Gaps Syndrome In Pregnant With Schizophrenia: Report Of One Case

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Gaps syndrome in pregnant with schizophrenia: report of one case

Summary

The case of a 29 -year -old patient with prodromic symptoms of schizophrenia at age 16 is presented, being diagnosed with paranoid schizophrenia at age 19, in treatment with atypical antipsychotics, with evolution torped by the constant abandonments of treatment of treatment. After 11 years of the first psychotic outbreak, the patient begins to ignore her mother and brother, increasing disorganization and aggressiveness already existing in the patient.

The interest of the case presented lies in evidencing the characteristics of the patient’s delirium, which coincide with the bolt syndrome described in the literature, it also allows usComplementary non -pharmacological treatment in these cases.

Introduction

Within the syndromes of false identification (SFI) 4 variants have been described, whose differences are found in the clinical presentation of each subtype .Within these variants is the Capras Syndrome (SC), Frégoli syndrome, intermetamorphosis syndrome and subjective doubles syndrome

The SFIs, among them, can be related to various psychiatric and non -psychiatric pathologies, within psychiatric pathologies, the most frequent is paranoid schizophrenia, less often can be found in mood disorders and disordersOrganic mental, cases of SFI have been described in non -psychiatric pathologies including endocrinological diseases such as hyperthyroidism, diabetes mellitus, as well as in vitamin B12 deficit, strokes, dementias, among other diseases, so they should be discarded previously if there is diagnostic doubt

Capgras syndrome was first described in 1923 in a 53 -year -old patient with chronic psychosis . This syndrome is the most frequent of SFIs, presenting in more than 4% of patients with psychotic paintings.

In pipple syndrome, patients keep the capacity for facial recognition preserved, however there is a deficit in the ability to perceive familiarity when seeing some faces with which there is a very close affective bond, in the described cases it is evident that in themarried or cohabiting patients The main double is the couple and in single people it is a parent or a brother.

Within the psychiatric symptoms of the SC, paranoid ideas and feelings of hostility towards the substitute are distinguished, the patient perceives the substitute as a threat that seeks to harm him causing rejection in him, which could trigger violence and aggressions culminated occasionally in homicide. 

This syndrome can have a chronic or transient present. It is observed more frequently in women in a ratio of 3: 2, not being differences between ages.

There are numerous hypotheses that have been described around their ethiopathogenesis due to the complexity that a daily phenomenon carries with it such as recognizing the face of an close person. Neuroimaging studies conducted suggest a relationship between graduation syndrome and alterations in the right cerebral hemisphere, especially in the frontal and temporal area, not having found at the time a specific lesion

Regarding the treatment this has to be individualized and multidiscilpinary, making an integral assessment of each patient . Pharmacological treatment includes atypical antipsychotics such as choice treatment. In non -pharmacological treatment, the use of behavioral cognitive therapy has been described, thus enhancing the action of antipsychotic drugs in the treatment of delusional symptoms, helping the patient to modify beliefs, so that applying this cognitive behavioral technique will be indispensable will be indispensable, to help the patient modify and find more adaptive explanations that would decrease the symptoms of anguish and thus the frequency of aggressive behaviors that could occur to "the imposter" or "impostors"

Gaps syndrome in pregnant with schizophrenia: report of a case 

We present the case of a 29 -year -old female patient, natural and from Lima, single, with a complete secondary instruction, currently without occupation. It was the product of an unwanted or planned teenage pregnancy, with evolution of gestation and institutional vaginal delivery without apparent complications. He received all immunizations, was taken to healthy children’s controls until 3 years of age, apparently without any alteration. No physical pathological history of importance. Without a history of psychiatric diseases in the family. It presents the only alcohol consumption at 14 years of age. The family is formed by the 57 -year -old father;Mother, 47 years old and healthy, younger sister than 26 years of age and healthy;And brother less than 8 years of age and healthy.

He began psychiatric symptomatology at age 16, probably prodromic symptoms of schizophrenia, 1q2 characterized by isolation, reluctant, tendency to crying and headache, was evaluated by psychologist of Center for Studies and referred to attention by psychiatry care.

At 17, I continue with recurring episodes of headache, unconcerned by personal hygiene and dressing;She was evaluated in 2 hospitals in Lima, she performed a nuclear magnetic resonance where no alteration was evidenced that explains the symptoms. A couple of months later, the patient for the first time "fled the house", finding her 3 days later in Pucusana. When the mother asked her why she had done it, the patient said she had confused a car and wanted to go to Huaraz originally.

At 18, the patient continued with tendency to crying for no apparent reason, Soliloquios, decreased her toilet at once a week, neglected her dressing and began telling her mother phrases like "Now why don’t you die?, Your blood will run on the track ". The mother comments that during this year it was the first time that the patient took a knife and pursued her through the house. For this reason the patient was taken to the insm H. Delgado-H.N., where they told him "clonazepam, risperidone and biperideno". The mother does not remember the doses of the medications she took during the following month or the diagnosis that the patient had. Patient continued to escape from home, aggressive against relatives, neglecting his cleaning and dressing, for this reason he is taken to Hospital H. Valdizán, where he was medicated with “Clonazepam, risperidone, biperideno, and quetiapina”, the mother does not remember the dose. With this medication, which was taken daily for an approximate time of 6 months, the heteroagresivity improved in general, pseudo -perceptions auditory commanders "kills your mother, go from the house", heteroagresivity against the mother, came to work in "aCeramic craft shop mandated ”. To the sixth month of treatment the patient again ran out of the house again and left the medication.

