 
terms  of individual therapy, which one would be appropriate for Harvey and
why?
  Psychotherapies - establish a relationship in which patients begin to trust a
therapist. Physicians may stimulate the motivation to receive help by
emphasizing a willingness to help patients with their anxiety or irritability
 Biological- In an emergency, severely agitated patients should be given an
antipsychotic drug intramuscularly. Antipsychotic drugs the treatment of choice
for delusional disorder. Hospitalization could also be considered for the need to
complete medical and neurological evaluation to determine whether a
nonpsychiatric medical condition is causing the delusional symptoms. 
 Social- When family members are available, clinicians may decide to involve
them as allies in the treatment plan

Individual therapy seems to be more effective than group therapy; insight-oriented,

supportive, cognitive, and behavioral therapies are often effective. A useful approach in
building a therapeutic alliance is to empathize with the patient's internal experience of
being overwhelmed by persecution. 

Cognitive-behavioral therapy — This approach is suitable for Harvey because this

aims to address his data gathering biases, interpersonal sensitivity, reasoning style,
worry, and insomnia. How he interprets evidence pertinent to delusions will also be
addressed and an alternative nonpsychotic explanation for the phenomena would be
introduced to him. Discussion and critique of the patient’s explanations for delusional
ideas are practical techniques aimed at breaking down the emotional underpinnings that
maintain the idea. 

23. What is the lifetime prevalence of this disorder? What are the genetic predispositions
among family members of a patient with this condition?

SCHIZOPHRENIFORM DISORDER: (Kaplan and Sadock’s)

 Little is known about the incidence, prevalence, and sex ratio of schizophreniform
disorder.
 Most common in adolescents and young adults and is less than half as common as
schizophrenia.
 A lifetime prevalence rate of 0.2 percent and a 1-year prevalence rate of 0.1 percent
have been reported.
 Several studies have shown that the relatives of patients with schizophreniform disorder
are at high risk of having other psychiatric disorders, but the distribution of the disorders
differs from the distribution seen in the relatives of patients with schizophrenia and
bipolar disorders. Specifically, the relatives of patients with schizophreniform
disorders are more likely to have mood disorders than are the relatives of patients
with schizophrenia. In addition, the relatives of patients with schizophreniform disorder
are more likely to have a diagnosis of a psychotic mood disorder than are the relatives
of patients with bipolar disorders.

DELUSIONAL DISORDER:
 The lifetime morbid risk of delusional disorder in the general population has been
estimated to range from 0.05 to 0.1%, based on data from various sources including
case registries, case series, and population-based samples. According to the DSM-V,
the lifetime prevalence of delusional disorder is about 0.02%.
 (https://www.ncbi.nlm.nih.gov/books/NBK539855/#:~:text=The%20lifetime%20morbid
%20risk%20of,delusional%20disorder%20is%20about%200.02%25.)
 Increased prevalence of delusional disorder and related personality traits (eg
suspiciousness, jealousy, secretiveness) in the relatives of delusional disorder probands.
 No increase in incidence of schizophrenia and mood disorders in families of
delusional disorder probands. No increase in incidence of delusional disorder in families
of schizophrenics. (Kaplan & Sadock’s Concise Textbook of Clinical Psychiatry)

Patient Outcome
Insight-oriented psychotherapy and marital counseling were instituted. Harvey continued to
have good compliance to therapy. Risperidone was further decreased to 2 mg 1 tablet qhs and
Biperiden was eventually discontinued. He remained symptom-free as of the last follow-up.

24. What is likely to happen to Harvey? How can relapses be prevented? Discuss the
prognosticating factors in this condition.
Nothing was said about preventing relapse for either diagnoses aside from compliance with
initial therapy.

SCHIZOPHRENIFORM DISORDER:
 Most estimates of progression to schizophrenia range between 60 and 80 percent.
What happens to the other 20 to 40 percent is not known.
 Some will have a second or third episode during which they will deteriorate into a
more chronic condition of schizophrenia.
 Small percentage who may have only a single episode and then continue with their lives
(rare occurrence and should be discussed with the patient and family).
 The psychotic symptoms can usually be treated by a 3- to 6-month course of
antipsychotic drugs (e.g., risperidone). Several studies have shown that patients with
schizophreniform disorder respond to antipsychotic treatment much more rapidly
than do patients with schizophrenia. 
 Patients should be made aware of the possible trial of lithium, carbamazepine, or
valproate for treatment in case of a recurrent episode.
 Psychotherapy is usually necessary to help patients integrate the psychotic
experience into their understanding of their minds and lives.
 Finally, most patients with schizophreniform disorder progress to full-blown
schizophrenia despite treatment. In those cases, a course of management consistent
with a chronic illness must be formulated.
(Kaplan and Sadock’s)

DELUSIONAL DISORDER:The prognosis of delusional disorder is better with treatment

and medication compliance. Almost 50% of patients have a full recovery; more than 20% of
patients report a decrease in symptoms and less than 20% of patients report minimal to no
change in symptoms. A good prognosis is also related to higher social and occupational
functioning, early onset before age 30 years, female, sudden onset of symptoms and short
duration. (https://www.ncbi.nlm.nih.gov/books/NBK539855/#)

Mark of successful treatment may be a satisfactory social adjustment rather than abatement of
the patient’s delusions. (Kaplan and Sadock’s Concise Textbook of Clinical Psychiatry)

Factors that make relapse more likely in any given individual remain poorly understood.
(https://academic.oup.com/schizbullopen/article/1/1/sgaa017/5818975)
25. What advice will you give the patient and his family?

SCHIZOPHRENIFORM DISORDER:
 Education about the increased likelihood of a relative to have mood disorders.
 Patient should be made aware of the possible trial of lithium, carbamazepine, or
valproate for treatment in case of a recurrent episode.

DELUSIONAL DISORDER: The therapist must sympathetically indicate to patients that their
preoccupation with their delusions is both distressing to themselves and interferes with a
constructive life without making disparaging remarks.

The patient and family need to understand that the therapist maintains physician-patient
confidentiality and that communications from relatives are discussed with the patient. The family
should be educated about the disorder and should be encouraged to support the patient. 

Over-gratification must be avoided as this may increase the patient’s hostility and
suspiciousness and that they must realize that not all demands can be met. (kaplan and
sadock’s).