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Read case studies and answer the following questions
CASE EXAMPLE A
Campus security was called to the dormitory to assess a 19-year-old man who barricaded himself in his room and covered the windows with aluminum foil. His roommate reported that this man hasn’t been attending classes for the past week, hasn’t bathed or eaten, and has been mumbling that the FBI is monitoring all his communications. Security removed the door and took the man into custody and to the community mental health center for evaluation.
History of current episode: Information obtained by interview with the patient and with collateral telephone interviews with each of his parents, his college roommate, and his English professors. This is the first year away from home for this young man, who has been described as an “odd and reserved” person since teen years. Academically he did well his first semester at college, although he has made few friends and does not participate in any social or extracurricular events. His teachers describe him as a bright and quiet student. His parents, who live in a small town over 70 miles away from the college, expressed sadness but not surprise at his behavioral deterioration because they didn’t expect him to be able to cope with the discrepancy of the large college campus compared to his small-town previous experience.
Psychiatric history: Although he has never been hospitalized or had outpatient psychiatric treatment, this young man has been showing signs of emotional and cognitive disorganization since his early teens. During his high school years the patient became more and more aloof, and strange with both his family and friends. At times he would be mute for days at a time, remained in his room and refused to bathe. He said he did not have control over his thoughts and he believed he was possessed. In his junior year of high school his counselor recommended he attend a breakout group to help him learn interpersonal skills and make friends, but he never attended. The summer before going to college his parents asked if he wanted to see a therapist or counselor to talk about transitions but he said he didn’t want to do that and that he wasn’t concerned about living away from his family for the first time.
Medical history: Has had regular preventive care and immunizations through local family practice. In good health, weight proportion to height, denies smoking or alcohol or drug consumption. Broke his left wrist at age 7 years when he fell off his bike. Moderate acne in late teens treated with oral doxycycline for several months. No drug or food allergies. Allergic reaction to bee sting when 10 years old with swelling, shortness of breath, now carries EpiPen.
Family history: Has an older brother, 23 years old, who graduated from college and is now attending graduate school in business administration. Younger sister is 15 years old and in good health. Father is a business executive, has chronic obstructive pulmonary disease (COPD) related to long-standing cigarette smoking. Mother is an Episcopal priest and is in good health. Maternal uncle died at age 49, diagnosed with schizophrenia.
Personal history: Normal pregnancy and uncomplicated childbirth. Was an active and creative child who enjoyed reading, art, and cooking with his mother and grandmother. Parents said he started to become reserved and shy in middle school for no apparent reason. By early teens he seemed socially inept, had few friends, and preferred solitary play. Never interested in romantic relationships or dating in high school and spent most of his time studying or reading fantasy novels. Seemed to be withdrawn and serious, although denied feeling sad, or depressed.
Trauma/abuse history: Mild bullying in middle school, otherwise no apparent trauma.
Mental status examination: Well groomed, neatly attired, cooperative. Polite without motor abnormalities or gait. Moderate eye contact when directly addressed. Alert, mildly sedated, oriented to time, place, person. Attentive during interview and provided accurate albeit minimal history that was corroborated by family members. Based on fund of knowledge seemed of average intelligence. Speech is normal rate and soft spoken and at times mumbled responses to questions. Stated that he hears a soft voice in his head that tells him to “be careful” but offered no other explanation of voices. Denied visual or other perceptual hallucinations. Thought processes are linear and coherent. Reports that he believes people talk about him behind his back and that he is being controlled by unseen forces. Refused to elaborate on these thoughts. Stated that he has never thought of killing himself or anyone else. Described his mood as “fine” and refused to elaborate. Affect is flat. Demonstrates impulse control and alludes to feeling like an automaton. Judgment is reasonable in terms of recognizing consequences of actions.
Current medications: No regularly prescribed medications. Given lorazepam 1.0 mg orally in urgent care when brought in by campus security because of his extreme agitation. Slept for an hour after administration while waiting to be interviewed.
Differential diagnosis: Brief Psychotic Disorder versus First Episode of Schizophrenia. The duration of the episode is greater than 1 day but uncertain if longer than 1 month, and no previous psychiatric hospitalization. Teen years are suggestive of prodromal period of schizophrenia that may be precipitated by stress of independence from family and college experience.
1.In reviewing this chapter, which factors are important to consider for this patient?
2.What additional information would you like to have to be more comfortable in working with this patient?
3.How will you explain your diagnosis and treatment plan in relation to the patient presentation? What treatment options will you recommend and why?
4.What is your initial approach in negotiating treatment for this patient?
5.What medication changes would you want to discuss with the patient and how will you negotiate that with her or him?
6.What time frame do you propose for this plan, and how will you transition with the patient?
7.How will you coordinate care with the other providers working with this patient?
8.After stabilization, which psychotherapeutic approach would you take?
