Case Presentation

Dr. Aung Ko Ko
23.1.2020
History was taken from patient and informant, his elder sister,
Daw Htay Htay Myint

Particulars of patient
• U Win Yu Aung
• 43 years old
• Single
• Manual worker, farmer
• 8th standard education
• Shan-Myanmar, Buddhist
• Pay-Kone Village, Ka-Thar Township
• DOA – 20.1.2020
 Reasons of admission / referral

Patient was brought to Mental Health Hospital Mandalay by

family members as he became aggressive and destroyed cycles.
 Chief Complaints
• Low Mood
• Easily close to tears x off and on for 1½ years

• Suicidal thought x 3 times within 1½ years

• Hearing of voices x 1 years

• Became aggressive and
destroyed others’ cycles x 1 month ago
 HOPI
• This is the first time of hospitalization to MHH-Mdy.
• 1 year and 8 months ago, his family had some financial
problem that there was about 20 lakhs of debts.
• So, he went to Phar-Kant to get better income.
• He worked as a manual worker (jade scavenger), but he
could not earn enough money that he expected.
• After 2 months of working, he felt depressed due to that
problems.
• He felt hopelessness and helplessness.
• He also lost his energy that he could not work well.
 HOPI
• He could not sleep well at night due to his worrying thought
about futures.
• He was crying alone at night time during these days.
• He blamed himself for earning no money and he felt guilty.
• The period of low mood was relieved spontaneously
without treatment after 4 days.
• After that, he decided to work under new boss for better
income.
• He said that most of his workmates were not hardworking
and they did not have cooperation.
• So, he could not save any money thought he was working
hardly.
 HOPI
• He experienced recurrent episodes of low mood nearly one
time per months.
• All the episode of low mood recovered spontaneously after
3-5 days, and he could work well between episodes.
• He had suicidal thought for 2 time during these episodes.
• He thought to do suicide by drinking all the traditional
medicine he had.
• But he did not follow his thought and he could resist the
suicidal thought.
 HOPI
• 1 years ago, he heard the voices of “Ko-Myo-Lwin” when
no one was around.
• The voices accused him as a thief, and also threatened him.
• When he saw Ko-Myo-Lwin and his teams, he believed that
they were taking about him.
• He believed that Ko-Myo-Lwin was spreading his news to
others that he had stolen a jade stone of Ko-Myo-Lwin.
• He also believed that Ko-Myo-Lwin and his teams were
following him, spying him and they would endanger his
life.
• So, he became frightened and came back home.
 HOPI
• After coming back home, he still heard the threatening
voices of Ko-Myo-Lwin and one unknown woman.
• He was frightened due to that voices.
• He had suicidal thought again because he could not
withstand the voices any more, but he could resist and did
not act according to the suicidal thought.
• The family members also noticed that he was very
frightened 1-2 months after coming back from Phar-Kant.
• After that, he became familiar with the voices and he could
work well.
 HOPI
• But, the voices became more severe and he heard almost the
whole day, except sleep time.
• The voices contained sexual related topics and bad thing
about him.
• Sometimes, the voices were commanding him to shout
abusive words to others.
• 3 months ago, he went to police station and asked to arrest
Ko-Myo-Lwin for disturbing him.
• He believed that all of his thought were known by other
people, and so Ko-Myo-Lwin and the unknown woman
were able to disturb him with voices.
 HOPI
• He also believed that some of relatives and neighbors were
talking bad things about him together with Ko-Myo-Lwin.
• So, he sometimes shouted abusive words to relatives and
neighbors within 3 months.
