History
A 20-year-old roofer is brought to the emergency department by the police. He is under arrest after having been charged with assaulting his girlfriend. They had both been drinking and then had an argument during which he punched her several times. During the ensuing struggle he fell and struck his head on the kerb. Following this he was unresponsive for a few seconds. When the police arrived he was alert and denied any physical problems. While in the police van, on the way to the police station, he vomited and appeared to become unresponsive for approximately 30 seconds.
In the custody cell, he is loudly shouting and swearing at the accompanying police officers. On attempting to get a history, he becomes more agitated repeatedly shouting, ‘I know what you’re here for. They want you to give me a lethal injection.’
He is normally fit and well and has no previous history of psychiatric disorder or substance abuse. The accompanying police officers say that he has not been previously known to the police.
Mental state examination
He presents as a slim, reasonably kempt young man who smells of alcohol. He is agitated and restless, and eye contact is variable. He is difficult to engage and answers most questions by being verbally abusive. After some persuasion, he eventually acknowledges that he is being offered help and he agrees to cooperate with the assessment. His speech is loud, rapid and slurred. He says that he is worried that the police might want to kill him and that he can see bats flying around the department. Upon cognitive testing he is able to correctly tell his name and date of birth but is not able to correctly state the current day, month or year. His short-term memory also appears to be impaired.
Physical examination
Cardiovascular, respiratory and abdominal examination is normal. Upon neurological examination he has an up-going left plantar response but no other abnormality.
Questions
• What investigations would you want to carry out in this patient?
• The police and nurses tell you that he is ‘just drunk’ and request your advice about returning him to police custody as soon as you have finished your physical examination. What would be your response?
• Obtain further collateral history – previous medical records (including psychiatric and general practitioner notes if available) and further information from the police and the patient’s girlfriend/family.
• Urine illicit drug screen to exclude intoxication with drugs such as amphetamine or cannabis.
• Blood tests including full blood count (FBC), urea and electrolytes (U+Es), calcium, liver function tests (LFTs), thyroid function tests (TFTs) and C-reactive protein (CRP). The results of these tests will help to exclude infection or metabolic derangement.
• Computerized tomography (CT) brain scan to exclude cerebrovascular event (i.e. haemorrhage or infarction) or space-occupying lesion (i.e. tumour, subdural haematoma or abscess).
INVESTIGATIONS
ANSWER 54
Although he appears intoxicated with alcohol and agitated following the argument with his girlfriend there are several indicators of a possible organic cause for his current presentation (such as subdural haematoma). He has a history of having sustained a recent head injury that caused him to lose consciousness and since then he has vomited and had a further brief period of possible loss of consciousness. There is also a non-specific abnormality on neurological examination. His speech is slurred and he is agitated (although this could also be due to alcohol intoxication). In addition to this he has psychotic symptoms (believing that the police want to kill him and seeing bats) and cognitive impairment (disorientated to time and impaired short-term memory) which are probably of acute onset. While visual hallucinations can occur in functional mental illnesses (such as schizophrenia) they are relatively rare and often indicate the presence of an underlying organic disorder. Given all these factors it is important to rule out any possible organic causes of this man’s presentation by physical examination and appropriate use of investigations.
Given the high index of suspicion of an organic basis for this man’s presentation it is imperative that he does not leave the emergency department until this has either been excluded or he has received appropriate treatment. Your response to these requests should be to politely but firmly point out that there are some parts of this man’s presentation that do not fit with a simple diagnosis of ‘acute alcohol intoxication’. You should state that it is important he receives appropriate clinical care, based on the results of these investigations, to exclude other organic causes. If an organic cause is excluded and he is thought to be mentally ill, then the police could detain the patient under section 136 of the Mental Health Act 1983 to allow further assessment of whether he should be compulsorily admitted to a psychiatric hospital under the Mental Health Act 1983.
• The acute onset of cognitive problems or psychotic symptoms (especially visual hallucinations) may indicate an acute organic condition.
• Always have a high index of suspicion for organic causes of ‘psychiatric’ presentations and employ appropriate physical examination and investigations to rule them out.
