CASE PRESENTATION

Biodata:

Gender: Female
Age: 43 years
Resident of Rawalpindi
Married, Mother of 3
Never formally educated 
Homemaker

Informant: Patient herself and her biological son and

daughter. They are the primary caretakers of patient and
reliable informants.
Patient presented through Psychiatry OPD PIMS.

Presenting Complaints:
1. Giving religious ‘bayaan’ on phone to her neighbour for
upto 6 hours a day-1.5 years
2.Believing that she can hear everyone’s thoughts and also
reply to them non verbally through mental connection-6
months
3.Believing that she is a prophet of God-6 months
4.Believing that she has contact with important political figures
and can influence economic and political conditions of the
country via mental powers
History of Presenting Illness(HOPI)
Patient was in her usual state of health one and a half years ago when she was falsely accused by
her distant relatives of scheming against them to obtain expensive gifts. Patient was disturbed by
this accusation and developed a firm belief that her neighbor, who was related to the accusers was
transferring her conversations to the government. Patient started to send that neighbour voice
notes, she would speak loudly, the content would be religious and this would carry on in episodes of
upto 2 hours at a time for a total of 6 hours a day. This was associated with disturbed sleep, poor
appetite and irritability towards family members when they forbade her from sending the messages.
Patient’s husband was supportive of her belief but disturbed by her behavior, and she was
especially irritable towards husband due to which she separated from him and shifted from Kashmir
to Rawalpindi
Then 6 months ago, when patient’s son took away her phone and blocked the neighbour, patient
developed the belief that she is a prophet of God, that she can obtain other people’s thoughts and
also answer them back mentally. She also believed that she can control matters of national level
through her mental powers. Patient expressed suicidal ideation a few times but never plan or intent,
neither did she make any such attempt.
In the last 2 months, patient started praying Tahajjud and Fajar regularly, which she did not do
before, and her consumption of Naswar increased significantly as well.
Informants denied any history of low mood, lack of interest, disturbance in functionality, crying
spells, overspending, overfamiliarity, excessive anger/aggression, self talking, self laughing, poor
self grooming, social withdrawal.
Patient and her offspring have changed 9 houses in the past 1.5 years due to
neighbors complaints about patient’s behaviour and the loudness of her ‘bayaan’.

Past Psychiatric History:

Insignificant

Past treatment history:

Patient started oral treatment prescribed by a psychiatrist, 10 days before presentation, which did
not yield any improvement. Patient was resistant to receiving psychiatric treatment and had to be
brought to PIMS by coercion.
 Family only opted for faith healing during the initial course of illness which yielded no improvement.
Past history:
No history of diabetes mellitus, asthma, hypertension, ischemic heart disease,
cerebrovascular event.
No history of epilepsy,pyretic fits,head injury.
History of 2 admissions for infective illnesses in past 10 years, documentation or
reliable history not available.

Family psychiatric history:

Insignificant. History of suicide/ murder / substance use or psychiatric
illness was denied.
Family medical and surgical history:
Insignificant
Personal History:

Birth History:
Childhood History:
Reliable account of childhood and birth could not be obtained.

Adolescence: Patient’s mother passed when patient was 15 years old,

afterwards her father married a 2nd time. Reliable information about patient’s
adjustment to maternal loss could not be obtained.

Education: never formally educated. Never received Quran tutoring either.

Marital History: married at 16 years of age. Strained relationship with husband.

According to patient’s son, he witnessed physical abuse towards mother on
approx. 3 occassions
Personal History:

Family of Origin: 2nd of a total of 3 biological sisters. Close relationship with

sisters. Has 7 younger step siblings who she does not speak to. Patient has
strained relationship with father whom she has not met for many years

Forensic History: no h/o prosecution or incarceration.

Son was incarcerated for 6 months , 5 years ago in a case of burglary. Patient
had low mood during that period but attained baseline mood following son’s
release.

Substance Use: Naswar use since adolescence

Occupational History: Homemaker. Never been formally employed.

