CUANTIFICACIÓN DE LA BIOMASA FORESTAL RESIDUAL:

History

A 24-year-old man presents to casualty having got into a fight as he thought he was being watched and felt threatened. He appears to have fractured his thumb but is reluctant to let you examine him or order an X-ray. He looks suspicious and wary. When asked about his concerns he says that over the last few months he has been carefully monitored by government agencies. He has been hearing a voice out loud giving a running commentary on his thoughts and these are being broadcast to the government. Any machine enables the government to get inside his head and the voice is telling him it would be unwise to face the X-ray machine. The voice is not one that he recognizes and it is sometimes derogatory telling him he is stupid for giving his thoughts away for free. Initially the voice came and went but over the last few weeks it is present almost constantly and he cannot always sleep because even when he sleeps the voice comments on what he is thinking. He is exhausted.

The man is absolutely convinced that the government is after him but he cannot explain why. There is no previous history and he denies any substance use. Until a few weeks ago he had been working as a kitchen assistant but was sacked for leaving jobs unfinished. There is no family history of any psychiatric illness.

Mental state examination

The man looks unkempt. He is wary and looks quite frightened and agitated. His eye contact is fleeting and he constantly looks around him in a perplexed manner.

His speech is rambling and he does not express himself coherently. He occasionally uses words that you have not heard before and repeats them as though they have some significance. He does not come across as depressed. He has delusions of persecution. He has auditory hallucinations that provide a running commentary on every aspect of his behaviour. He has thought broadcast and thought withdrawal. He is orientated in person, but unclear about the time. He seems aware that he is in hospital but not quite sure why.

Questions

•What is the likely differential diagnosis in this case?

•What is the significance of the running commentary?

•What other symptoms may be commonly associated with this type of auditory hallucination?

ANSWER 15

The differential diagnosis is schizophrenia, schizoaffective disorder, drug-related psychosis and organic medical conditions. To make a diagnosis of schizophrenia, the symptoms and signs should be present for at least 1 month (as per ICD-10 criteria) and impact upon social and occupational or educational functioning. The following are usually present: delusions, hallucinations, formal thought disorder, ‘negative’ symptoms and abnormal behaviour.

A delusion is a firmly-held idea that a person has despite clear and obvious evidence that it is untrue. Common delusions in schizophrenia include:

• Delusions of control – belief that one’s thoughts or actions are being controlled by outside, alien forces (passivity). Common delusions of control include thought broadcasting where private thoughts are being broadcast or transmitted to others, thought insertion (thoughts being planted in their heads) or thought withdrawal (thoughts being taken from their heads). Thought passivity is the terminology used to describe control of one’s thoughts.

• Delusional perception – a real perception triggering a sudden delusional belief. • Delusions of persecution – belief that others are wanting to do the individual harm.

These persecutory delusions often involve bizarre ideas and plots.

• Delusions of reference – a neutral environmental event is believed to have a special and personal meaning. For example, a person with schizophrenia might believe an innocuous phrase on TV is intended to send a message meant specifically for them. • Delusions of grandeur – belief that one is a famous or important figure or the belief

that one has unusual powers.

• Somatic delusions are false beliefs about your body – for example, that a terrible physical illness exists or that something foreign is inside or passing through the body. Hallucinations can be experienced in any of the sensory modalities and include:

• Auditory hallucinations (hearing voices in external space that other people cannot hear). Certain types of auditory hallucination are diagnostic of schizophrenia. These include hearing voices providing a running commentary on the person’s behaviour or thoughts, two or more voices conversing with each other in the third person about the person, or if the individual hears his thoughts being echoed back. • Somatic hallucinations (these suggest schizophrenia or an organic cause).

• Visual hallucinations (seeing things that are not there or that other people cannot see). • Tactile, olfactory or gustatory hallucinations.

Formal thought disorder is a persistent underlying disturbance of conscious thought that is usually seen through spoken and written communication. This involves fragmented thinking experienced by the listener as being ‘ununderstandable’ or the train of thought or associations between statements is disconnected. They may respond to queries with an unrelated answer, start sentences with one topic and end somewhere different, speak incoherently, or say illogical things. There may be ongoing disjointed or rambling monologues in which a person seems to be talking to himself/herself or imagined people or voices. People with schizophrenia tend to have trouble concentrating. Some use neologisms, which are made-up words or phrases that only have meaning to the patient, or they exhibit perseveration, which involves the repetition of words and statements. Catatonic behaviour is sometimes present.

Negative symptoms reflect the reduction or absence of mental function and include reduced motivation, reduced use of speech and affective flattening.

• Schneider’s first rank symptoms described in 1939 remain the cornerstone of the diagnosis of schizophrenia. They include:

• Thought insertion, thought withdrawal and thought broadcasting.

• Running commentary, third person auditory hallucinations and thought echo.

• Delusional perception, passivity phenomena, delusions of control and somatic hallucinations.

History

A 21-year-old man presents in an extremely frightened state. He is absolutely convinced that he has been followed and his life is at risk. When walking through town he was sure people were watching him, talking about him and planning how to kill him. He can trust no one including his friends. He has come to the hospital rather than go to the police because he believes the police are behind the conspiracy. He believes they have installed surveillance cameras in his flat and have been watching him. He feels others are jealous of his talents and success. He is convinced he has special powers and that is how he found out about the plots against him. He has had to start carrying a knife so he can protect himself from all his enemies.

The man has had no previous contact with psychiatric services and he has no medical history of note. All was well until the last few days. His sister recalls that about six weeks ago her brother and a few friends went to a music festival. She is aware that his friends have smoked cannabis and taken Ecstasy (E) but she thinks it is unlikely that her brother joined them. He does not smoke and has no prescribed medications.

The man is about to begin his final year at university. He has been studying physics and philosophy at university. He and his girlfriend finished their relationship just before the music festival. It was a reasonably amicable break up, but had been a three year intense relationship. His interests include music and computer games. He has a good group of friends although over the last few days he has been avoiding them as he feels threatened by them.

Mental state examination

He is clearly frightened and suspicious, constantly looking around and trying to check what is going on. He makes intense eye contact when not looking elsewhere. He struggles to focus on the interview. His speech is rapid and his thoughts are not coherent. He jumps around from topic to topic. His mood is labile in that at times he seems to settle down but then quickly becomes alert and appears to be overactive. He has delusions of persecution and rather grandiose ideas about his own skills. He has auditory hallucinations, which tell him that he should kill if he needs to. He thinks the cameras in his house are being used to monitor his thoughts but he does not quite have thought withdrawal. He does not have any self-harm ideation. He is orientated in person in that

CASE 16: