Case Write-Up

Psychological and Behavioural Medicine

M Kandiah Faculty of Medicine and Health Sciences, UTAR

Student Name: Deipan A/L Arjunan

ID No: 20UMB03886
Year: 4
Name of lecturer: Dr. Thong Kai Shin
Marks allocation for Case Write-up
Chief complaints /5 Investigations /5

History chronologically clear /20 Report on management /10

from patient and progress of the
patient in the ward / on
follow up

Mental state examination and /20 Discussion and literature /10

physical examination review

Summary / Formulation /10 Proper use of English language, /5

and write-up is clear & logical

Discussion of diagnosis / /15 Total score /100

differential diagnosis with
justifications
Signature of Lecturer: ____________ Date: __________________
PATIENT IDENTIFICATION

Patient’s Initials: Mr. H R/N: -

Age: 44 y/o Gender: Male

Ethnicity: Chinese Language: English

Marital status: Single Occupation: Supermarket worker

Date of clerking: 8/12/2023

CLINICAL CASE

Chief Complaint

Aggressive behaviour and threatened to harm others for one day.

History of Presenting Illness

Mr. H, a 44-year-old, Chinese gentleman with underlying schizophrenia for 24 years was
admitted due to aggressive behaviour and threatened to harm his coworkers after a disagreement.

Mr. H was well until 2 months ago when he started to suspect the government is spying
and actively trying to harm him. He does not know the reason the government’s intention on
doing that to him and cannot explain further on why he feels that way. He feels that they want to
harm him most of the time especially when he hears or see news related to the government such
as press conference by ministers on television. However, no harm has been inflicted upon him so
far by the government. This has caused Mr. H to have sleeping difficulties as he is paranoid that
someone is going to harm him. He sometimes does not sleep for several nights due to his
paranoia and will spend those nights watching the door and keeping watch for people who want
to harm him. He used to sleep around 7 hours per night however due to his paranoia he only
sleeps around 3 hours per night. He usually feels lethargic the next morning due to lack of sleep.
Other than that, Mr. H also hears voices in third person commenting about him being evil
and commenting about his actions. He hears the voices even when he is alone with no sounds

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in his surroundings. Other people are also unable to hear the voices. He sometimes talks back to
the voices or argues with the voices, but the voices do not disappear.

On the day of admission, Mr. H was at work during which one of his colleagues started
scolding him for not doing his work properly. This caused him to get angry and started to be
verbally abusive towards the coworker that criticised him as well as other coworkers present
during the incident. He threatened to harm them, and he started to shout at them continuously.
His coworkers were afraid and decided to call the police. Mr. H was then brought to the
emergency department at Hospital Kuala Lumpur and subsequently referred to psychiatry
department and admitted.

Otherwise, Mr. H denied any other delusions such as delusion of grandiosity, delusion of
control or delusion of reference. He does not have other hallucinations such as visual, olfactory,
gustatory, or tactile hallucinations. He also states he did not experience negative symptoms such
as diminished emotional expression or avolition. He hasn’t experienced manic symptoms such as
elevated mood, decreased need for sleep, talkativeness, racing thoughts, distractibility, increase
in goal-directed activity and excessive involvement in activities that have a high potential for
painful consequences. He also does not experience depressive symptoms such as depressed
mood, feelings of worthlessness, difficulty concentrating, recurrent thoughts of death or suicidal
ideation as well as previous suicide attempt. He has no loss of weight or loss of appetite,
headache, seizures or nausea and vomiting. He does not abuse any substances such as heroine,
methamphetamine, cannabis, tobacco, or alcohol.

Past Psychiatry History

Mr. H was diagnosed with schizophrenia 24 years ago and is currently under follow up
under HKL. He says that he is compliant with his follow ups. This is his third admission in HKL.
His previous two admissions were seven and fives years respectively ago due to similar
circumstances in which he displayed aggressive behavior and threatened to harm others. Other
than that, there is no other past psychiatric history.

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Past Medical, Surgical and Hospital Admission History

Mr. H does not have any underlying diseases such as diabetes, dyslipidemia, or
hypertension. He also does not have any past surgical history.