At 19 the patient was taken to Hospital H. Valdizán for an episode of psychomotor agitation, in this attention they told him the diagnosis of paranoid schizophrenia. Parenteral medication was indicated and continues with a habitual medication, but with higher doses. This medication was taken daily by the patient for a time of 1 year. During this year the patient persisted with auditory hallucinations, visual and inappropriate behaviors such as walking along the ceiling of the morning house. The mother comments that the patient at times helped in the chores of the house how to cook or wash things.

At 20, the patient was still threatening with relatives, which is why he returned to Hospital H. Valdizán, where he “increases the dose” of habitual medication, with which the patient becomes less irritable and aggressive. He was "more voluntary, he bathed daily, helped in the chores of the house". In addition, auditory and visual hallucinations, and Soliloquios decreased frequently. Apparently he continued taking his medication for about 2 to 3 months, after which he escapes from home again, thus interrupting the continuity of his treatment.

From the age of 21 to 29 years, the patient did not want to go to her controls at the Valdizán hospital, so that sometimes they had to take her forced. The mother comments that when the patient took her medication she helped with the chores at home. During these years the patient persisted with similar irritability symptoms, soliloquies, auditory hallucinations, but at a lesser frequency.

Four months before admission, the patient is taken by her mother to the Sergio Bernales hospital, where the 4 -day 4 -day gestation doctor and suspends psychiatric medication ("risperidone, quetiapina, clonazepam, biperidene"). This medication was being taken daily by the patient;However, she still presented the desire to want to escape her house, referring that she felt "as boring", little appetite and irritability.

Three months before admission, the patient escaped from her home about 3 times, returning by her own means to her home after 1-2 days. She is evaluated in Sergio Bernales hospital where they could not give her medication due to pregnancy. At the end of that month, it is taken by relatives to Huaraz, where he escaped again for 4 days, was found on the edge of the road, "unconscious and beaten". For this reason she was taken to the hospital of Caraz where she was treated and discharged. Upon returning to Lima, the patient continued to escape from home, this time for 4 days. When she returned home, the patient did not know her mother, she said “You are not my mother, go out of the house, I’m going to stay with my dad. My mother is a pretty, gringo -haired woman;Instead you are an old lady. Go away". The patient also did not know her younger brother. She said that “that child is not Frank (brother), he is another little boy. My true little brother is lost, I’m going to look for it ". It is for this reason that the patient used to leave her house and played the door of her neighbors "looking" to her brother. These two facts of ignoring these relatives began to present more frequently over the weeks persisting until their hospitalization.

Two months before admission, the patient continued to escape from her house about 5-6 times. In addition, he said that he listened to the voice of "Jehovah", which gave him orders to flee his house, in addition to visual hallucinations and inappropriate behaviors like undressing on the roof of his house. On several occasions he threw himself to the floor and "made abdominals", saying that "I didn’t want to be fat". In addition, on one occasion he threatened his mother with a knife from behind, but he did not attack her, "he only stated it", this because apparently a voice had indicated it.

In the month of admission the patient continued exercising at home despite being brewing. He escaped from home frequently for up to 3 days, which is why he lost his appointments for both his prenatal controls, and for his psychiatry controls at Hospital Sergio Bernales. For this reason patient enters for emergencies of the HD-HN INSM where the patient manifested to listen to voices. Ambulatory medication with haloperidol 10 mg vo 1d- 1n was indicated. A day after being seen in emergency, while her father was preparing breakfast, the patient took a knife and made a cut, apparently superficial on her back;This is because the patient heard a voice of her that told her that her father wanted to "abuse her and that he had to kill him". For this reason, it is brought again to the emergence of the INSM HD HN. Due to "attempted homicide and active psychotic symptoms" its entry to emergency observation is decided.

During the 8 days that the patient remained in emergency, he persisted with auditory hallucinations, referring that "Jehovah" spoke to her and gave indications. In addition, she said that she was not pregnant and that for this reason she had to exercise to "lower the belly". He continued to ignore relatives, he said they were "other unknown people" and that they wanted to hurt him. In addition, he denied presenting some disease. Also studied a scabiosis picture for which he received emergency treatment.

