PeriPAN Case of the Month – December 2023
Each month, OBs and PCPs call PeriPAN with a wide variety of mental health questions. Find out how PeriPAN helped an OB during this consultation.
Patient: 26-year-old female G6P5. Baby was 2 months old at the time of the consult.
Reason for PeriPAN Consultation: OB called PeriPAN for assistance with a diagnosis and treatment. The PeriPAN psychiatrist referred for a Direct Consult for depression and anxiety.
Explanation of the Case and Outcome of the Call: The patient reports dealing with anxiety, depression, bipolar, and schizophrenia since the age of 12 years old. Symptoms started following sexual, physical, and emotional abuse from her mother’s boyfriend from age 9 to 12 years old. Since that time, the patient has had frequent self-harming behaviors, suicide attempts, psychiatry hospitalizations, medication trials with poor adherence, multiple stays at the juvenile detention for crimes, incarceration in prison, and polysubstance (Alcohol, Methamphetamine, cocaine, and cannabis) use since the age of 12. CPS was involved and for three years the patient and siblings lived with her father, but she was running away from home and started using recreational substances and alcohol by the time she was 12 years old. Her current depressive symptoms started about one year ago. She had an unplanned pregnancy and given the reported symptoms of depression and PTSD symptoms, her OB started her on Zoloft, which she took for a few months but stopped due to homelessness. The patient continued to have persistent symptoms of depression, anxiety, panic, and PTSD symptoms. The patient also reports that she is experiencing worsening of command auditory hallucinations of a male voice telling her to hurt herself, which started when she was 12 years old; the voice is very distressing and more prominent when her depression is worse. Also reports VH of seeing shadows.
Additional Patient Information
Substance use History:
Alcohol: Started at 12 years and drinks about 12 packs daily on the weekend. The last drink was one month ago. The patient has tried AA in the past, which was beneficial.
Cannabis: Smoke marijuana from 12 years old to 20 years old. The patient smoked one pound daily.
Cocaine: The patient used Cocaine from 12 years old to 20 years.
Methamphetamine: Started at 25 years old and used for a few months. The last use was 4 months ago. Vaped for a couple of months and stopped due to physical ill health.
The patient is in a stable and supportive relationship with her boyfriend for 3 years. The patient has been pregnant six times and has five children. Four of her children live with her, and one lives with her godmother. Her baby is two months old, and she is bottle-feeding the baby. The patient’s highest level of education is tenth grade. She is currently unemployed and is trying to get a job to support herself and her children. She currently supports them through food stamps. Her mother recently got out of jail.
After a direct PeriPAN Consult, we were able to formulate the below diagnoses:
DSM -5 DIAGNOSIS(ES) CONFIRMED
Post-Traumatic Stress Disorder, Chronic
Major Depressive Disorder, Moderate, with mood congruent psychotic features
Poly Substance (Methamphetamine, cocaine, and cannabis) Use Disorder, Severe, In early remission
Alcohol Use Disorder, Severe, In early remission
DSM- 5 DIAGNOSIS(ES) STILL UNDER CONSIDERATION
Bipolar II disorder, Depressed, with mood-congruent psychotic features
DSM–5 DIAGNOSIS(ES) WE RECOMMEND REMOVING AT THIS JUNCTURE: Schizophrenia
Take Home Point:
The greatest take-home message from this case is how much trauma and adverse childhood experiences can predispose, precipitate, and perpetuate mental illness. The more adverse childhood experiences, the worse the mental illness.
There is also a huge interplay between people’s environment and the outcome of their mental illness. In her case, hanging out with friends who used substances made her engage in it, which worsened her condition. Also, she could not adhere to her medication regimen due to homelessness.
Also, I noticed that a lot of people with responses to trauma present with symptoms that can mimic several psychiatric diagnoses like bipolar and schizophrenia. In this case, due to her trauma response, she was diagnosed with schizophrenia and bipolar.
A patient like this would need multisystem and multidisciplinary intervention to recover. Some of the systems that can come into play are social services, medical, psychiatry, chemical dependence rehabilitation, and even her family. She will benefit from Assertive Community Treatment to ensure compliance with her medication and hospital visit.