MULAGO HOSPITAL MENTAL CLINIC

MAKERERE UNIVERSITY, KAMPALA

COLLEGE OF HEALTH SCIENCES

DEPARTMENT OF PSYCHIATRY

(A case write up on schizophrenia)

Student: MUSIIME HAROLD

Registration #: 12/U/695

Tutor: Dr. BIRUNGI CAROLINE

Ward: Psychiatric clinic

Date: 10th/02/2016

PATIENT DEMOGRAPHIC DATA:

Name: Nandaula Hajarah

Age: 21 years

Sex: female

Address: Kitagobwa

Tribe: Muganda

Occupation: None

Religion: Muslim

Next of kin: None

Informant: Nandaula Hajarah
Marital status: single
Education level: Ordinary level(senior one)
Source of referral: home
PRESENTING COMPLAINTS

Hearing voices for 7/12 months

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Sleeplessness for 3/12 months

Wandering away from home for 2/52 weeks

HISTORY OF THE PRESENTING COMPLAINTS

The patient was well until 7 months ago when she started hearing voices. The voices were
commanding her to undress and walk naked and also to go and eat from rubbish pits. She also
reported hearing voices of about three people talking about her, the voices claimed that she was ugly
and that she had a body odor. She however does not know the people talking. She reports no history
of hearing voices commenting about her activities.

The patient also reports seeing snakes and when she screams for help, people who come to help only
see either a rope or a string being mistaken for a snake. She reports fear of cars along the road that
they might be following her and people in the cars might harm her. She reports that one night when
she was going back home, some people caught her and cut off her nipples and external genital parts
but now they are growing. She however reports no history of thought insertion, thought withdrawal,
thought echoing and broadcasting. The patient reports wandering away from home. This was because
of the fear she had after the voices told her that the villagers wanted to kill her for reasons she did not
know. She reports having been imprisoned for one day after beating a lady in the neighborhood for
insulting her mother

The patient reports having reduced sleep. She reports that sometimes the voices tell her not to sleep.
This is because the people talking in the voices a not asleep but busy working to earn a living and also
she should do the same thing. She reports history of feeling sad, reduced energy and suicidal ideations
at times. However, she reports no history of agitation, inflated self-esteem, feeling worthless, no loss
of appetite. There is no history of history of alcohol or substance abuse, epilepsy/seizures or loss of
consciousness, past serious life threatening fevers.

N.H’s illness could be to the early separation of her parents, it could also be due to the history of
mental illness in the family. The patient stopped in senior one because of her illness. She is currently
staying home and helping her mother with house chores.

PAST PSYCHIATRIC HISTORY

This is her fifth episode, the first being in 2006. During the first episode she was hearing voices
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commanding her to do things she did not want such as walking naked. She was treated and became fine
for some time. She remembers having been talkative, irritable and restless in certain episode last year.
She however claims not to be remembering everything that happened in each episode and when she
had them. Most episodes have been managed at the outpatient except for only two at which occasion
she was admitted in Mulago mental hospital. She does not remember why she was admitted. She
reports feeling well in between the episodes after taking her medications. She only remembers three
drugs that she has been using i.e chlorpromazine, carbamazepine and artane.

PAST MEDICO-SURGICAL HISTORY

She is HIV seronegative and reports having tested some time back(not sure of exact month) late last
year. She does not know her syphilis status. She has no history of chronic medical illnesses such as
epilepsy, thyroid disease, diabetes and among others. She reports having been knocked by a car when
she was still in her primary one however she did not sustain any major trauma, only a laceration on the
upper lip because the car was not in high speed. No history of operations involving the head and blood
transfusion.

FAMILY-SOCIAL HISTORY
She reports both her parents being alive. They however divorced for reasons she does not know. She is
currently staying with her mother. She is the fourth born of the six children, two boys and four girls.
All her siblings are well and do not have any mental illness. She reports that she has a good
relationship with them. She reports that one of the uncles on the paternal side has a mental illness and
he is on medication.

PERSONAL HISTORY
Birth history
She could not account for this history. She claims that her mother never told her circumstances
around her delivery.
Childhood history
She was generally a quiet, social girl who was soft-spoken and with relatively low self-esteem and
not shy. She was confident and not easy to tease. She reports no history of any form of child abuse.