Drug and Allergy History

Mr. H is taking tablet Olanzapine and is non-compliant as he does not like the side effects
of the medication and hasn’t been taking his medication regularly prior to admission. He does
not recall the dosage. Other than that, he is not taking any other medication. He does not take any
traditional herbs or supplements. He does not have any drug or food allergies.

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Family History

Mr. H’s father passed away due to myocardial infarction three years ago. His mother is
otherwise well with no underlying diseases. He has a younger sister who are well with no
underlying diseases. He is unaware of any history of psychiatric illness in his family both direct
and extended.

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Social History

Mr. H is not married and lives in an apartment in Jalan Ipoh with his mother. Mr. H has a
history of frequently changing jobs due to his mental disorder. He now works as a supermarket
employee in which he does multiple jobs such as cashier, filling the racks and so on. His job does
not pay enough for him to be financially independent thus he relies financially on his mother’s
pension. His relationship with his family is poor as he claims he usually does not interact with
them and when he is at home, he usually stays in his room most of the time or watches television
alone. Mr. H does not have any close friends whom he keeps in touch with. Mr. H never
completed tertiary education as the mental disturbances prevented him from enrolling to any
course upon completion of his SPM. Mr. H does not exercise regularly. He does not smoke,
drink or use illicit drugs.

Systemic Review

General  No changes in sleep pattern

 No loss of weight or appetite

 No night sweats

 No nausea

 No vomiting

 No dizziness

 No fever

Cardiovascular  No palpitations
system
 No chest pains

 No arrythmia

 No orthopnoea

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  No paroxysmal nocturnal dyspnoea

 No pitting oedema

 No claudication

Respiratory  No haemoptysis
system
 No wheezing

 No cough

 No nasal discharge

Gastrointestinal  No gum bleeding

system
 No oral ulcers

 No dysentery

 No abdominal pain

 No diarrhoea

 No change in stool colour

Genitourinary  No change in frequency and urine output

system
 No pain during urination

 No haematuria

 No change in urine appearance

 No foul-smelling urine

Nervous system  Occasional dizziness due to side effect of medication

 No headaches

 No tinnitus

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  No blurred vision

 No fitting

 No numbness

 No pin and needles sensation

 No confusion

Dermatology  No skin rashes

Endocrine  No heat or cold intolerance

system
 No voice changes

 No excessive sweating

 No excessive thirst

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 MENTAL STATE EXAMINATION (MSE)

Appearance

Mr. H appeared as a Chinese gentleman in his mid-40s with medium build. He had short tidy
hair and was dressed in hospital attire with fair hygiene. Throughout the interview, he had
reduced eye contact but appeared calm and was cooperative. There was no aggressive or
hostile behaviour and no hallucinatory behaviour as well.

Speech

Mr. H spoke in English with normal tone, volume, and speed. He was not talkative. His speech
was coherent and relevant.

Mood and Affect

Mr. H was euthymic. His affect was appropriate to thought content.

Thoughts and Perceptions

Mr. H’s continuity of thought was relevant. He denied any auditory or visual hallucinations
and suicidal ideation.

Cognitive Assessment

Consciousness and Alertness

Mr. H was conscious and alert.
Orientation
Mr. H was orientated to time, place, and person.
Attention and Concentration
Mr. H was able to perform the serial 7 subtraction test and spell “world” forward and
backward.
Memory
Mr. H’s memory was intact. He was able to tell his date of birth, what he ate for breakfast and
repeat 3 unrelated items that he was asked to remember shortly before.
General knowledge

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Mr. H was able to name the current prime minister of Malaysia.
Abstract Thinking
Mr. H’s abstract thinking was intact as he could categorize apples and oranges as types of
fruits.
Insight
Mr. H had poor insight. Mr. H does not understand what his psychiatric condition is and does
not know the signs and symptoms of his illness. He is not compliant with his medication. He
also believes there is nothing wrong with him.
Judgement
Mr. H has good judgment as when given a scenario of being caught in a building on fire, he
would and run out of the building and call the fire brigade.

