35 year old female presented with wrist Slash, telling some one told me to do so. she is married having two children.No significant stressors.History suggestive of psychotic illness for past four years which is episodic. Poor compliance with treatment.Premorbid personality well adjusted.No history of BPAD or MDD. when the patient reported she was on olanzepine 15 mg and sertraline 50 mg from a psychiatrist when she tried self harm now for first time.Mood depressed ,no depressive ideas ,percecutary and referential ideas present along with pseudohallucination commanding to commit suicide. Also complaints of palpitations,fear , running out behaviour in response to pseudohallucination. Olanzepine uptitrated to 25 mg, Sertraline changed to desvenlafaxine 50 mg along with bzd considering associated low mood which was persisting.Parient became euthymic suicidal ideation disappeared full improvement noticed in 20 days. Suddenly next day started pseudohallucination and running out behaviour,mood changes ,dsh ideation. Considering the primary diagnosis of Psychosis , possible worsening of psychotic features with SNRI desvenlafaxine stopped.Patient returned to premorbid level in one week and discharged on olanzepine 25 mg and bzd. Due to complaints of sedation bzd tapered down next visit and within two days patient attempted suicide telling commanding hallucination. How can be proceeded with the case . Please opine. @Dr. Shama Rathod @Dr. Sumi Aswin

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Dear Dr Saleem Psychiatrist Hello Really a nice case for differential diagnosis n latest in management .....worth discussing from the above mentioned sign n symptom with history of treatment ... i would like to opine as Psychotic Depression .... because of presenting signs n symptoms .. along with the above medication i would like to keep her on Long acting antipsychotic .....preferably - flupenthixol or haloperidol - every 15 days ... to have a sustained concentration of anti psychotic in blood to prevent relapse. Then i would like to gradually reduce the oral medication .. in my experience they respond best to long acting antipsychotic n very well ... in addition after recovery .. i would like to add dietary supplement .. as supportive n then psychotherapy individual n family psychotherapy .... for further prevention of relapse ... n complete recovery till the return of premorbid personality. this is my experience of last 15 years with almost 1000 patient ... with very good results now a days i am using ....neurostimulation therapy RTMS n Ultra Brief Pulse therapy ..... under anesthesia ... which gives almost complete recovery in 15 days .... thanks for putting up nice case .
Sir... In this case the possibilities which I would like to strongly consider are complex partial seizures, treatment non adherence and psychosis breakthrough on antipsychotic maintenance medication (BAMM). Kindly rule out CPS. In my limited experience, I have many such cases ultimately turning out to be CPS and improvement with mood stabilizing anticonvulsant. Ask the relatives to get a video of such breakthrough episodes, do a EEG and if possible video EEG. Otherwise also, starting valproate will be good. Check for treatment adherence and if u consider BAMM as possibility, start on long acting antipsychotics and if depression is the problem, why not go for clozapine which has anti suicidal effects too...
What are Contraindication of e c t therapy.
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Considering the worsening of symptoms... over time... and seriousness of yhe symptoms in view of suicide attempts and poor compliance ... following us suggested.. 1. ECT ... which will help in benefit over a very short time... reducing suicide ideation and allay psychotic ft.... This will help in acute mg... should be given atleast 6.. in nxt 3 wks. 2. Shift her on LAI.... uf olanzapine is acting good thn Olanzapine Pamoate... Otherwise Resprdn consta is quite effective. 3. No antidepressants at this stage... hwvr after ECT ... valproate can be added fr mood features and fluctations. 4. BZD during night xcpt on days prior to ect. Hope it is helpful
Thank you
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Consider alternate diagnosis like dissociative disorder. First rank symptoms are often seen as a part of dissociation. Or complex PSTD. Or Disorders of Extreme stress NOS (DESNOS) . Stressors invariably include abuse history. If not fitting, then maybe schizo-affective? Lithium/lamotrigine is often helpful (together with an atypical) esp given preponderance of depressive symptoms.
Thank you for your time
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What is your opinion regarding e c t with anti psychotic as alternative treatment in this case?
Thank you for your suggestion
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Many times people try committing suicide when the depressive symptoms are improving not when they r fully depressed since they don't have the adequate energy for attempt although they have suicidal ideations. In this case may b he tried when he was mostly euthymic. As far as treatment concerned earlier answers sufficient Modified ECT most preferably Long acting psychotics
I think they r not pseudo but classical hallucinations. Olanzapine at 25 mg has very high sedation and I doubt how she was functional. Even a bzd add on was given so why not a mood stabilizer? Partially treated psychotic depression or schizoaffective disorder might be taken into view. I highly recommend ECTs for her acting out behaviour.
Thank you
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A question although... Hw r they qualifying as pseudo hall. Acting out on hallucination points to lack of insight.... so prob commanding hall. As fr dx... its a psychotic disorder.. prob qualifying as schiz. Pls also rule out organic contributing disorders with metabolic profile and ncct brain
Yes ,acting out is clear but during entire treatment period repeated MSE quality of true hallucination cannot be established ,she identify it's coming from internal space and she clearly differentiate its quality as 'not like ' the talk I hear every day. I guess may be due to she was on antipsychotic drugs on the day of admission itself .. what you think..
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Mood incongruent to thought Commanding Hallucination Suicidal attempt or whatever due to may be True Hallucination provisional diagnosis Schizophrenia.. ECT Should be given...Its a psychiatry emmergency case...
Thank you
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Command hallucinations and suicide with poor compliance, episodic .. probably schizo or schizoaffective.. mect and clozapine can be of use.. after acute management can consider adding mood stabiliser..
Thank you doctor
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