School history
She studied up to senior one. She reports having had many friends. They used to play many games
including hide and seek and net ball. She was never bullied.
Occupational history
She has no job but reports that her mother is trying to find her one. She however does her house
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work very well and this impresses her mother.
Sexual history
She reports that she is and has never been interested in any man and has never engaged in any
sexual act of whatever kind.
FORENSIC HISTORY
She reports having been imprisoned for one day after beating a lady in the neighborhood because she
insulted her mother. She has never been taken to local council leaders.

MENTAL STATE EXAMINATION

General Appearance and Behavior

Young lady who does not look to be of her stated age of 21 years; she is of average size, well
nourished and well dressed in clean clothes, her hair is well braided. She was calm and kept eye
contact during the interview. There were no mannerisms or other abnormal movements noted

Speech
She is fluent in language. Speech is organized and does not wander from the question asked.
The speech is of average rate, loud and well articulated.

Mood and Affect

The affect is blunted and congruent with the mood.

Thoughts
Form: coherent and logical.
Content: She has nihilistic and paranoid type delusions, but no delusions of reference, erotomanic type
delusions, no jealous type delusions, and no somatic type delusions.
Alienations: Has no thought insertions, thought withdrawal, thought broadcasting, or thought echoing..
Perceptions
She has both auditory and tactile hallucinations, but no visual hallucinations, no olfactory
hallucinations, no gustatory hallucinations and no somatic hallucinations. She has illusions. She has
no derealisation or depersonalisation.

Cognition
Orientation: She knows where she is, date and time.
Memory: After telling her three words: Cow, Cup and Blanket, she is able to repeat them.
Attention and concentration: When she is able to subtracts 3 from 20, and she spelt the word ‘world’
backwards.

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General knowledge: She knows only Museveni of all the people contesting to be president.
Judgment and Abstraction: If she had seen a baby in the middle of the road and a car coming toward
the baby, she would pick the baby from the road so that the car does not knock the baby.
Insight: She has good insight because she knows that she is sick.

SUMMARY
Nandaula Hajarah, a 21 year old female Muganda from Kitagobwa who is single and HIV
seronegative presented with 7 month history of hearing voices commanding her to walk naked and eat
from rubbish pits. Voices sometimes talk about her as being ugly and smelling badly. She has
illusions of seeing a rope as a snake. She fears cars along the road because she believes they have
people who intend to harm her. She has reduced sleep also due to voices commanding her not to sleep.
Wandering aimlessly away from home because of fear of being killed by villagers. She has no history
of thought insertion, withdrawal, broadcasting or echoing. She has history of feeling sad, reduced
energy, suicidal ideations but with no agitation, feeling of worthlessness, no loss of appetite, no
inflated self esteem. There is a family history of mental illness on the paternal side. She dropped out
of school because of her illness Young lady looks not of her stated age of 21 years, average size,
smartly dressed, she oriented in place, time and date. Good concentration and attention.

PHYSICAL EXAMINATION
She is a young lady of average size. She is afebrile to touch. She has no jaundice, no pallor of skin or
mucous membranes, no cyanosis, no finger clubbing, no oedema, no lymphadenopathy, and no
dehydration

DIAGNOSIS

Axis I Diagnosis:
 Principle diagnosis:
Schizophrenia (In view of: paranoid delusions , auditory and tactile hallucinations , affective
blunting and illusions and duration of the symptoms is greater than six months.)
 Differential diagnosis:
1.Acute psychotic episode. (In view of: paranoid delusions , auditory and tactile hallucinations ,
affective blunting and illusions but duration is not less than one month.)
2. Major depressive disorder.(In view of History of sadness, reduced energy ,suicidal ideation)
3. Schizoaffective disorder. (In view of symptoms which meet the criteria for schizophrenia, and
some mood symptoms though these do not meet the criteria for a mood episode.)
4. Schizophreniform disorder. (Though criteria met for schizophrenia the duration of symptoms is
less than one month)
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5. Brief psychotic disorder. (Though criteria met for schizophrenia and the duration of symptoms is
less than 1 months it has now been interrupted by medical intervention.)
6. Substance induced psychosis. (Nanduala reports no history of alcohol use or drug use)

Axis II Diagnosis: paranoid personality

Axis III Diagnosis: Though patient reports none I wish to rule out HIV, Syphilis, Thyroid disease,
cerebral tumour, Wilson’s disease, and Huntington’s chorea.