Premorbid Personality:

Personality traits: irritable, interfering

Prevalent mood: low

Relationship history: wide social circle. Frequent quarrels with relatives/

neighbors due to patient’s habit of inserting herself into people’s personal matters.
(according to son). patient;’s family is socially isolated due to her behaviour.

Substance use: naswar use

Reaction to stress: poor stress coping, frequent visits to faith healers

 
Beliefs and attitudes: conservative. Islamic. Superstitious
Mental State Examination:

Appearance: Middle aged female of average height and build.

Appropriately dressed, covering her face with a shawl. Good self
hygiene and grooming.

Behavior: Rapport difficult to establish. Patchy eye contact.

Uncooperative. Hostile when her daughter was being interviewed, tried
to snatch the file at one point. Threatening to call down Allah’s wrath on
the interviewer and insisting that she be discharged since she is
perfectly fine.
Mental State Examination:

Mood: “theek hun bilkul”

Affect: flat

Speech: spontaneous, coherent, mostly irrelevant. Fast rate, normal

volume. Confused and quiet when her beliefs are challenged.

Thought content:
Thought form: Tangential
Delusions: Delusion of thought insertion, thought withdrawal and
thought broadcast is present. Delusion of grandiosity is present. Patient
denied delusions of control, persecution, hypochondriasis, erotomania.
Mental State Examination:

Thought content:

Overvalued ideas: denied

Obsessions: denied
Preoccupations: with other people’s thoughts that crowd her mind, acc
to the patient
Phobias: denied
Suicidal ideation: present. Denied plan or intent
Homicidal ideation: denied
Mental State Examination:

Perceptual disturbances:
Denied Visual and auditory hallucinations.
Denied tactile, gustatory and olfactory hallucinations. 

Denied depersonalization and derealization

Insight:
Poor
Cognitive Functions:
Oriented in time, place and person

Attention & concentration:

Registration: 3/3
3 Object recall: 3/3

Judgment:poor

Thinking: abstract
Biopsychosocial Model
According to ICD-10 and multiaxial system
AXIS 1
Provisional Diagnosis: Paranoid schizophrenia
Differential Diagnosis:
1.Organic Brain Disorder
2.Bipolar affective disorder, current episode Mania

AXIS 2
Personal Care 5/5
Occupational Disability 5/5
Family & Household 5/5
Social Context 2/5
AXIS 3
PREDISPOSING PRECIPITATING PERPETUATING
FACTORS FACTORS FACTORS
1. Early maternal loss
2. Social isolation 1.Conflict with relatives 1. Long period of untreated illness
3. Superstitious
personality
4.Marital conflict
Treatment according to BPS model:
Relevant Investigations and Scales:
• CBC
• TFTs
• LFTs, Serum cholesterol
• RFTs
• Serum glucose level
• CT Brain Plain

• PANSS: Positive and Negative syndrome scale

• BCASS:Brief Clinical assessment scale of schizophrenia
• SANS, SAPS, CGI-SCH, BPRS,Calgary Depression scale for Schizophrenia

oBIOLOGICAL

Atypical antipsychotics
Improvement in behaviour achieved with Risperidone 8mg
Treatment according to BPS model:
oPSYCHOLOGICAL
1. Informational care to patient regarding illness.
2. Supportive psychotherapy
3. Occupational therapy
4. Social Skills Training
oSOCIAL
1. Informational care to family
2. Family therapy
Good prognostic Factors:
Good physical health
Good compliance to treatment

Bad Prognostic factors

Poor relationship with family of origin
Resistant nature of delusions to treatment
Early loss of mother
Poor insight
Social isolation of family
Continuing, reducing, switching, or stopping antipsychotics in individuals with schizophrenia-spectrum
disorders who are clinically stable: a systematic review and network meta-analysis
Ostuzzi, Giovanni et al.
The Lancet Psychiatry, Volume 9, Issue 8, 614 – 624

