Question

A 25-year-old young woman is brought to the emergency department by the police after being found walking in traffic at a busy city intersection. The police place her on an involuntary commitment after she states that she was instructed to kill herself by accusatory, commanding voices. On examination the patient appears disheveled, with an indifferent and flat affect, and disorganized thought processes. She answers most questions monosyllabically. When questioned about experiencing auditory hallucinations she answers in the affirmative, but she is unable to articulate coherently the details of her experience. Throughout the examinations she appears intermittently distracted by internal stimuli; when asked what her experience is in the moment, she states: "They are talking to me." The patient's family reports that she became increasingly withdrawn after she moved away from home to attend graduate studies at a local university. The family reports that her academic performance in college was above average, but since starting university she has struggled to complete her school work. Since moving, she has also become more isolative: she made no new friends, stopped talking to her college friends, and maintained only sporadic contact with her family. The family was unaware of the patient experiencing any hallucinatory experiences. She had no past history of drug misuse and her urine toxicology screen was negative, effectively ruling out a drug-induced psychosis.

QUESTIONS:

1. What could have possibly triggered this young woman's episode?

2a. What are two differential or possible diagnoses for her?

2b. Briefly explain each of these possible diagnoses.

3. What are the evidences which have informed each of the two possible diagnoses you listed in #2?

4. What is this young woman's actual diagnoses, and explain possible treatment options

Answer 1

1. From the information available, it can only be said that moving away from her home to study at the University may be the triggering factor behind her mental health issues and her episodes.

2. a) Two possible diagnosis which can be made are of Schizophreniform Disorder and Schizophrenia.

2. b) Schizophreniform Disorder: This is a psychotic disorder which falls in between the Schizophrenia spectrum and in this disorder the patient may have delusions, hallucinations as well as disorganised behaviours. Emotional expression may be diminished and inadequate. For diagnosis of this disorder, these symptoms must be present for atleast one month.

Schizophrenia: All the symptoms discussed in Schizophreniform Disorder are the same as Schizophrenia but the main difference is about the duration. For diagnosis of Schizophrenia, these symptoms must be present for atleast six months.

3. The main reasons behind the two possible diagnosis are:

• The patient was having auditory hallucinations.
• Her speech was not coherent.
• Her thoughts were disorganised.
• Her speech tone was monotonous.
• The family reported that she got detached after joining University.

These symptoms are indicative of a Schizophrenia spectrum disorder.

4. There is no information given about the duration of persistence of these reported symptoms but it can be assumed that she has completed atleast one semester in the University (as it has been said that her University performance has deteriorated from the college performance). Thus, it can be assumed that the symptoms are present for atleast six months and a diagnosis of Schizophrenia can be given. Though, it must also be said that information must be gathered about the duration for more accurate diagnosis.

In the context of treatment, antipsychotic medications can be prescribed to the patient such as olanzapine and Cognitive Behaviour Therapy can be used as a treatment option alongside medication. Both pharmacotherapy and Cognitive Behaviour Therapy must be given together for better prognosis.