Axis IV Diagnosis:
o Predisposing factors:
 Poverty.
o Precipitating factors:
 Stress of parents separating
 Poverty.
o Perpetuating factors:
 Unmarried..
 Poor social support..
o Protective factors:
 Florence currently has no disabling medical illness, family support.

Axis V Diagnosis:
Nandual behaviors are not influenced by delusions and hallucinations. She is able to function well in
almost all areas. Score >50 of the Global Assessment of Functioning (GAF) Scale.

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INVESTIGATIONS
Investigati Immediate Short term Long term
Biological  Routine (RFTs,   CBC, RFTs
Extended electrolytes, Differential &Extended electrolytes,
LFTs, CBC) WBC count (if LFTs
clozapine annually
 HIV and Syphilis test used) weekly  Differential WBC
(TPHA) 18 count (if clozapine used)
 T3, T4, TSH ( to x /52. after the 18/52, fortnight
rule out thyroid disease)  Blood up to
pressure 1 year.

 CT scan (to rule out a monitoring  Blood

cerebral tumour) during dose lipids and
 Serum ceruloplasmin (to titration. weight at 3/12,
rule out Wilson’s disease) then annually.
 Other baseline  FBG at
investigations (Blood lipids and 4-6 months
body weight, Fasting blood then annually
glucose (FBG), ECG, Blood (more frequent
pressure measurement, for olanzapine
Prolactin concentration). & clozapine).
 Blood
Psychological Positive and Negative PANSS PANSS
Symptoms Scale. (PANSS)

Social Collateral history from next of Collateral history Follow-up

kin ( Nyangoma Jennifer). from other reports from
family members family
and neighbours members and
neighbours at
home.

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MANAGEMENT

Nandaula is to be managed as an outpatient because:

 Her behavior is not influenced by her delusions and hallucinations.
 She is able to function well in almost all areas.
Management Immediate Short term Long term
Biological -Antipsychotic: -Dose adjustment or switching -Dose adjustment or
-Typical: Tabs Haldol drugs if necessary. switching drugs if
10 mg b.d OR -Continue p.o. antipsychotics necessary. (Consider
Chlorpromazine OR for 3/52. Clozapine if
Stelazine. OR -Start depot antipsychotic ( IM Intractable
-Atypical: Tabs Schizophrenia) OR
Haldol decanoate 100mg
Olanzapine 10mg o.d monthly OR IM Fluphenazine -Continue depot
OR Risperidone) decanoate 25mg q2weeks). antipsychotic
-Tabs Artane 2mg b.d medications.
-Continue Artane.
(Management of -Continue Artane.
extrapyramidal
symptoms due to
typical

medical conditions
found from
investigation.
Psychological -Psychoeducation - Cognitive-behavioural -Follow up of the
about her illness and Therapy (CBT): encourage the patient to ensure
the purpose of patient to stop responding to sustainability of the
medication. the voices. behavior.
-Interpersonal psychotherapy. -Interpersonal
-Family therapy psychotherapy.
-Family therapy
-Group therapy
(Uganda
Schizophrenics

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 Social -Educating the patient -Educating family members -Discharging the
about her illness. about the patient’s illness. patient.
-Emphasizing the role -Seeking family support for the -Following up the
of drugs to the patient. patient in management of the patient, to monitor
condition e.g. reminding the her progress.
patient to take medications.
-Talking to the husband to
support the children and

PROGNOSIS
The prognosis in my patient is good. Because she has social support, does not use any substance, the
patient herself knows that she is sick and comes to hospital for medication and review at the time she
is scheduled to come.

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CASE DISCUSSION

Nandaula Hajarah, a 21 year old female with psychotic episode most likely Schizophrenia.
Schizophrenia is a chronic relapsing illness that has a downward clinical course from the onset and
starts with positive symptoms then ends with negative symptoms . It can be subtyped into:
a. Paranoid Type: Patient is preoccupied with particular delusions or hallucinations but does
not show a major disturbance of speech or behavior (e.g. catatonia). Nandaula certainly had this
type.
b. Disorganized Type: Disorganized speech and behavior and a flat or inappropriate affect are
all common
c. Catatonic Type: There are disturbances of motor activity.
d. Undifferentiated Type: Schizophrenia in which the criteria for Paranoid, Disorganised or
Catatonic Type are not met.
Epidemiology:
Our patient is a young adult, and Schizophrenia affects people in their late adolescence or early
adulthood. It is equally distributed among men and women.
Diagnosis:
The condition was diagnosed basing on the patient’s symptoms below which fulfilled the Criteria
required by the DSM-IV-TR:

