Paranoid Schizophrenia Prepared by : Noor Al-Hakami pharm-d candidate KSU
Paranoid schizophrenia is one of several types of schizophrenia which affect around 40 % of people with schizophrenia It tends to appear later in life, usually around the age of 25 to 30 The main features are a preoccupation with one or more delusions or frequent auditory hallucinations, but nothing prominent in terms of disorganized speech, flat or inappropriate emotions The delusional content (the beliefs) of the person with paranoid schizophrenia is marked by grandiosity, or persecution, or both
Case presentation
T.F is a 30 y.o saudi female, single, jobless since childhood she was isolated, not interacting with her family, not socializing always prefer to stay alone In the last 5 years before admission she become paranoid, saying that she invented the washing machine and mobile, suspicious toward her family, not eating with them because she believe that they put poison in her food, so she was cooking for her self She became aggressive, hitting her mother and father, breaking the furniture, easily provoked, her sleep became disturbed, not taking care of her self, believe that her family want to kill her, talking to her self, hearing voices, always says there is F.B.I machines follow her, and also says I am talking to Allah and I am Mariam Bint Imran and there is special Quran for me
Two years after that, she started follow up at Al-Habib clinic and they diagnosed her as schizophrenia case, and she was started on Risperidone injections and the only thing was improved was the aggression and she became calm but still had delusions After 6 months of taking injections, she refused to continue and her case was deteriorating After that, she threatening to kill her self, she went to the kitchen and got a knife but her sister was beside her and took it In the last year before admission she stared threatening to kill her family and she was collecting knifes in her room, she tried to kill her mother by knife but her sister prevent her In the day of admission(15/11/2011), she tried to kill her father but brother also prevent her
Her father is 68 y/o and her mother is 46 y/o and they don t have any medical illness She has 8 brothers and 5 sisters and no history of psychiatric illness among them Normal mile stone, reach to secondary school then she refuse to complete her study in university, because ((university is under her level)) Jobless, living with family in Riyadh with good financial state
Medical: unremarkable Psychiatric: she was following at Al-Habib center 7 years ago, in 2011 was the first admission in Al-Amal complex Pre-morbid personality: No history of drug abuse, she was isolated, paranoid, not attending social gathering, prefer to stay alone
Appearance and behavior: she was covering her face, talking alone, refusing to answer, giving irrelevant answers. Talk: talkativeness, coherent but irrelevant answers with high tone Mood: irritable Thought content: persecutions delusions, losing of association Perception: auditory hallucination ( group of people talk about her) Insight: poor insight
Plan: Haloperidol 5mg IM (STAT) Risperidone 2 mg PO HS Clonazepam 2mg PO PRN Benztropine 2mg IM/PO PRN
Assessment Pt. is doing fine, no complains, Mood, sleep and appetite is good, but Still has the same psychiatric features Plan: (16/11) Risperidone 4 mg PO HS (20/11) Risperidone 6 mg PO HS
Assessment Pt. is still psychotic and disorganized, no improvement Plan: Start trifluoperazine 5 mg PO HS x 2days,Then to be 5 mg PO BD Risperidone 4 mg PO HS x2 days,then 2 mg PO HS x2 days,then D/C Benztropine 2mg PO PRN
Assessment Pt. still psychotic, has grandiose delusion, persecuted delusions, somatic delusions and hearing voices Plan: Trifluoperazine 5 mg PO AM - 10 mg PO HS (4/12/2011) 10 mg PO BD (11/12/2011) 10 mg PO AM 20 mg PO HS (25/12/2011) 5 mg PO AM 5 mg PO afternoon 20 mg PO HS (28/12/2012)
Assessment Pt. still psychotic, has grandiose and bizarre thoughts, in addition to auditory hallucinations Plan: Trifluoperazine 5 mg each 2 days until D/C Do basic investigations ( CBC with differential + ECG) Start clozapine 25 mg HS for 2 days then push up by 25 mg every 2 days tell we reach 400 mg CBC with differential every week
Assessment Pt. is doing fine, no more auditory hallucinations, sleep and eat well. But she is complaining of jerky movement and perioral abnormal movements Plan: Add, valproic acid 250 mg PO HS, then increase to 500 mg PO HS Continue, Clozapine 100 mg PO AM 300 mg PO HS Take valproic acid level after 5 days
Assessment Pt. general condition is stable, euthymic mood, denied current delusions or perceptual disturbance She has poor insight, but agree on taking medications regularly Plan: Dischage on: Valproic acid 500 mg PO HS Clozapine 100 mg PO AM 300 mg PO HS To follow up in clozapine clinic
Assessment Pt. is stable, but complain of increase salvation, little movement in her lip and mild jerky movement Plan: Valproic acid 750 mg PO HS then 1000 mg PO HS Clozapine 500 mg PO AM 300 mg PO HS Add, Benztropine 2 mg PO OD