NU673 Unit 5 Wilson Disease Seminar Reflection Example

Psychiatric Until Something Says Otherwise: A Seminar Reflection on a First Psychosis, a Hand Tremor and a Liver Test Nobody Had Explained

[Student Name]

Purdue University Global

NU673: PMHNP Diagnosis and Management Across the Lifespan I

Unit 5 Seminar Reflection

[Instructor Name]

[Date]

The patient and seminar group are composite; values are bracketed.

The Case and My Starting View

Our fifth seminar case was [Priya], a [24]-year-old graduate student in chemistry admitted with [three] weeks of paranoia, believing her lab mates were contaminating her samples, poor sleep and irritability. She had no psychiatric history. Her urine drug screen was negative. The case notes gave her admission bloods: a normal blood count, normal thyroid function, and an ALT of [96] U/L with an AST of [71], which the admitting team had attributed to "possible alcohol or supplement use," although she denied both.

When the facilitator asked for initial impressions, I said this looked like a first episode of a primary psychotic disorder, probably schizophreniform, and that I would start a low dose of an antipsychotic. I believed, and said, that a young adult with psychosis, a negative drug screen and normal basic tests has a psychiatric illness until proven otherwise. I treated the liver enzymes as incidental.

What Happened in the Seminar

The facilitator released a second part of the case. On day [four], after starting risperidone, [Priya] developed a coarse tremor of both hands that worsened when she held her arms out, her speech became slurred, and she drooled slightly. The team first attributed this to the antipsychotic. My classmate, Marcus, asked whether anyone had considered Wilson disease, pointing out that a young person with psychiatric symptoms, a movement disorder and unexplained abnormal liver tests has all three of its main features.

I pushed back at first, saying that extrapyramidal side effects from risperidone explained the tremor well. Marcus agreed that they might, but asked why her liver enzymes had been raised before she took any medication. That question stopped me. I had explained each finding separately and never asked whether a single illness could explain them all.

The facilitator released the next results: serum ceruloplasmin [9] mg/dL, well below normal, and a slit-lamp examination showing Kayser-Fleischer rings. Twenty-four-hour urine copper was raised. The diagnosis was Wilson disease.

What I Learned About Wilson Disease

Wilson disease is an inherited disorder of copper metabolism that causes copper to accumulate in the liver, brain and other tissues. The EASL guidelines describe its presentations as hepatic, neurological or psychiatric, and they recommend testing for it in patients with unexplained liver disease combined with neurological or psychiatric symptoms, using ceruloplasmin, urinary copper and a slit-lamp examination for Kayser-Fleischer rings (European Association for the Study of the Liver, 2012).

A review of its psychiatric aspects found that [30 to 40] percent of patients have psychiatric manifestations at diagnosis and that [20] percent had seen a psychiatrist before being diagnosed. When psychiatric symptoms came first, the average delay to diagnosis was more than two years (Zimbrean & Schilsky, 2014). The review also noted that psychiatric symptoms without obvious liver or neurological signs can lead to misdiagnosis.

Wilson disease is treatable with copper chelation or zinc, and delay can allow irreversible liver and brain damage. That is what made my confident first impression dangerous.

How My View Changed

I did not conclude that every young person with psychosis has a rare medical disease. Most do not. What changed was my understanding of the purpose of the first-episode workup. Freudenreich and colleagues describe it as combining broad screening, exclusion of specific treatable diseases chosen by their likelihood and consequences, and baseline measures (Freudenreich et al., 2009). I had done the broad screening and stopped. I had not asked which treatable diseases fit her particular pattern, and I had dismissed an abnormal result instead of explaining it.

I also noticed how quickly I attributed the tremor to the drug I had just started. The explanation was plausible, which made it easy to stop thinking. I think the same thing happened with the liver enzymes on admission: a label, possible alcohol or supplement use, was attached to a result that did not fit her history, and the label then stood in for an explanation. In a patient who has just been given a psychiatric diagnosis, every other finding is at risk of being read as noise, and that is the habit this seminar asked me to break.

Commitments for My Own Practice

1. When a first-episode patient has any unexplained abnormal result, I will not call it incidental until I have asked whether it fits a single diagnosis with the psychiatric picture.

2. In young people with psychosis and abnormal liver tests or a new movement disorder, I will consider Wilson disease and ask for a ceruloplasmin level.

3. When a new neurological sign appears after starting a medication, I will list the medication as one explanation, not the only one.

4. I will review the first-episode workup against a structured list, not just the tests that came back normal.

References

European Association for the Study of the Liver. (2012). EASL clinical practice guidelines: Wilson's disease. Journal of Hepatology, 56(3), 671-685. https://doi.org/10.1016/j.jhep.2011.11.007

Freudenreich, O., Schulz, S. C., & Goff, D. C. (2009). Initial medical work-up of first-episode psychosis: A conceptual review. Early Intervention in Psychiatry, 3(1), 10-18. https://doi.org/10.1111/j.1751-7893.2008.00105.x

Zimbrean, P. C., & Schilsky, M. L. (2014). Psychiatric aspects of Wilson disease: A review. General Hospital Psychiatry, 36(1), 53-62. https://doi.org/10.1016/j.genhosppsych.2013.08.007