• Alcohol intoxication may mask the presence of underlying physical conditions.
KEY POINTS
CASE 55:
STALKINGHistory
A 20-year-old mathematics student is referred by the university counselling service. He is currently suspended from his studies due to alleged harassment of a female student. He has been repeatedly sending this student text messages (over 20 per day for the last 6 months) and spends much of his day loitering around the halls of residence where she lives. He has told his family that he and the female student are engaged and that when they met, it was ‘love at first sight’. The female student denies this saying that she has never had a relationship with him, has no wish to do so and that she finds his behaviour towards her extremely upsetting. She has informed him on numerous occasions that she does not wish to have any contact with him. At the request of his tutor he was seen by the university counselling service. During the initial assessment he told the counsellor that he and the female student were in love and that he felt angry that she could not admit this and had reported him to the university. Since she did this his behaviour towards her has become more intense and he has had thoughts of killing her saying that this would be the only way to maintain their ‘pure love’ without the interference of others.
He has always been a somewhat shy and introverted person and he has never previously had an intimate relationship. He has no personal or family history of psychiatric disorder. He is socially isolated and has few friends, preferring to spend his free time playing computer games. In the last two months he has been cautioned by the police regarding his behaviour towards the female student but has no previous convictions.
Mental state examination
He avoids eye contact and is difficult to engage. He speaks in a monotonous voice and becomes much more animated when discussing his love for the female student and his hobby of playing computer games. His mood appears normal and there have not been any recent changes in his sleep pattern or appetite. Throughout the interview he professes his love for the female student and says that this is mutual but that she cannot show others how she feels because they would be jealous of their ‘special relationship’. He confirms that he has had intermittent thoughts of killing the female student as a way of maintaining their ‘pure love’. There is no abnormality of perception and his cognition is normal.
Questions
ANSWER 55
This stalking behaviour may be due to erotomania (also known as de Clerambault’s syndrome) in which a person falsely believes, with delusional intensity, that another person is in love with them. Erotomania is a descriptive term rather than a diagnosis and some its potential causes are shown below.
• Delusional disorder involves the presence of delusions with an absence of other psychopathology (i.e. no evidence of hallucinations or abnormality of mood). • Schizophrenia will have evidence of hallucinations, thought disorder and delusions. • Schizoaffective disorder has an equal presentation of schizophrenic and mood
symptomatology.
• Hypomania includes evidence of disinhibited behaviour and grandiose beliefs. • Organic disorders will show evidence of substance abuse or physical illness on
physical examination.
• Schizoid personality disorder shows a long-standing pattern of avoidance of social situations, emotional coldness and social awkwardness.
• Schizotypal personality disorder has a long-standing pattern of odd behaviour and ideas with magical thinking and quasi-psychotic experiences.
• Autistic spectrum disorder – since early childhood evidence of impairment in social relationships and communication; often accompanied by a narrow restricted range of interests and repetitive behaviour. Mindblindness means that they have
difficulties understanding the emotions of others and frequently misinterpret their intentions and feelings.
The main management of erotomania is treatment of the underlying disorder. However, in cases such as these an assessment should be made of the risk that the patient may pose to others. The object of the patient’s affection may be at particular risk and strong feelings of love may suddenly turn to feelings of frustration, grievance and hate if the patient feels his advances have been unfairly rejected. Other people may be at risk if the patient feels that they are somehow responsible for the failure of the ‘relationship’. In order to effectively manage this risk it may sometimes be necessary to involve other services/agencies such as the police, probation service and social services. Given that the patient may pose a particular risk to an identifiable individual, the issue of warning the person that he/she is potentially at risk should also be considered. Doing this may be a justifiable (and necessary) breach of medical confidentiality. This should only be done following discussion with a senior colleague and careful evaluation of the risks and benefits of disclosure and non-disclosure of this information.
• Stalking behaviour may be a symptom of mental illness.
• The management of such individuals may be complex and require the involvement of several different agencies (for example, psychiatric services, police, probation service and social services).
• Where there is evidence that a named individual may be at risk from the patient consideration should be given to breaking confidentiality and informing this person.
KEY POINTS