Published June 23, 2022

Background
Although antipsychotic maintenance treatment is widely recommended to prevent relapse in chronic
psychoses, evidence-based guidelines do not provide clear indications on different maintenance treatment
strategies, including continuing the antipsychotic at standard doses, reducing the dose, switching to another
antipsychotic, or even stopping the antipsychotic. We aimed to compare the effectiveness of these
maintenance treatment strategies, hypothesising the superiority of all strategies over stopping, and of
continuing at standard doses over both switching and reducing the dose.
Methods
We did a systematic review and network meta-analysis of randomized controlled trials (RCTs) that investigated antipsychotics for relapse prevention in
adults with schizophrenia-spectrum disorders who were clinically stable, and which compared four treatment strategies: continuing the current
antipsychotic at standard doses recommended for acute treatment; reducing the current antipsychotic dose; switching to a different antipsychotic; and
stopping the antipsychotic and replacing it with placebo. We excluded RCTs with fewer than 25 individuals, a prerandomisation washout period greater than
4 weeks, a follow-up shorter than 6 weeks, and those recruiting treatment-resistant individuals. We searched MEDLINE, EMBASE, PsycINFO, CINAHL,
CENTRAL, and online trial registers for published and unpublished RCTs from inception to Sept 1, 2021, combining terms describing all available
antipsychotics, and terms describing continuation, maintenance, or long-term treatment for schizophrenia-spectrum disorders. Relative risks (RRs) and
standardised mean differences were pooled using random-effects pairwise and network meta-analyses. We assessed risk of bias of each RCT with the
Cochrane Risk-of-Bias 2 tool, and confidence of pooled estimates with CINeMA. The primary outcome was relapse prevention. The study protocol was
registered in advance in the Open Science Forum registry.
Results:Of 3936 records identified, 119 records, reporting on 101 RCTs, were eligible, 98 of which (including 13 988
individuals) provided data that could be meta-analysed for at least one outcome. The mean proportion of female participants
per study was 38% (range 0–100; median 39%, IQR 29–50), whereas for male participants it was 62% (range 0–100; median
61%, IQR 50–71), and the overall mean age was 38·8 years (range 23·2–63·9; median 39·3, IQR 35·0–43·9). Of the 98 RCTs
meta-analysed, 89·8% were done in high-income and upper-middle-income countries. The ethnic group White or so-called
Caucasian was the most represented (mean 56% participants per study), although this information was relatively scarce. All
continuation strategies were significantly more effective in preventing relapse than stopping antipsychotic treatment, with a
large risk reduction for continuing at standard doses (RR 0·37, 95% CI 0·32–0·43; number-needed-to-treat [NNT] 3·17, 95% CI
2·94–3·51) and antipsychotic switching (RR 0·44, 0·37–0·53; NNT 3·57, 3·17–4·25), and moderate risk reduction for dose
reduction (RR 0·68, 0·51–0·90; NNT 6·25, 4·08–20·00). Continuing and switching antipsychotics did not differ significantly (RR
0·84, 0·69–1·02; with lower values favouring continuing), whereas reducing antipsychotic dose was outperformed by both
continuing (RR 0·55, 0·42–0·71; NNT 4·44, 3·45–6·90) and switching (RR 0·65, 0·47–0·89; NNT 5·17, 3·77–18·18). Results
were supported by moderate confidence of evidence and confirmed by secondary analyses and by several sensitivity and
subgroup analyses, including removing studies with abrupt antipsychotic discontinuation or fast tapering (≤4 weeks). No
tolerability differences emerged between treatment strategies. According to the Cochrane Risk-of-Bias tool, version 2, 16·8% of
included RCTs had an overall high risk of bias for the primary outcome. We found moderate heterogeneity (τ 2=0·13; I2=61%)
and no overall incoherence for the primary analysis. Results were supported by moderate confidence of evidence and
confirmed by secondary analyses.
Conclusion:Contrary to our original hypothesis, we found that continuing antipsychotic
treatment at standard doses or switching to a different antipsychotic are similarly effective
treatment strategies, whereas reducing antipsychotic doses below standard doses is
associated with higher risk of relapse than the other two maintenance treatment
strategies and should therefore be limited to selected cases. Despite limitations, including
moderate heterogeneity and moderate certainty of evidence, these results are of
pragmatic relevance for clinicians, and should support the update of evidence-based
guidelines.