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 PHYSICAL EXAMINATION
Anthropometric Measurement

 Height: 175 cm
 Weight: 70 kg
 BMI: 22.85 kg/m2 (Normal)

Vital Signs

 Temperature: 36.9 ℃ (Normal)

 Heart rate: 80 beats per minute (Normal)
 Respiratory rate: 20 breaths per minute (Normal)
 Blood pressure: 114/76 mmHg (Normal)
 SpO2: 99% under room air (Normal)

General Examination (unremarkable)

Mr. H was sitting comfortably on the bed with no signs of anxiousness. He is conscious,
alert and well oriented. There were no nail changes such as nicotine staining or finger clubbing
and no fine tremors noted. The capillary refill time was less than 2 seconds. The face was
symmetrical with no dysmorphic features. There was no neck swelling and no lymph node
enlargement.

Cardiovascular Examination(unremarkable)

The carotid pulse was palpable with no thrills bilaterally. Apex beat was palpable at the
left 5th intercostal space, mid-clavicular line. There were no thrills palpable and no left

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parasternal heave. First and second heart sounds were heard with no murmur and no additional
sound.

Respiratory Examination(unremarkable)

Mr. H’s chest was symmetrical and moved with respiration. There was no tracheal
deviation and no tenderness on the anterior and posterior chest. On percussion, there was
resonance all over the chest with hepatic and cardiac dullness. On auscultation, there was normal
vesicular breathing with no added sounds.

Abdominal Examination(unremarkable)

The abdomen was flat and moved with respiration. There was no flank fullness. There
were no scars, surgical wound, striae, prominent veins, or abnormal pulsation seen. On palpation,
there was no tenderness or abnormal mass felt. There was no hepatosplenomegaly and kidneys
were not ballotable. On percussion, Traube’s space was resonant. Shifting dullness and fluid
thrill were negative. On auscultation, bowel sounds were normal. There were no aortic bruit,
renal bruit, hepatic bruit, and splenic bruit heard.

Neurological Examination(unremarkable)

Mr. H’s mental status was intact and was able to understand and answer questions
logically. There was no slurring of speech. Mr. H was able to understand and follow commands.
There were no scars, muscle wasting, involuntary movement or fasciculation of the upper and
lower limbs noted. On neuromuscular examination, muscle tone was normal on both upper and
lower limbs. The power is 5/5 bilaterally for both upper and lower limbs. All reflexes were
normal. Sensation of upper and lower limbs were intact, and gait was normal. All cranial nerves
were intact.

Musculoskeletal Examination (unremarkable)

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 On inspection, there were no deformities, limb length discrepancy or muscle wasting
noted. Upon palpation, there was no localized rise in temperature or tenderness noted. No
abnormal structure or bony prominences palpable. Active and passive range of movement were
all within the normal range.

SUMMARY OF CASE

Mr. H, 44-year-old, Chinese gentleman with underlying schizophrenia for 24 years was
admitted to the psychiatry ward in Hospital Kuala Lumpur due to aggressive behaviour and
threatened to harm others. He was well until 2 months ago when he started to experience
persecutory delusion whereby, he feels that the government wants to harm him for unknown
reason, which also caused him to have sleeping difficulties. He also experienced third person
auditory hallucinations whereby he heard voices commenting about him being evil and
commenting about his actions. On the day of admission, Mr. H displayed disorganized behaviour
by wanting to harm his coworkers. Otherwise, Mr. H did not have any other hallucinations,
delusions, negative symptoms, manic symptoms, depressive symptoms, or any substance abuse.
On MSE, Mr. H had reduced eye contact but was calm and cooperative. He has poor insight.
Other components of MSE were unremarkable.