A. Characteristic symptoms: history of the following symptoms. (DSM-IV-TR

Required atleast 2)
1. Delusions
2. Hallucinations
3. Disorganized speech (e.g. frequent derailment and incoherence)
4. Grossly disorganized behavior.
5. Negative symptoms, i.e., affective flattening, alogia.
B. Social/ Occupational dysfunction: Nandaula stopped studying because of her illness.
C. Duration: The disturbance has persisted for over 6 months according to the patient (DSM-
IV-TR required at least 6 months).
D. Schizoaffective and mood disorder exclusion: Major Depressive, Manic and Mixed Episodes
were ruled out according to the patient’s history.
E. Substance/general medical condition exclusion: has no history of alcohol use.
F. Relationship to a Pervasive Developmental Disorder: There is no history of Autistic Disorder
or any other Pervasive Developmental Disorder according to Nandaula

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Aetiology:

No single cause has been identified for Schizophrenia in general several genetic and multiple
environmental factors interact to affect the brain development.

Genetics: From Nandaula’s family history, she may have been genetically predisposed though
further investigations will be required to confirm this report.
Anatomical: Brain scans and histology may show ventricular enlargement and disorganized
cytoarchitecture in the hippocampus, supporting the neurodevelopmental theory of aetiology.

Biochemical: Dopamine receptors are up regulated in the mesolimbic system, but the serotonin
system may also be involved..

Clinical features:
Nandaula had the following first rank symptoms of Schizophrenia as Described by Kurt
Schneider
a German Psychiatrist:
 paranoid delusion perception with nihilistic features
 auditory hallucination
 tactile hallucination.
Though she did not have a disorganized speech or Somatic passivity which are also Schneider’s
first rank symptoms.
She also had some negative symptoms of schizophrenia including affective blunting. Other
negative symptoms like to occur include Alogia and Avolition and anhedonia.

Investigations:
Investigations are biological, psychological and social and are done with the following purposes:

 Ascertain the diagnosis.

 Rule out other possible causes of the presentation (differential diagnosis) e.g. HIV,
Syphilis, Cerebral tumour, Wilson’s disease.
 Determine severity of the illness e.g. using the Positive and Negative Symptom Scale
(PANSS)
 Monitoring treatment with antipsychotics so as to guide management.

 Assess progress in treatment e.g. using PANSS.

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Management:

Patient should be managed biologically, psychologically and socially. The biological

management includes:

 Antipsychotic (Neuroleptic) drugs. Which may be:

 Typical antipsychotics:
o Phenothiazine derivatives can be divided into 3 main groups.
o Group 1: chlorpromazine, levomepromazine (methotrimeprazine), and
promazine.
o Group 2: pericyazine and pipotiazine.
o Group 3: fluphenazine, perphenazine, prochlorperazine, and trifluoperazine.
o Butyrophenones (benperidol and haloperidol);
o Diphenylbutylpiperidines (pimozide);
o Thioxanthenes (flupentixol and zuclopenthixol).
o Substituted benzamides (sulpiride).

 Atypical antipsychotic: amisulpride, aripiprazole, clozapine, olanzapine, quetiapine,

risperidone, and zotepine.
 Antimuscarinics like Trihexyphenidyl (Benzhexol/ Artane) should be given to manage the
Extrapyramidal symptoms due to typical antipsychotics and some atypical ones like Risperidone.

Prognosis:

The prognosis of schizophrenia is variable. A review of treatment studies suggests that 15-25%
of people with schizophrenia recover completely; about 70% will have relapses and may develop
mild to moderate negative symptoms, while about 10% will become seriously disabled.

REFFERENCES:

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 Linford Rees, Maurice Lipsedge, Chris Ball, 1997, TEXTBOOK OF PSYCHIATRY,
Page 66-69.
 American Psychiatric association, 2000, DESK REFFERENCE TO THE DIAGNOSTIC
CRITERIA FROM DSM-IV-TR, Page 153-166.
 Parveen Kumar, Michael Clark, 2009, KUMAR & CLARK’S CLINICAL MEDICINE,
6th Edition, Page 1307-1309.-

End.

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