• He admitted that he still felt recurrent episode of low mood
that sometimes make him cry.
• He experienced low mood one time in every 1-2 months
each last about 3-5 days like previous episodes.
• However, he said that his previous low mood were due to
financial and job problems and the later ones were due to
disturbing voices of Ko-Myo-Lwin.
 HOPI
• 1 month ago, several men were fishing near his house and
he believed that these men were talking bad things about
him.
• So, he told them to go away from his house.
• They neglected his request and so he became aggressive and
destroyed their 2 cycles.
• There was no offence, but the family had to pay
compensation for damaged cycles.
• The family members brought him to spiritual healer and
treated him for 1 month.
• After that, he was brought to MHH-Mdy.
• Today is 3rd day of hospitalization and hearing of voices
were reduced.
 Family History
• Father – U Hla Shein, died at the age of 77, 3year ago, due
to unknown cause.
• Mother – Daw Tin, 75 years, 4th standard education,
dependent, alive and healthy.
• Patient is the youngest of 5 siblings.
• 1st - Daw Than Nyo, 50 years, single, 4th standard
education, farmer.
• 2nd - Daw Than Cho, 49 years, married, Graduated with
Master Degree, Lecturer at Oriental Studies Department,
Meikhtila University.
• 3rd - Daw Htay Htay Myint, 47 years, married, 8th standard
education, shop keeper.
• 4th - U Soe Yu Aung, 45 years, married, 8th standard education,
farmer.
• Youngest – patient.
• Now patient lives with his mother and 3rd sister, and has good
relationship with family members.
• Denied history of mental illness in family members.
• GSS – below average
 Personal History
• Patient was delivered normally at full term with BF
• No prenatal, intra-natal and postnatal complication
• He had normal developmental mile stones
• During childhood, he was healthy and no history of fit,
head injury, TB and major illness.
• No history of bed wetting, temper tantrum and nail biting.
 Schooling
• Schooling started at the age of 6 years and passed yearly up to
8th standard.
• He quit school to help in family jobs.
• During schooling, he denied history of truancy and substance
abuses.
• He enjoyed his school life and had good relationship with his
friends and teachers.
 Occupational History
• After leaving from school he worked as a farmer in family
job for 25 years.
• 1 year and 8 months ago, he worked as a manual worker
(jade scavenger) at Phar-Kant for 8 months.
• He came back from Phar-Kant due to mental illness, 1year
ago.
• After coming back home, he worked as manual worker at
electricity distribution company for 3 months.
• Then he work as a farmer in his brother’s farm.
• He cannot work for 1 months because family member did
not let him work.
 Marital History
• He is single.
 Substance History
Alcohol history
• At first, he was an occasional drinker.
• He started to drink at 20 year of age and he only drink 1
time per 2-3 months.
• On each time, he drink 1-2 peg of country spirit.
• While he was working in Phar Kant, his drinking became
increased due to tiredness.
• He drunk ¼ to ½ bot of ‘Kachin country spirit’ per day
and 4-5 days per weeks for 8 months.
 Substance History
• He drunk alcohol only in the evening, after coming back
from work, to relieve muscle ache and tiredness.
• He denied withdrawal symptoms during the day without
alcohol.
• He could work well and there was no working problem
due to alcohol.
• He denied morning drinking.
• He gave up alcohol after coming back from Phar-Kant
• Last drink was 1 year ago.
 Substance History
Opioid use history
• He used opium 2 time in his life.
• He ingested about a peanut grain size of opium one time
per day for 2 day, 1 ½ year ago, while working in Phar-
Kant.
• He used opium to relieve pain from injuries of fall from
height.

