Case Presentation Dr Andrew Hill GPST2 Dr Jackson/Routh team Leverndale Hospital, Glasgow

76 yr old female ‘xx’ PC: Initially presented to GP with anxiety and panic attacks PC: Initially presented to GP with anxiety and panic attacks HPC: Reviewed by GP on Day 0. Gave history of several months. More rapid deterioration in 2/52 prior to presentation. HPC: Reviewed by GP on Day 0. Gave history of several months. More rapid deterioration in 2/52 prior to presentation. Problems multifactorial in origin Problems multifactorial in origin

Main concerns: anxiety, overvalued idea regarding argument with neighbour. Suffering from panic attacks. Main concerns: anxiety, overvalued idea regarding argument with neighbour. Suffering from panic attacks. Also concern over mood. Appetite poor, weight loss noted by family. Feelings of worthlessness. Sleep very poor. Concentration poor. Loss of function and behavioural change. Also concern over mood. Appetite poor, weight loss noted by family. Feelings of worthlessness. Sleep very poor. Concentration poor. Loss of function and behavioural change. Started on mirtazepine 15mg nocte for ‘agitated depression’. Further consultation prompted urgent referral to CMHT Started on mirtazepine 15mg nocte for ‘agitated depression’. Further consultation prompted urgent referral to CMHT

Reached crisis. Was staying with daughter. Wandered from house. Found in nearby field near a river. Hypothermic. Intent unclear but thoughts of wanting to die. Reached crisis. Was staying with daughter. Wandered from house. Found in nearby field near a river. Hypothermic. Intent unclear but thoughts of wanting to die. Assessed by Psychiatry. Discharged with local follow-up. Assessed by Psychiatry. Discharged with local follow-up.

Reviewed by Dr xx and CPN (xx). Impression: Severe depression with distress Reviewed by Dr xx and CPN (xx). Impression: Severe depression with distress Deterioration in mental state. Increasingly withdrawn. Mood deterioration. Delusional quality to beliefs re. neighbours. Deterioration in mental state. Increasingly withdrawn. Mood deterioration. Delusional quality to beliefs re. neighbours.

Day prior to admission family described as mute, unresponsive. Eyes closed. Had to be lifted from chair to bed. Sleepy. Day prior to admission family described as mute, unresponsive. Eyes closed. Had to be lifted from chair to bed. Sleepy. Following day, increased agitation. For fixated on delusions. Then 15:00 withdrawn and unresponsive again. Mute with no interaction at all. Following day, increased agitation. For fixated on delusions. Then 15:00 withdrawn and unresponsive again. Mute with no interaction at all. Admitted as emergency to xx Hospital ~Day30 Admitted as emergency to xx Hospital ~Day30

Past Psychiatric History Nil Nil Past Medical History Hypertension Hypertension Retinal Vein Occlusion Retinal Vein Occlusion Varicose veins Varicose veins

Drug History (Prior to admission) On repeat: On repeat: Aspirin 75mg od Aspirin 75mg od Simvastatin 20mg nocte Simvastatin 20mg nocte Losartan 50mg od Losartan 50mg od Acutes: Acutes: Diazepam 2mg PRN Diazepam 2mg PRN Mirtazepine 15mg nocte Mirtazepine 15mg nocteNKDA

Family History Youngest of 4 siblings Youngest of 4 siblings All 3 brothers suffered from depression (all deceased now) All 3 brothers suffered from depression (all deceased now) Eldest brother committed suicide in 1984 by drowning. Has also had ECT. Eldest brother committed suicide in 1984 by drowning. Has also had ECT. Mother: Suffered from mental health problems. No known diagnosis. Died when xx was 13 years old in Psychiatric Hospital ‘of starvation’ Mother: Suffered from mental health problems. No known diagnosis. Died when xx was 13 years old in Psychiatric Hospital ‘of starvation’ Father died of cancer Father died of cancer 2 children with no mental health problems 2 children with no mental health problems

Personal History Born and brought up in xxyy place, Ireland Born and brought up in xxyy place, Ireland Lived in isolated location Lived in isolated location Mother died at young age. Little contact in 2 years prior to this. Mother died at young age. Little contact in 2 years prior to this. Good relationship with father. Happy childhood despite difficulties. No abuse Good relationship with father. Happy childhood despite difficulties. No abuse Got on well at School. Left aged 14 and went to work in local bakery. Got on well at School. Left aged 14 and went to work in local bakery. Moved to Scotland when around 20 years old for ‘a better life’. Worked in hotel as telephonist. Met husband in 1962 in Scotland. Moved to Scotland when around 20 years old for ‘a better life’. Worked in hotel as telephonist. Met husband in 1962 in Scotland.

Married daughters (1965, 1967). Sadly, one stillbirth (girl) 1969 and one son born 1970 (died at age of 1 during operation). Married daughters (1965, 1967). Sadly, one stillbirth (girl) 1969 and one son born 1970 (died at age of 1 during operation). Worked in various jobs. Latterly as Home help organiser in Social Work department. Retired in 1996 Worked in various jobs. Latterly as Home help organiser in Social Work department. Retired in 1996 Recently, declining health of husband. Main carer following recent hip operation Recently, declining health of husband. Main carer following recent hip operation Premorbid personality: ‘Solid’, ‘great organiser’. Private person but good at making friends. Premorbid personality: ‘Solid’, ‘great organiser’. Private person but good at making friends.