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 PROVISIONAL DIAGNOSIS
Schizophrenia with multiple episodes, currently in acute episode
Supporting Evidence
 Has underlying schizophrenia for 24 years
 Disorganized behaviour on day of admission
 Persecutory delusion for 2 months
 Auditory hallucinations for 2 months
 Impaired social relationship and occupational functioning
 No mood symptoms
 No substance use
Evidence Against
 No negative symptoms
 No disorganized speech

DIFFERENTIAL DIAGNOSIS
1. Bipolar disorder with psychotic features
Supporting evidence
 Presence of psychosis
 Disorganized behaviour
 Irritable (on day of admission)
 Insomnia
Evidence against
 No history of mania
 MSE:
o No pressured speech
o No flight of ideas

2. Substance-induced psychotic disorder

Supporting evidence
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  Disorganized behaviour on day of
 Persecutory delusion
 Auditory hallucinations
 Impaired social relationship and occupational functioning
Evidence against
 No substance use

3. Psychotic disorder due to brain lesion

Supporting evidence
 Disorganized behaviour on day of admission
 Persecutory delusion for 2 months
 Auditory hallucinations for 2 months
Evidence against
 No loss of weight or appetite
 No seizures
 No headache
 No nausea and vomiting
 No family history of malignancy

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 INVESTIGATIONS
Biological Investigations
Investigation Indication

Full Blood Count  As a baseline investigation for monitoring drug therapy

Renal Profile and Serum  As a baseline investigation to assess the renal function for
Electrolytes drug clearance

Liver Function Test  As a baseline investigation to assess the liver function for
drug clearance

Thyroid Function Test  To rule out hyperthyroidism

Fasting Blood Glucose  As a baseline investigation for monitoring drug therapy as

atypical antipsychotic such as olanzapine can cause
Lipid Profile metabolic syndrome

Urine Toxicology  To rule out substance use

ECG  To rule out any existing prolonged QT and evaluate the

risk of torsade de pointes

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 1. Full blood count

Blood Components Reference Range Results Interpretation

Red blood cell (x10^6/µL) 4.5-6.5 4.82 Normal

Haemoglobin (g/dL) 13-18 15.2 Normal

Haematocrit (%) 35.7-48.9 44 Normal

Mean cell volume (fL) 80.6-95.5 89.2 Normal

Mean cell haemoglobin (pg) 26.9-32.3 27.4 Normal

Mean cell haemoglobin concentration (g/dL) 31.9-35.3 34.7 Normal

Platelet count (K/µL) 150 - 400 314 Normal

Red cell distribution width (%) 11.5-15.0 13.1 Normal

White blood cell (K/µL) 4-11 7.2 Normal

Interpretation: All parameters are within normal range.

2. Renal profile and serum electrolytes

Parameters Reference Range Results Interpretation

Urea (mmol/L) 3.20-8.20 3.5 Normal

Sodium (mmol/L) 135 - 145 141 Normal

Potassium (mmol/L) 3.5 – 5.3 3.9 Normal

Chloride (mmol/L) 95 - 108 99 Normal

Creatinine (µmol/L) 62-115 68 Normal

Calcium (mmol/L) 2.08-2.65 2.11 Normal
Magnesium (mmol/L) 0.66-1.07 0.95 Normal
Phosphate inorganic (mmol/L) 0.78-1.65 1.07 Normal
Interpretation: All parameters are within normal range.
3. Liver Function Test

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 Parameters Normal range Results Interpretation
Total bilirubin (µmol/L) 3-17 12.1 Normal
Total protein (g/L) 60-80 69.5 Normal
Albumin (g/L) 35-50 42 Normal
Alkaline phosphatase(U/L) 30-130 52 Normal
Alanine transaminase (U/L) 5-35 19 Normal
Aspartate transaminase (U/L) 5-35 13 Normal
Interpretation: All parameters are within normal range.

4. Thyroid Function Test

Components Reference Range Results Interpretation
Thyroid stimulating hormone (mIU/L) 0.27-4.20 1.82 Normal
Free thyroxine (pmol/L) 12-22 19.6 Normal

Interpretation: All parameters are within normal range.

5. Fasting Blood Glucose

Component Reference Range Results Interpretation
Glucose (fasting) (mmol/L) 3-6.1 4.2 Normal

Interpretation: Fasting blood glucose is within the normal range.

