Case Study
Dr Mohammed Al-Uzri
 Background
 History
& MSE
 Progress
 Issues
information
& Risk
to consider & Take away
message
Background Information
X
is in her 20’s single, unemployed
and living with her mother
 Parents separated but father lives
nearby
 Mother suffers from ME and has
strong beliefs regarding alternative
therapies
Family History of Mental Health
problems and suicide
Three family members have committed suicide
 Paternal Great Uncle - hung himself (diagnosis of
manic depression)
 Paternal Great Grandfather – drown himself
(diagnosis of depression)
 Paternal Great Uncle - shot himself (diagnosis of
depression)
Three other family members have attempted to
commit suicide
 Paternal Great Aunt: Depression
 Paternal Grandfather: Depression
 Father: Diagnosis of anxiety /depression.
History



July 2009 stopped going out, isolating herself and
felt very tired most of the time.
first contact with the psychiatric services was
October 2009 when admitted to the Bradgate
Unit under the MHA after the police attended the
family farm where she had tried to throw herself
to a fire that she set to hay bales.
presented as suspicious and paranoid, expressing
delusional beliefs about having published a diary
which had caused offence and the Government
was going to torture and kill her.
History
 reported
that she had been sexually
abused, but did not elaborate on it
 discharged from in November 2009
under the care of the PIER team
(Early Intervention in Psychosis)
 May 2013 her care was transferred
to the CMHT
History


July 2013, when under the care of CMHT, urgent
referral to the Crisis Resolution and Home
Treatment Team (CRHT) due to her emerging
psychotic symptoms in the form of increasing
preoccupation with persecutory delusional
believes. She was also reported to have a poor
sleep pattern at the time. With the patient’s
agreement CRHT prescribed oral antipsychotic
Did not engage well with the CRHT and despite
their daily visits, at one stage, she refused to
take any anti-psychotic medication.
History


further deterioration in her mental state marked
by experiencing a “hanging noise” which she
related to changes in the electromagnetic energy
marking the end of the world.
She contacted the National Space Centre in
Leicester to ask them about any changes in the
weather conditions that could explain her noises
and resultant thoughts. She provided her contact
details to them, in case they needed more
information from her on this regard.
History


called the police on one occasion, in the early
hours of the morning, saying that she was a
psychic and explained some of her thoughts
about the end of the world.
Later she reported that she had met a healer who
had put his hands on her head and had cured her
from her mental health problem; therefore she
did not need the medication any more.
History


The emergency services were called as she was
dancing in her bedroom and threw herself
backwards onto her bed hyper extending her
head. She felt a sudden tearing sensation at the
back of the neck and complained of pain and
numbness in her limbs. She was taken to
hospital.
Once the physical problem was evaluated and
cleared, she was assessed by (CRHT) and
admitted informally into Bradgate unit on 20
August 2013.
History


“thoughts coming into her head. On direct
questioning, she denied hearing voices but later
admitted to hearing “silly things”. She also
admitted that her voices were asking her “to
prove her worthiness” and “to do things”. She
confirmed that she had washed her in the toilet
bowl following instructions from the voices. She
also suggested that by making her wash her hair
in the toilet bowl, the voices were actually
“inviting her to convert to Buddhism”.
She reported that she was pregnant and that she
was going to give birth to the Messiah. She was
trying to swallow coins to show on x-ray that she
is pregnant.
MSE

was noted to have wet hair as she had had three
cold showers since her arrival to the ward as she
felt hot. Noticed to be shivering from cold and
was easily distractible. Her speech was noted to
be normal in pace and volume. Subjectively, she
reported that her mood was “round about
normal”. She was also found to be vague and
guarded. She initially denied abnormal
perceptions but later confirmed that she was
experiencing command auditory hallucinations.
She was found to be oriented in time, place and
person with intact cognition. She exhibited little
insight into her condition.
Progress


mental health assessment was requested and she
was detained under Section 3 of the Mental
Health Act due to her high risk of serious selfharm (responding to commands) and placed
under level one observation
Later There was uncertainty regarding her
compliance with oral medication, therefore
Risperidone was discontinued and she was
started on Flupenthixol Depot. She expressed
concerns about the Depot harming her baby,
causing him/her “HIV or something else”. She
reported to be feeling the baby’s movements.
Progress




Physical examination and investigations were
normal
Considered leaving family home to settle in
nearby city to enrol on a education course or take
employment
Considered the use of Community Treatment
Order
Patient responded well to Olanzapine and
discharged with view to transfer to care of
Assertive Outreach
Medication History



Risperidone was reduced, at the request of
patient, from 3mg in December 2009 to 0.5 mg
in July 2010 as she was feeling better. This
reduction in the dose caused a “re-emergence of
her delusional and intrusive thoughts”.
Medication increased but changed to Quetiapine
and later in October 2010 changed to Olanzapine
15mg on patient requests and intrusive thoughts
progressively faded from December 2010 to
February 2011.
Patient requested again the reduction in the dose
of Olanzapine. Medication was reduced; as she
wanted to be off medication as soon as possible.
Medication History


July 2011 she experienced a re-emergence of her
delusional thoughts, but she did not want to
increase the dose of Olanzapine therefore the
medication was changed to Aripiprazole but no
improvement.
Therefore it was changed to Amisulpride February
2012. There was a good response to this
medication, but patient experienced side effects
and in May 2012 she was moved back to
Aripiprazole and later back to Amisulpride as
delusional intrusive thoughts were increasing.
Medication History



The dose of Amisulpride needed to be increased
in July 2012 and the intrusive thoughts faded
away again. However, patient reduced the dose
progressively completely discontinued it, against
medical advice in May 2013.
During admission in 2013, had side effects on
Typical and Atypical depots and was keen on
going back to oral antipsychotics
Discharged on oral Olanzapine as he recovered
from her symptoms
Care & Support provided






she could rationalise thoughts, hence required
constant reassurance and logical challenges.
Insisted that alternative therapies were going to
help with her problem as “toxins were the cause
of her experiences”.
She started and stopped the psychology sessions.
Referral to Safeguarding and counselling for
victims of rape
Intensive support/visits from team hence referral
to CRHT and AO
Referral for SW regarding Social Care needs
Risk
 Relapse
of Mental Illness
 Self Harm
 Poor engagement with services
 Non-compliance with medication
 Vulnerability
Issues to consider
1. Severity of symptoms and risk
2. Complex needs
3. Different services involvement and engagement
4. Treatment options and compliance
5. Use of MHA
6. Social Care issues
Take Away Message
Individually Tailored Care
Thank You