Social History Lives with husband in their own home Lives with husband in their own home Independent Independent Retired but looks after husband Retired but looks after husband No financial concerns and no dependents No financial concerns and no dependents Non smoker. No alcohol. No drugs Non smoker. No alcohol. No drugs No forensic history No forensic history Ongoing legal dispute with neighbours Ongoing legal dispute with neighbours Protective factors: important role in family. Strong Catholic faith. Protective factors: important role in family. Strong Catholic faith.

On examination (on admission to xx Hospital) A&B: Casually dressed lady, moderate build. Looks her age. In wheelchair. Eyes closed. Showing no emotion. No interaction. A&B: Casually dressed lady, moderate build. Looks her age. In wheelchair. Eyes closed. Showing no emotion. No interaction. Obeying commands, then resumes previous posture. Looks tense/rigid. Held arms in position placed in during examination. Obeying commands, then resumes previous posture. Looks tense/rigid. Held arms in position placed in during examination.

MSE Cont’d Speech: Mute. Prior to deterioration had been slow and monotonous Speech: Mute. Prior to deterioration had been slow and monotonous Mood: Appears sad. Flattened affect. Mood: Appears sad. Flattened affect. Thought: Unable to assess. Delusional according to history (persecutory, guilt) Thought: Unable to assess. Delusional according to history (persecutory, guilt)

MSE cont’d Perception: Not obviously responding to any hallucinations Perception: Not obviously responding to any hallucinations Cognition: Unable to assess. No concern from family. Cognition: Unable to assess. No concern from family. Insight: Unable to assess. Prior to presentation had shown some insight ‘this is what mental illness is like’ Insight: Unable to assess. Prior to presentation had shown some insight ‘this is what mental illness is like’ Risk: Risk regarding nutrition. No immediate risk of DSH. However, previous act Risk: Risk regarding nutrition. No immediate risk of DSH. However, previous act

Impression Differential diagnosis Differential diagnosis Initial management plan Initial management plan

Ongoing assessment Physical examination unremarkable Physical examination unremarkable Bloods reveal hyponatraemia (129), otherwise normal. Normal urine and serum osmolalities. ?iatrogenic Bloods reveal hyponatraemia (129), otherwise normal. Normal urine and serum osmolalities. ?iatrogenic Mirtazepine stopped (in part due to concern from family re. psychosis) Mirtazepine stopped (in part due to concern from family re. psychosis) PRN diazepam PRN diazepam

Progress following admission Initial catatonic presentation seemed to resolve. Asking if she had been in coma. Replaced by severe psychomotor retardation. Flattened and restricted affect. Aware unwell but limited insight. Attributed all problems to lack of sleep. Initial catatonic presentation seemed to resolve. Asking if she had been in coma. Replaced by severe psychomotor retardation. Flattened and restricted affect. Aware unwell but limited insight. Attributed all problems to lack of sleep. Next few days, deteriorating mental state. Delusions of guilt and nihilistic delusions ‘I’m not real’, ‘You’re not real’. Sleep poor. Started on diazepam and zopiclone Next few days, deteriorating mental state. Delusions of guilt and nihilistic delusions ‘I’m not real’, ‘You’re not real’. Sleep poor. Started on diazepam and zopiclone Fluctuating consciousness over next few days. One episode of decreased responsiveness associated with urinary incontinence Fluctuating consciousness over next few days. One episode of decreased responsiveness associated with urinary incontinence

Further Action 13/8/12. Observed over weekend. Psychotic Depression. Started on Sertraline. 13/8/12. Observed over weekend. Psychotic Depression. Started on Sertraline. EEG to exclude seizure activity EEG to exclude seizure activity CT Brain CT Brain 15/8/12. Deterioration. Refusing medications at times. Refusing food. Detained on STC. Started on olanzapine. 15/8/12. Deterioration. Refusing medications at times. Refusing food. Detained on STC. Started on olanzapine.

Ongoing treatment 20/8/12. Decreased oral intake. No progress despite good medication compliance. Decision made for course of ECT (T4 then T3). ‘ECT doesn’t exist’ ‘My family don’t exist’ 20/8/12. Decreased oral intake. No progress despite good medication compliance. Decision made for course of ECT (T4 then T3). ‘ECT doesn’t exist’ ‘My family don’t exist’ 24/8/12. Received first ECT. Patient has now had 7 treatments and has shown signs of improvement 24/8/12. Received first ECT. Patient has now had 7 treatments and has shown signs of improvement 4/9/12. CTO application made (granted 18/9/12). 4/9/12. CTO application made (granted 18/9/12). 10/9/12. Improvement noted. Improving sleep. Less delusional. Better compliance. Sertraline increased. 10/9/12. Improvement noted. Improving sleep. Less delusional. Better compliance. Sertraline increased.

Points of interest Unusual age of first presentation given family history and significant stressors in life Unusual age of first presentation given family history and significant stressors in life Unusual presentation Unusual presentation Catatonia Catatonia