6. Lipid Profile
Components Reference Range Results Interpretation
Total Cholesterol (mmol/L) < 6.2 4.5 Normal
HDL (mmol/L) > 1.0 1.3 Normal
LDL (mmol/L) < 4.9 2.7 Normal
Total Triglyceride (mmol/L) < 2.3 1.8 Normal

Interpretation: All parameters are within normal range.

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 7. Urine Toxicology
Result: Negative
Interpretation: Mr. H is not under influence of substances.

Psychological Investigations
Investigation Indication

Brief psychiatric rating scale  To assess the severity of positive and negative
(BPRS) symptoms and also general psychopathology

Positive and negative syndrome  To assess the presence and severity of positive
scale (PANSS) and negative symptoms

Social Investigation
Investigation Indication

Collaborative history from  To have a more detailed history of Mr. H’s behaviour
family members at home, socioeconomic status, and financial support.

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 MANAGEMENT

I would approach this case through the bio-psycho-social-spiritual approach. According to

Clinical Practice Guidelines (CPG) Malaysia for the management of schizophrenia, the general
principles of management of schizophrenia are as follows:

 Assessment and early treatment

 Early referral to specialist care in the following circumstances:

1. Presence of prodromal or attenuated symptoms

2. Unclear diagnosis o plan for psychosocial rehabilitation
3. Treatment adherence issues
4. Poor response to treatment o potential violent behaviour to self or others
5. Intolerable side effects from medication
6. Co-morbid substance use disorder
7. Special group e.g., pregnancy, paediatric and geriatric age

 Initial treatment and urgent referral in the acutely ill cases

 Collaboration with hospital-based psychiatric services

 Registration of cases at health clinics and the National Mental Health Registry

The modalities of treatment in schizophrenia are pharmacological, physical,

psychosocial, and service level interventions.

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Biological Approach

Pharmacotherapy is the mainstay of schizophrenia management, however there may be

residual symptoms that persist. In the event of an acute psychotic episode such as in this case,
drug therapy should be administered immediately. The medications commonly used are first-
generation (typical) antipsychotics (FGAs), second-generation (atypical) antipsychotics (SGAs)
and benzodiazepines. Side effects should be anticipated, and antidotes should be readily
available.

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21
Choice of medication depends on underlying cause of the aggression. Parenteral [intramuscular
(IM) or intravenous (IV)] medications are used during acute exacerbation of schizophrenia to
stabilise the aggressiveness of the patients. Clozapine is the exception out of the other SGAs due
to the risk of agranulocytosis therefore clozapine is not recommended unless indicated. SGAs are
the preferred choice FGAs as it is associated with lower risk of extrapyramidal symptoms (EPS)
such as acute dystonia, akathisia, pseudo parkinsonism, and tardive dyskinesia compared to
FGAs. However, SGAs tend to have metabolic and cardiac side effects. Examples of FGAs and
SGAs registered in Malaysia are as follows:

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 In cases where non-adherence is an issue, depot or long-acting injectable (LAI)
antipsychotic agents offers a viable option. Depot or LAI antipsychotics may be considered
based on the patient’s preference or when there is medication adherence issue for maintenance
treatment in schizophrenia. Some examples of LAI antipsychotics preparations available in
Malaysia includes:

1. Fluphenazine decanoate
2. Flupenthixol decanoate
3. Zuclopenthixol decanoate
4. Risperidone microspheres
5. Paliperidone palmitate
6. Aripiprazole

In cases of treatment-resistant schizophrenia where patient’s symptoms show no response

or partial and suboptimal response to trial of two different antipsychotics for at least 6 weeks,
clozapine monotherapy with monitoring of white blood cell count may be initiated.

Sedative such as benzodiazepine may also be prescribed to help induce sleep by

promoting relaxation and drowsiness. Oral lorazepam 1mg PRN is recommended to prevent
dependence and tolerance.

Physical interventions such as electroconvulsive therapy (ECT) may be considered in

schizophrenia as and adjunct to antipsychotics to achieve rapid and short-term improvement of
severe symptoms after an adequate trial of antipsychotic is proven ineffective and in treatment
resistant schizophrenia.