Betel chewing (+) – 7-8 pieces par day

Denied smoking and other substance abuse.

 Past Medical History

• Denied history of Diabetes, hypertension, Hepatitis,

Gastritis, TB and epilepsy.
 Past Surgical History
• History of injury to both wrist joints and multiple
abrasion injuries over the body due to fall from height
(about 20 feet), 1 ½ year ago.
• There was no history of head injury and loss of
consciousness.
• He used opium to relieve pain from that injuries.
 Past Psychiatric History
• This is the first time of hospitalization to MHH-Mdy.
• Denied previous history of manic episode.
 Drug History
• NKDA
 Forensic History
• Denied history of arrest, conviction and imprisonment.
 Premorbid Personality
• He had good relationship with his family members and friends.
• His predominant mood is cool and calm, and he only has few
friends.
• He is not sensitive, quarrelsome and suspicious.
• His hobby is playing football.

• His leisure activity is listening to music and gardening.

• Reaction to stress is not easily frustrated
• He is mildly religious.

• His ultimate concern is to be a rich person.

 System Review
• CNS, CVS, Resp, GI, GU – No Relevant
 Physical Examination
General examination

• Well conscious and well orientated

• Eyes – no squint, anaemia, jaundice
• Pupils – equal, LR(+)

• Alar nasi are not working

• Mouth – teeth and gums are healthy, no gum bleeding
and oral thrush
• Upper limbs – no clubbing, cyanosis, palmar erythema and
tremor
• Lower limbs – no pitting odema and clubbing
• Some finger-nails and toe-nails were damaged and distorted,
(? fungal nail infections)
• No signs of bleeding manifestation over the body.
 Physical Examination
• CVS – PR – 88/min (RR, MV)
BP – 110/70 mmHg
Ht – I + II + 0

• Resp
• Abd – NAD
• CNS
 Mental State Examination
• Done on 2nd day of hospitalization
• General appearance – About 40 years old male patient with
average weight and height was sitting comfortably in the
chair.
• Fairly dressed, but poor eye to eye contact.

• He looked downwards during conversation.

• Answered my questions well
• Speech – relevant but irrational.

• Sample of talk –
• Mood and affect – depressed.
• Perception – Auditory hallucination (+) 2nd person
quality - Voices of Ko-Myo-Lwin and one unknown woman
accusing him as a thief
telling bad thing about him
telling sexual related topics to him
commanding to shout abusive words
• Thinking – Persecutory delusion (+)
- believed that Ko-Myo-Lwin and his team were following him,
spying him and trying to harm him
- Ko-Myo-Lwin and one unknown woman were spreading his
news that he was a thief and he had stolen their jade stone.

- Delusion of reference (+)

- believed that some of relatives and neighbors were talking bad
things about him
- believed that the men who were fishing near his house were
talking bad things about him and so destroyed their 2 cycles

- Delusion of thought broadcasting (+)

- believed that all of his thought were known by other people
including doctors, his sister and Ko-Myo-Lwin.

- denied suicidal thought

Cognition
• He is well conscious and orientated to T, P, P.
• Attention and concentration –can count week days
backwards.
• Memory – immediate memory – 4/5
– recent memory – 4/5
– remote memory – fair
• General information – touch with current affairs
• Abstract thinking – can abstract well
• Insight – Nil

• Judgment – fair
 Formulation
• U Win Yu Aung, 43 years old, single, manual worker,
farmer, 8th standard education, Shan-Myanmar, Buddhist
from Pay-Kone Village, Ka-Thar Township was admitted to
MHH-Mdy on 20th Jan 2020 with the chief complaints of
low mood and easily close to tears off and on for 1½ years,
suicidal thought for 3 times within 1½ years, hearing of
voices for 1 years, became aggressive and destroyed others’
cycles 1 month ago.
 Formulation
• According to history, he faced with financial problem,
changing of work and difficulty at work.
• Then he became depressed, felt hopelessness, helplessness and
crying alone off and on for 1 ½ years
• He also felt lost his energy, decreased sleep, worrying thought
about future within each episode and it last only 3-5days.
• The low mood episode occur 1 time per 1-2 months.
• He had suicidal thoughts for 3 time within 1 ½ years.
 Formulation
• He heard the voices of Ko-Myo-Lwin and one unknown girl
that were accusing him as thief, talking bad thing about him,
talking sexual related topics and commanding for 1 years.
• He believed that Ko-Myo-Lwin and his team was trying to
persecute him, neighbors and some people coming near his
house were talking bad things about him, and all of his
thought were known by others for 1 years.
• He shouted abusive words to neighbors off and on for 3
months and destroyed others’ cycles for 1 time, 1month ago,
due to suspiciousness.
• Denied family history of mental illness.
• History of alcohol use (+) last drink was 1 year ago.
• Denied history of medical illness and head injury.
 Formulation
According to MSE,
• He was well cooperative and answer my question, but poor eye to
eye contact
• Speech was relevant but irrational

• Mood and affect was depressed.

