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Dr. Andrew Rynne

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Having psychotic symptoms. Family history of chronic mental illness. Any treatment?

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Practicing since : 2003
Answered : 2190 Questions
This is more information on the case we have been taking about

• XXXXXXX has spoken to XXXXXXX siblings and learned that XXXXXXX had an episode like this while in college. His behavior was erratic and peculiar, and he eventually assaulted his college roommate, believing that the roommate worked for the KGB. It took about eight months for the situation to go from initial symptoms to the assault, and the symptoms escalated rapidly toward the end. XXXXXXX was placed on some type of medication by the college psychiatrist, but since XXXXXXX would not discuss it, the siblings knew no more. They reassured her that, "Oh, XXXXXXX is just fine. It was growing pains at college, being away from home for the first time XXXXXXX The siblings stated there was no mental illness in the family, except for Uncle XXXXXXX, who "had a little case of the nerves XXXXXXX XXXXXXX later learned that Uncle MoXXXXXXXdied in a state hospital for the mentally ill, where he had spent 14 years.
•     In retrospect, XXXXXXX says that early in their marriage, XXXXXXX had a huge fight with his department head, whom XXXXXXX believed was plagiarizing his work. They moved across country for another job as a result. XXXXXXX triumphantly told her that he had evidence of the plagiarism when the last two articles both of them had published began with the same letter of the alphabet.
• XXXXXXX recently came across some journals XXXXXXX had been keeping. She was troubled by them, but decided not to bring them to the interview, because "so much of it was nonsensical. How could it be useful?"
•     Finally, XXXXXXX and his wife both confirmed that after the accident, all the medical tests suggested by the physician were run, and the physician concluded that XXXXXXX suffered no medical effects from the accident. They bring the medical reports, including reports of various brain scans, which document this.

1. What would the new diagnostic AXIS hypotheses would be?
2. What further diagnostic evaluation do you believe is warranted?
Wed, 12 Dec 2012 in Mental Health
Answered by Dr. Jonas Sundarakumar 22 hours later

After this new information, we can take into account the following points:
- strong evidence of psychotic symptoms such as paranoid delusions.
- though there is one clear "episode" mentioned when he was in college (lasting for over 8 months), there are other pointers of an episodic psychotic process - apparent by the incident of accusations about plagiarism, plus some amount of disordered thinking, evidenced by his illogical conclusions that both the published articles began with the same letter. We find more evidence of this disordered thinking even later on, where his wife mentions about the "nonsensical" journals.
- organicity ruled out
- family history of chronic mental illness - most likely suggesting a schizophrenia in his uncle

Now, if we were to consider the most recent episode (in the initial case history) as a mood episode (as discussed earlier), then his symptoms would fulfill the criteria for a schizoaffective disorder (prominent mood and psychotic episodes, with atleast a 2 weeks continuous period of psychosis alone). So, in my opinion, the revised Axis hypothesis would be:

Axis I : Schizoaffective disorder
Axis II : None
Axis III: None
Axis IV: Occupational problems
Axis V: GAF 30 - 40

Further evaluation would be to confirm the recent mood episode, with a more targeted history and a detailed mental state examination. We also need to look for any other past mood episodes, in addition to the psychotic symptoms which have been highlighted. Rating scales like BPRS need to employed to quantify the severity of the current episode and for the purpose of monitoring treatment response. Further exploration of his personality can also yield additional information, say for example, whether there are any paranoid personality traits (nevertheless, his clear-cut delusions, disordered thinking and irrational behaviour leave no doubt of a psychotic syndrome).

Dr. Jonas Sundarakumar
Consultant Psychiatrist
Above answer was peer-reviewed by
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