Psychosocial Approach

There are various forms of psychosocial intervention which are not limited to psychotherapy
and psychological techniques in the management of people with schizophrenia. The aim of these
psychosocial intervention varies depending on the treatment goal.

1. Psychoeducation

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 Psychoeducation improves understanding of mental health issues, recognising early warning
signs of relapse and understanding psychiatric services work. A psychoeducation programme
includes key information about diagnosis, symptoms, psychosocial interventions, medications
and side effects as well as information about stress and coping, crisis plans, early warning signs
(EWS) and suicide and relapse prevention.

2. Supported employment

Recommended to offer supported employment programmes to people with psychosis or

schizophrenia who wish to find or return to work. Apart from that, it is recommended to consider
other occupational or educational activities, including pre-vocational training, for people who are
unable to work or unsuccessful in finding employment.

3. Cognitive remediation therapy

Cognitive remediation therapy (CRT) is a behavioural treatment intervention aims to improve

the cognitive processes e.g. memory, attention, executive function, metacognition and social
cognition. It uses techniques which modify cognition in people with schizophrenia e.g. errorless
learning, repetition and positive reinforcement.

4. Social skills training

Social skills training (SST) is a psychosocial intervention, whether group or individual, aimed
at enhancing the social performance and reducing the distress and difficulty in social situations.

5. Peer support services

Peer support is a social emotional support which is mutually provided by persons having a
mental health condition to others sharing a similar problem to bring about a desired social or
personal change. It is recommended to consider peer support for people with schizophrenia to
improve their experience and quality of life. It should be delivered by a trained peer support
worker who has recovered from schizophrenia and remains stable. The workers should receive
support from their whole team and, support and mentorship from experienced peer workers.

6. Family therapy

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 Family therapy is a form of psychotherapy involving significant family members together
with the person with schizophrenia based on individual family need. It focuses on relationship in
which the problem is manifested by providing support, skills and education through solution-
oriented approach. It aims to reduce level of distress and improve communication within family.

7. Cognitive behaviour therapy

Cognitive behaviour therapy (CBT) is a structured, short-term, present-oriented

psychotherapy, it focuses on problem solving and modifying dysfunctional thinking and
behaviour. The application of CBT is based on conceptualisation of individual person’s belief,
behaviour, and emotional experience.

8. Supportive psychotherapy/ counselling

Supportive psychotherapy/counselling relies on therapeutic alliances with the aim to assist

change in attitude and behaviour and, reinforce the ability to cope.

Service Level Intervention

1. Crisis and emergency service

Crisis and Emergency Mental Health Service provides intensive care in the community for
people with acute psychiatric symptoms, thus avoiding the need for hospitalisation. It is
recommended to offer crisis resolution and home treatment teams as a first-line service to
support people with schizophrenia during an acute episode in the community and should be
considered before admission to the hospital and as a mean to enable timely discharge.

2. Assertive community treatment

Assertive community treatment (ACT) is a service that provides continuous care for people with
serious mental illness in the community especially those who have difficulty engaging with the
mental health services. People with schizophrenia should receive ACT if there is a history of

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poor engagement with services leading to frequent relapse or social disruption, high use of
inpatient services and presence of residual psychotic symptoms.

3. Intensive Case Management

Intensive case management (ICM) is a small caseload (up to 20 people) of community-based

psychiatric service for people with serious mental illness that may follow many models e.g.
ACT, case management etc. ICM should be considered for people with psychosis or
schizophrenia who are likely to disengage from treatment or services.

4. Community-based service intervention

The community health workers were defined as non-healthcare workers who had at least 10
years of schooling, good interpersonal skills, systematic training over six weeks and assessment
for competency.

5. Day hospitalisation/ day treatment

Day hospital or day treatment centre is an ambulatory treatment programme that emphasises
psychosocial and pre-vocational treatment modalities designed for people with serious mental
disorders who require co-ordinated, intensive, comprehensive, and multi-disciplinary treatment
not provided in an outpatient clinic setting.

Spiritual Approach

Patients can be encouraged to involve in more religious activities.

1.

