Case Studies

Case 9 - A 50-year-old man living in a hostel

You are asked to see Mr Tomkins, a 50-year-old living in a hostel for people with chronic mental health problems. The staff there have observed him making strange movements of his mouth and tongue. He denies feeling bothered by these movements, and says that he wants to talk no more about anything. The support worker tells you that he spends most of his day smoking and engages very little with staff or other patients. He needs encouragement to wash. He does not pose any management problems and the staff feel he is quite happy in himself.

Mr Tomkins has lived in the hostel for 20 years. He was placed there after closure of the local psychiatric asylum where he was an inpatient for most of the 1970s. You obtain the old notes and find that he was diagnosed with paranoid schizophrenia in 1975. He has not had any delusions or hallucinations for over five years. His current medication is procyclidine 5 mg tds and haloperidol decanoate (depot) im 150 mg every four weeks. This has been decreased gradually from a dose of 300 mg every four weeks during his last admission five years ago.

• a. What is the most likely psychiatric diagnosis and why?

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  Correct answer:

  Residual or chronic schizophrenia. He had paranoid schizophrenia years ago, with delusions and hallucinations, but for the last five years he has not had these ‘positive symptoms’ (see Chapter 6). He exhibits a number of negative symptoms of schizophrenia: lack of motivation, social withdrawal and lack of concern for social conventions.

• b. Why do you think the patient was prescribed procyclidine?

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  Correct answer:

  Procyclidine is prescribed to treat the Parkinsonian side-effects often caused by typical antipsychotics (see Chapter 34).

• c. The Support worker has noticed the strange movements develop over the last six months and asks what is causing them. What do you tell him?

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  Correct answer:

  That the movements are known as tardive dyskinesia and are often seen in people who have been on long-term treatment with typical antipsychotics; long-term use of haloperidol is the most likely cause in this case.

• d. How could you treat his movement disorder?

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  Correct answer:

  His depot medication could be gradually reduced further, and the procyclidine could also be reduced. Tetrabenazine is sometimes helpful if these measures do not improve the symptoms.

• e. Give two advantages and two disadvantages of depot medication compared with taking tablets.

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  Correct answer:

  Advantages: the patient does not need to remember to take tablets; adherence to treatment can be monitored more reliably. Disadvantages: having injections can be unpleasant; there may be problems with the injection site as for all injections; many patients find the experience disempowering.