Hello,

Thanks for your query,

The important aspects of your query are:
•     Age 36 years
•     smoking marijuana
•     Complaints of: STM loss, stubbornness, disorganised behaviour, procrastination, belief that you are trying to control him and lack of insight for problem
•     Personality: Impulsive

Before answering, I need following information to help you better:
•     Total duration of problematic behaviour, STM loss and ADHD like symptoms.
•     Your relationship with patient
•     Any history suggestive of: suspicion that others are talking about him or want to kill him, talking or laughing to self
•     Approximate amount of marijuana smoked per day

Waiting for your reply,

Regards

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Hello again,

It is nice that you are a medical person too and it will help me to make you understand the scenario better.

Regarding ADHD, being absent minded and impulsiveness, before the onset of current exacerbation of symptoms, are points in favour of ADHD. But we cannot assume all current problems because of ADHD.

As current exacerbation symptoms are for 6 months in duration, then substance induced behaviour problems become the first diagnosis in planning the management of the patient.

Even in presence of Schizophrenia like symptoms it will be considered substance induced disorder.

Apart from ADHD and substance induced disorder, third possibility which is to be considered is Personality disorder especially cluster B group.

To understand it better I am giving brief information regarding personality disorders:

Definition: Personality disorders as enduring subjective experiences and behavior that deviate from cultural standards, are rigidly pervasive, have an onset in adolescence or early adulthood, are stable through time, and lead to unhappiness and impairment. When personality traits are rigid and maladaptive and produce functional impairment or subjective distress, a personality disorder may be diagnosed.

Personality disorder subtypes classified in DSM-IV-TR are: schizotypal, schizoid, and paranoid (Cluster A); narcissistic, borderline, antisocial, and histrionic (Cluster B); and obsessive-compulsive, dependent, and avoidant (Cluster C).

Many persons exhibit traits that are not limited to a single personality disorder. When a patient meets the criteria for more than one personality disorder, clinicians should diagnose each. Personality disorders are coded on Axis II of DSM-IV-TR.

Personality disorder is a common and chronic disorder. Its prevalence is estimated between 10 and 20 percent in the general population, and its duration is expressed in decades. Persons with personality disorder are frequently labelled as aggravating, demanding, or parasitic and are generally considered to have poor prognosis.

Personality disorder is also a predisposing factor for other psychiatric disorders (e.g., substance use, suicide, affective disorders, impulse-control disorders, eating disorders, and anxiety disorders) in which it interferes with treatment outcomes of other psychiatric disorder and increases personal incapacitation, morbidity, and mortality of these patients.

Persons with personality disorders are far more likely to refuse psychiatric help and to deny their problems than persons with anxiety disorders, depressive disorders, or obsessive-compulsive disorder. Personality disorder symptoms are alloplastic (i.e., able to adapt to, and alter, the external environment) and ego-syntonic (i.e., acceptable to the ego).

Points in favour of Personality Disorders in your husband case are:
•     Impulsivity
•     Lack of concern
•     Substance abuse
•     Procrastination
•     Rebelliousness

But again current exacerbation of symptoms can be explained only by substance induced disorder. Long term and excess of substance abuse (marijuana) can lead to delirium and cognitive deficits which can manifest in form of Short Term Memory loss.

Hope I have not confused you much.

Wishing a good health for your husband.

Regards,

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