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 DISCUSSION

Introduction

Schizophrenia is a term that describes a major psychiatric disorder characterized by

hallucinations, delusions and disturbances in thought, perception, and behaviour. It was ranked
as the 11th leading cause of disability in the world in the year 2013. According to the National
Mental Health Registry on Schizophrenia in 2003 to 2005, schizophrenia in Malaysia has an
incidence rate of 5 cases per 100000 population per year which was lower than expected,
possibly due to delayed or under reporting and administrative reasons. The early onset of the
disease, along with its chronic course, make it a disabling disorder for many patients and their
families. Traditionally, symptoms have been divided into two main categories: positive
symptoms, which include hallucinations, delusions, and formal thought disorders, and negative
symptoms such as anhedonia, poverty of speech, and lack of motivation. Disability often results
from both negative symptoms and cognitive symptoms, such as impairments in attention,
working memory, or executive function.

Epidemiology

 Prevalence: < 1%
 Sex: ♂ > ♀ (∼1.4:1)
 Age of onset: late teens to mid-30s
o Men: typically early 20s
o Women: typically late 20s

Risk Factors

 Genetic factors: risk significantly increased if relatives are also affected

o One schizophrenic parent: ∼ 10%
o Two schizophrenic parents: ∼ 40%
o Concordance rate in monozygotic twins: 30–40%
o Concordance rate in dizygotic twins: 10–15%
 Environmental factors

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 o Stress and psychosocial factors
o Frequent use of cannabis during early teens (associated with increased
incidence and worse course of positive symptoms)
o Urban environment
o Advanced paternal age at conception

Pathophysiology

Dysregulation of neurotransmitters

 Decreased dopamine in prefrontal cortical pathway may cause negative symptoms of

psychosis.

 Increased dopamine in mesolimbic pathway may lead to positive symptoms of psychosis.

 Increased serotonergic activity

 Decreased dendritic branching

 Decreased glutamatergic neurotransmission may lead to psychosis.

 Decreased GABA leads to increased dopamine activity.

Structural and functional changes to the brain

 Enlarged lateral and third ventricles

 Decreased symmetry

 Decreased volume of the limbic system, prefrontal cortex, and thalamus

 Decreased volume of the hippocampus and amygdala

 Hypoactivity of the frontal lobes and hyperactivity of the basal ganglia

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Clinical Features

Schizophrenia typically manifests with a prodrome of negative symptoms (e.g., social

withdrawal) and psychosis that precedes the positive psychotic
symptoms (e.g., hallucinations and bizarre delusions).

Positive symptoms of schizophrenia

Psychosis

 Hallucinations and/or illusions (auditory hallucinations are most common)

 Delusions, e.g., grandiosity, ideas of reference, paranoia, persecutory delusions

 Disorganized thought or disorganized speech: e.g., loose associations, word

salad, tangential speech

Abnormal motor behaviour

 Grossly disorganized behaviour: an abnormal behaviour characterized by

inadequate goal-directed activity (e.g., purposeless movements) and bizarre emotional
responses (e.g., smiling or laughing when inappropriate)

 Catatonia

Negative symptoms of schizophrenia

 Flat affect: reduced or absent emotional expression

 Avolition: reduced or absent ability to initiate purposeful activities

 Alogia: impaired thinking that manifests with reduced speech output or poverty of
speech (e.g., always replying to questions with one-word answers)

 Anhedonia: inability to feel pleasure from activities that were formerly pleasurable or
from any new positive stimuli

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  Apathy: lack of emotion or concern, especially regarding matters that are normally
considered important

 Emotional and social withdrawal

Other features:

 Cognitive symptoms

o Inattention

o Impaired memory

o Poor executive functioning

 Mood symptoms and anxiety

o Mostly depression

o Social or specific phobia

o Post-traumatic stress disorder

o Obsessive-compulsive disorder

o Panic disorder

 Neurological abnormalities: sensory disturbances and impaired coordination

 Metabolic abnormalities: hypertension, diabetes, hyperlipidaemia

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Diagnostic Criteria

To diagnose schizophrenia, according to the DSM-5, the following criteria must be met:

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In this case, Mr. H fulfils criteria A whereby he had persecutory delusions for 2 months and
auditory hallucinations for 2 months. However, disorganized behaviour was present for one day
only on the day of admission.
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Mr. H also fulfils criteria B whereby he did not manage to enrol into tertiary education instituion
due to the disturbances and did not have much close relationship with friends and family since
the onset of his disturbances.