During the first month of hospitalization (November 2018), the patient persisted ignoring her relatives, referring that they were unknown and did not know why they came to visit her. The patient continued with the desire to exercise and at times she said she wanted to kill her baby. On November 22, 2018, the change of antipsychotic risperidone to Olanzapina is decided. The patient also studied melolcent vaginal flow associated with prurit. The patient also went during this month to her prenatal control in the Gineco-Obstetrics service at the Cayetano Heredia hospital, where it was indicated that there were no problems with pregnancy and also that it would be programmed for an elective caesarean section at 38 weeks. During the second month of hospitalization (December 2018), the patient continued to ignore her relatives. He also indicated that he listened to voices, but that they had decreased "a little" in frequency and that when he listened they told him words like "fat, get up", but that she decided to ignore them. The patient was quieter, she was more collaborative and participatory in the activities scheduled by nursing staff. By the middle of the month, the patient no longer tried. During this month the patient also went to her prenatal control at the Cayetano Heredia hospital, where no intercurrence was reported with pregnancy. During her third month of hospitalization (January 2019), the patient says that he still persists listening. The patient recognizes her mother at times, although she still persists ignoring her father and her brothers, she says she does not know where they will be. The patient has also increased her appetite, she acknowledges that she is brewing and refers to feel the fetal movements frequently. He has gone to his prenatal controls at the Cayetano Heredia hospital, where he was performed a final ultrasound where no alteration with the fetus was evidenced. He has been cited a new prenatal control for 01/23/19.

Discussion

The delirium of captures or "illusion of doubles", or illusion of sosias, is a psychopathological term that receives his name thanks to Jean Marie Joseph Capgras and J. Reboul- lachaux, which introduced this term to describe the picture in which a person has the firm conviction that someone in their environment has been replaced by another person, usually an imposter. The conviction of this idea can become so solid that it is quite complicated to change it, although the patient can notice that the person he does not know presents similar or almost identical physical characteristics. In the Captras Syndrome, the other person’s facial recognition is preserved, however;A failure occurs in the sense of familiarity with this. In addition, it turns out to be highly selective (family, friends, etc.), fact that differentiates it from another alteration of neurological origin, such as prosopagnosia.

In the case presented, a 29 -year -old pregnant patient is shown with the diagnosis of paranoid schizophrenia, who, within his clinical manifestations, presents a conviction that both his parents and his brothers are not really their "real relatives". When asked about the physical and facial characteristics of her parents and siblings, the patient affirms that these people are closely resembleThey are the real ones. This conviction that they are not their true relatives persists despite the questions that were made during their evaluations. In addition, this patient does not specify exactly where their true parents and siblings would be, referring that they are probably living elsewhere and have left it in the care of these people. These data referred to by the patient resemble the characteristics indicated in the Capgras Syndrome, which in this case would be part of a primary psychiatric disorder such as schizophrenia. Similar to the rest of the Mala identification syndrome, graduate.

In the case of patients with schizophrenia, collect syndrome can occur at any age and at any time during the evolution of the disease, a prevalence of 11% to 15%. On the other hand, in the general psychiatric population, the prevalence of bad identification syndromes reaches up to 1% and 3% in patients admitted to psychiatric hospitals. The patient of the case presented begins to express the table of theusional almost acutely, after a house leak event, persisting until today. During her hospitalization, after the beginning of antipsychotic treatment, there were days in which the patient referred to that she recognized her mother who visited her, however;In the following days she did not know her again. Regarding his father and his brothers, no change was evidenced regarding the conviction that they were not the real. To treat pipple syndrome, neuroleptics can be used, especially atypicals, due to their best tolerance, however;It has not been evidenced that these can be more effective than typical. The associated use of cognitive behavioral therapy for this type of delusion is also proposed, however;No results have been published regarding the use of this type of treatment. In the case presented, two atypical antipsychotics were used at different times, first risperidone and then wave, mainly for the treatment of schizophrenia, evidencing a slight improvement with respect to the painting of theusant after receiving treatment with the second antipsychotic. But this improvement was of a short duration, after that, the delusional syndrome was persisted as well as the rest of psychotic symptoms. The use of cognitive behavioral therapy could probably be associated with this pharmacological treatment and see in the future if this association produces any improvement with respect to the painting. It could also be considered a possibility, the use of electroconvulsive therapy, as in the case presented by Rapinesi et al, where after 6 electroconvulsive therapies applied to a patient with an episode of treatment syndrome resistant to treatment, the delusions could be resolved. This electroconvulsive therapy would serve not only for the treatment of the delusory picture, but also for the treatment of schizophrenia in this pregnant patient, which could be applied after childbirth. It is worth mentioning that bad identification syndrome, usually have a fluctuating courses of disappearance after the remission of the comorbid and reappearance disorder during relapses;However, it is important to mention that these delusional syndromes are usually the ones that persist most within the psychotic symptoms presented by patients with schizophrenia.

It is worth mentioning as a characteristic of this delusion, when it occurs within the context of a psychiatric disease such as schizophrenia, that there may be aggressive, violent behavior towards the person qualified as an impostor. These behaviors can manifest as verbal aggressions to physical aggressions, being able, even, even homicide, which in frequent cases can be parricides or infanticides. While it is true that in the case presented, the patient assaulted her parent due to a commanding audience, referred to by the same patient, it is likely that this has been added to the painting of theusional and thus has been able to strengthen in a certain wayThe decision to attack his father. In a way, it is important to identify in patients with a primary mental disorder, such as schizophrenia, the presence of this type of delusion, since when finding it, it can be a risk for both family members or subjects to whom they areHe does not know, as well as for the patient himself, even more so if it is a pregnant woman.

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