1. Case Presentation Dr. Hawari team Presented by: Dr. Ali mohammed Bahathig

2. Aim: This case was presented for: management purposes

3. HISTORY 35 year old saudi male, single, major, lived in Riyadh with his Family. Informants were patient ’ s Father & brother. Brought by his family & policeman. Chief complaints: Abnormal believes. Isolation. These symptoms started 2 months ago.

4. History of present illness: Patient was in his usual state of health till 2 months ago when his family observed that: Isolated. Easily provoked. Preoccupied. Having idea that his colleagues are detectors, especially one of his close friends. (they want to recruit him) Later on, he said that his father also works as a detector. Talking non sense with his father about this issue.

5. Accordingly, he started to react with this idea: Not drinking or eating with them. Excessive checking of TV, radio ….etc He left his home and stayed in a flat. His family discovered incidentally that he was Abusing cannabis and absent from his work

6. When he felt that his family knew his location, and his brother confronted him regarding cannabis abuse. He threatened his family. Then he left his flat and stayed in a hotel. The family went to check the flat and found that he covered the TV and all mirrors, disassembled the receiver. finally, he escaped from Riyadh. He went to Jaddah & Taif & lived in hotel their. His family brought him to Riyadh by police & he was arrested for 24 hours.

7. There was no hx of depressive symptoms. There was no hx of manic or hypomanic symptoms. No other psychotic symptoms. No death wishes or suicidal ideas.

8. Past Psychiatric history: There was no psychiatric illness before Medical& Surgical history: Patient not known to have any medical illness. No surgical history

9. Family history: Father 69 year old hypertensive, retired from ministry of higher education. Mother 65 year old Hypertensive, diabetic, housewife. He had 6 brothers& 2 sisters, he is the 5 th among them. Older brother has a psychiatric illness.

10. Personal history: Attended school at 6 years of age. Excellent performance. Good relationships with his teachers and siblings. Graduated from Air forces school. Premorbid personality assessment: Introverted, sociable Stable relationships with his friends.

11. Mental state examination: Appearance: Young male, around his stated age, accepted grooming & hygiene. Guarded, not cooperative. Talk: relevant, ↑ tone &volume. Mood: irritable.

12. Though: No formal though disorder Denied any abnormal thought or perception. Denied any substance abuse. Denied death wishes, suicidal idea or homicidal tendency. Cognitive function: intact. Insight: poor insight.

13. Impression: Axis 1: DDx: Substance induced psychosis Schizophreniaform Delusional disorder Axis 2: deferred. Axis 3: nil. Axis 4: no obvious stressor.

14. Plan: Admit this patient: clarify the diagnosis stabilize this patient Basic investigation + urine toxicology start olanzapine 10 mg Po Nocte

15. Provisional diagnosis: Delusional disorder

16. Hospital course: First month : aggressive, guarded, argumentative, isolated poorly insighted. denied any drug abuse asked to be discharged or transfered to RKH he refused : to take his medication. to be visited by his family. to talk about his problem.

17. He claimed that his family want to control his life, they are forcing him to do things against his well and they admitted him as a punishment. He claimed that the treating team is against him and they are not real doctors. Also he claimed that there was conspiracy between his family and treating team.

18. Urine sample was +ve for cannabis Plan: Olanzapine ↑ to 20 mg PO Nocte. Clopixol accuphase 100 mg IM Q3/7 as PRN

19. Second month: Patient still the same Still refusing any visitor Started to take his medication easily. Plan: personality assessment → He Refused D/C Olanzapine strated Risperdal

20. Third month: At beginning : patient show some improvement: More sociable Interacting well Taking his medication easily But, still refusing any visitor. To be transfer to RKH. Patient deteriorated again.

21. He started again to be uncooperative He refused to be seen by any doctor Refused to attend ground round Started to be suspicious toward treating team, nursing staff and some patients???? Not interacting with other patients and Praying alone.

22. Plan: continue on Risperdal 6mg Po Nocte start Risperdal consta 25 mg IM Q2/52

23. Forth month: Patient still the same uncooperative, argumentative refuse to see us or his family He claimed that he had a wife & 1 baby ( his family wanted him to be separated from his wife & to get married with another woman)

24. He wandered how could we brake the rules, and keep him for this long period without any obvious reason. He is not satisfied with our treatment. Still want to be transferred to RKH.

25. Thank you