He also fulfils criteria C whereby he had experienced the signs of disturbances for more than 6
months.

He fulfils criteria D as he did not have any mood symptoms as well as any major depressive or
manic episodes.

Criteria E is also fulfilled as Mr. H has no history of substance use such as heroine,
methamphetamine, and cannabis.

Me. H fulfils all criteria and has history of multiple episodes whereby his previous most recent
episode was five year ago which led to his first admission at Hospital Kuala Lumpur, thus he can
be given the diagnosis of schizophrenia with multiple episodes currently in acute episode.

Investigation

Investigation of schizophrenia should be approached using a biopsychosocial modal:

Biological

Though schizophrenia is primarily a clinical diagnosis, specific laboratory and

radiographic investigations are useful to exclude other potential causes (organic causes). In this
case, the relevant investigations include full blood count, renal profile, liver function test, thyroid
function test, fasting blood glucose, lipid profile, urine toxicology and ECG. The indications for
these investigations are listed under the investigations subheading.

Psycho

Screening tools such as Brief Psychiatric Rating Scale (BPRS) and Positive and Negative
Symptoms Scale for Schizophrenia (PANSS) can be utilised for assessment for severity.

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Brief Psychiatric Rating Scale (BPRS):

BPRS is an 18-item scale used to measure psychiatric symptoms such as depression,

anxiety, hallucinations, psychosis, and unusual behaviour. It is also useful in assessing the
efficacy of treatment in patients who have moderate to severe psychoses. The patient enters a
number for each symptom construct that ranges from 1 (not present) to 7 (extremely severe).

Positive and Negative Symptoms Scale (PANSS):

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 The PANSS is a scale used for measuring symptom severity of schizophrenia. It is a 30-
item rating scale that quantifies positive symptoms which refer to an excess or distortion of
normal functions and negative symptoms which represent a diminution or loss of normal
function. It is also composed of 3 subscales: Positive scale, Negative Scale and General
Psychopathology Scale. Each subscale is rated with 1 to 7 points ranging from absent to extreme.
The range for the Positive and Negative Scales is 7-49, and the range for the General
Psychopathology Scale is 16-112. The total PANSS score is simply the sum of the sub scales.

Social

It is important to assess Mr. H’s social support and environmental background as these
factors can play a part in his compliance to treatment and affect his prognosis. We can obtain a
collaborative history from his family members to have a better understanding of his
socioeconomic status and financial stability as he claimed that his salary is not enough to sustain
himself and he financially depends on his family to support himself. We may also explore more
on the relationship Mr. H has with his family members as he claimed that he was not so close
with them and seldom interacts with them. If necessary, we can also refer him to social welfare
services to assess the socioeconomic background and living condition in his home to help plan
the management.

Treatment (As discussed above)

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 REFERENCES

American Psychiatry Association. (2016). Desk reference to the diagnostic criteria from DSM-5.
5th ed. Arlington: American Psychiatric Association.

Geddes, J., Price, J. & Mcknight, R. (2012). Psychiatry (4th edition). Oxford University Press.
ISBN 978-0-19-923396-0

Hany, M., Rehman, B., Azher, Y. & Chapman, J. Schizophrenia. Retrieved from
https://www.ncbi.nlm.nih.gov/books/NBK539864/.

Ministry of Health Malaysia. (2021). Clinical Practice Guidelines: Management of

Schizophrenia (second edition). Retrieved from
https://www.moh.gov.my/moh/resources/Penerbitan/CPG/Psychiatry%20&%20Mental
%20health/e-CPG_Management_of_Schizophrenia_(Second_Edition).pdf

Patel, K. R., Cherian, J., Gohil, K. & Atkinson, D. (2014). Schizophrenia: Overview and
Treatment Options. Retrieved from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4159061/.

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