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Case PresentationByDr Aziz MohammadPGT, Department of PsychiatryKhyber Teaching Hospital PeshawarHistoryMr AR, a 50 years old man from Jalal Abad, Afghanistan, married twice, father of 14 children, not formally educated, living life as a farmer but not working for the last two years. He was admitted via OPD after he failed to show significant response to treatment on outdoor basis for over two years.
History (cont..)He presented with complaints of having centipedes in his brain for the past two years. He would describe the movements and nature of these centipedes in great detail as they would crawl reaching one ear and the other, the back of the neck and behind his eye balls. Over the last few months The patient would shake his head with an attempt to stop movements of these centipedes but in vain. He was quite distressed by these symptoms and his social and occupational life was adversely effected.History (cont..)His mood remains low with diminished interest in daily activities and extreme difficulty going to sleep. Every time he feels movements of these centipedes especially when it feels behind his eye balls, he fears getting blind. In desperation he has tried to kill the centipedes by poisoning them by ingesting insecticides and kerosene oil on different occasions. He was still intending to poison them again with something more lethal if the doctors did not help him. History (cont..)He gets annoyed by alternative explanation for his symptoms by doctors, family or relatives and will reject the finding in CT brain which was performed an year ago by a local doctor. He visited a number of local doctors and went to India for treatment one year ago after a reported fail surgical attempt to remove the centipede from his brain. History (cont..)The operation was reportedly performed in Quetta by E.N.T surgeon where the patient was shown a dead centipede (Record not available). There was a surgical scar behind his left auricle.The patient believes that the surgeon failed to remove female pregnant centipede that has now given birth to several offspring.
Past HxApart from receiving treatment from multiple doctors and faith healers, he was treated by psychiatrist with olanzapine 10 mg daily and fluoxtine 40 mg daily for about three months with no significant improvement in his symptoms.Family HxHis father died 20 years ago because of a sudden death with no known causes. His mother is alive and has no known medical or psychiatric illness. He has 3 brothers and 4 sisters and is 2nd in birth order. His elder brother died because of some brain tumor 4 months ago. There is no other significant medical or psychiatric history in the family
Personal HxNormal delivery, normal Developmental Milestones. Reports uneventful happy early and late childhood. Has received no formal education. He Can read quran (Nazira). Has been working as a farmer in his village until over the past 2 years. Married, has 2 wives, 10 daughters and 4 sons, living in a house which consists of 6 rooms.Uses snuff, but denies use of any other illicit drugs. There is no history of any encounter with the police or law.Premorbid PersonalityPatient describes himself as sociable, with good coping skills in stressful conditions, has no known leisure activities and gives importance to religious and cultural values. His cousin describes him as a bit strict by nature, with mild anger outbursts from time to time but there is no history of paranoid, schizotypal or schizoid personality traits. Mental State ExaminationA middle aged bearded man, normal hight and built, dressed appropriately in shalwar qamees. There were no evidence of self neglect, abnormal behaviour or movements. He was cooperative, Rapport was established and maintained till the end of the interview. Mood was subjectively and objectively low, with no explicit death wishes or suicidal thoughts.His speech was relevant, coherent, of normal tone and volume. There were no formal thoughts disorder.He has got delusion of being infested by centipedes along with Somatic hallucinations. No obsessions, auditory or visual hullucinations could be illicited.His cognitions was intact, with normal attention and concentration. Both short term and long term memory were intact.Patient did not have insight into his illness.Physical ExaminationHis GPE and Systemic Examination including CNS Examination was unremarkable withBP 130/85, pulse 84/min, and temp 98 F.
DiagnosesOn the basis of history and MSE, my 1st diagnosis according to ICD-10 On Axis lF22.0 Delusional disorder with comorbid mild to moderate depression (F22 Persistent delusional disorders) Monosymptomatic hypochondriacal psychosisMy differential diagnoses includeDepressive Illness with Psychotic FeaturesSchizophrenia Diagnoses (cont..)On axis ll ( Disabilities).. Score 1-5Personal Care: 2Occupation: 5Family and House Hold: 4Broader Social Context: 4On Axis lll (contexual Factors)Wrong treatment by faith healers and other health care providers.Problem related to education and literacyInadequate social support, has to look after a large family.Death of brother 4 months ago
ManagementShort termPatient was admitted to Psychiatry ward for management.The patient and his family were reassured and counseled about nature of the illness and its management. Informational care was provided empathatically. Initially direct confrontation was avoided to build a therapeutic alliance with the patient. He was advised baseline investigations including FBC, Liver and Renal Functions tests, CXR and ECG.He was started on on risperidone 6 mg in divided doses, fluoxetine 40 mg OD in the morning and Lorazepam 2 mg at Night. Management (cont..)IntermediateSerial MSE were carried out.HAM-D was applied to assess severity of depression which showed mild to moderate depression. He was assessed for Psychosocial support. The dose of risperidone was increased to 10mg daily after 2 weeks of admission.
Management (cont..)Attempts were made to shake the belief of the patient. Psychodynamic formulation was wade and he was assessed for suitability for Cognitive Behaviour Therapy.CBT sessions were started, however patient was not very keen on continuing CBT sessions and wanted a quicker relief. He insisted to be discharged so that he could go to a Neurosurgeon for removing the centipedes completely.In view of the poor response to medications in the past, he was started on ECT along-with his antipsychotic medication.
Management (cont..)IntermediateThe patient showed improvement with medications and ECT with reduction in his distress, low mood, improved sleep and he no longer needed to shake his head because of reduction in movement of the centipedes and healing of the wounds. Although he was still convinced about the dormant state of centipedes and expressed fear of their reactivation after getting discharged from the hospital.
Management (cont..)Long Term ManagementPatient was discharged on will after improvement with 3 ECTs. we have to assure good compliance with medications and set realistic treatment goals without instilling false hopes. We would have continued with CBT sessions but he could not stay longer in the ward because of his personal problems.We will monitor him for complete recovery by regular follow up to our OPD.
PrognosisShort Term: In view of response to medications and ECT the short term prognosis seem satisfactory.
Long Term: Inspite of good prognostic factors like absence of 1st rank symptoms of schizophrenia, negative family history, stable and sociable pre-morbid personality and late onset of the disorder at the age of 53, the long term prognosis would depend on patients adherence with treatment, social support and health belief system and hence seems guarded.
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References (cont..)7) The British Journal of Psychiatry, Vol 153(Suppl 2), Jul 1988, 37-40.Monosymptomatic hypochondriacal psychosis.Munro, Alistair
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