• Hearing auditory hallucination 2nd person quality – accusing voices,
bad things about him, sexual related topics and commanding voices.

• Persecutory delusion (+), Delusion of reference (+), and Delusion

of thought broadcasting (+).
 Formulation
• He was well conscious and orientated to T, P, P.
• Attention and concentration, memory, general
information and abstract thinking were fair.
• Insight was Nil.
• Judgment was fair
 Provisional Diagnosis

• Major depressive disorder with psychotic features.

 Points for diagnosis of major depressive disorder with
psychotic features
- According to DSM-5
A 1. Low mood
2. Decreased sleep
3. Loss of energy and cannot work well
4. Blaming himself for saving no money (worthlessness)
5. Suicidal ideation for 3 times within 1 ½ years
B. Functional impairment
C. Last drink of alcohol was 1 year ago
Denied history of underlying medical illness.
D.
E. No history of manic episode
 Points for diagnosis of major depressive disorder with
psychotic features
• Psychotic features
- Auditory hallucination – 2nd person
> accusing him as a thief
> telling bad thing about him
- Delusion
> persecutory delusion
> delusion of reference

• Episodes of depression precede the psychotic features.

 Points against for diagnosis of major depressive
disorder with psychotic features

• (A) Each episode of depression were recovered spontaneously

after 3-5 days, and reoccur 1 time per 1-2 months.
• Psychotic features
- hallucination
> commanding voices to shout abusive words
> were heard nearly the whole day
- delusion of thought broadcasting (+)
• Psychotic features were present continuously for 1 years.
• Drinking alcohol for 8 months before psychotic symptoms
(Last drink was 1 year ago)
 Differential diagnosis
• Schizoaffective disorder.

• Alcohol induced psychotic disorder

 Points for diagnosis of Schizoaffective disorder
A. No interrupted period between mood episode and psychotic
features.
B. Psychotic features were present continuously in the absence
of depressive episode (> 2 weeks)
C.
D. Last drink of alcohol was 1 year ago.
Denied history of underlying medical illness.

Psychotic features - hallucination

> commanding voices to shout abusive words
> were heard nearly the whole day
- delusion of thought broadcasting (+)
Points against for diagnosis of Schizoaffective disorder

• (C) Psychotic features > depressive features

• Drinking alcohol for 8 months before psychotic symptoms
(Last drink was 1 year ago)

- drunk ¼ to ½ bot of ‘Kachin country spirit’ per day and 4-5

days per weeks for 8 months
 Points for diagnosis of
Alcohol induced psychotic disorder

A. Hallucination (+), Delusion (+).

B. Drinking alcohol for 8 months before psychotic symptoms.

C. No psychotic symptoms prior to drinking of alcohol.

D. Patient is not in delirium.
E. Functional impairment (+).
 Points against for diagnosis of
Alcohol induced psychotic disorder

Last drink was 1 year ago.

 Aetiology
• Predisposing

• Precipitating
- financial problem, changing work, problem at work.

• Perpetuating
- Lack of insight
- Poor family support.
 Investigations and treatment
I/V - RBS, ECG, electrolytes, Blood for CP, LFT, TFT, GGT,
Ultrasound abodmen.

Rx - Bio-psycho-social approach

Bio - Antidepressant - SSRI

Escitalopram 10mg cm
- Atypical antipsychotic
Olanzapine 5mg hs
- Gradually titrating dose
- Care for EPS.
Psycho social
• Psycho-education to patient and family
• Cognitive behavioral therapy

• Insight oriented therapy

• Plan for long-term follow up
 Prognosis
• Short term – Favorable (well response to Rx)

• Long term – Not Favorable

- Single
- Financial problems, poor family supports
- Unstable work
- History of alcohol (+)
- Psychotic features
- History of suicidal thought (+)
 Prognosis

• Favorable
- Denied comorbid medical illness
- Denied family history of mental illness
Thank You