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• W2994205159 abstract "CASE He bares it all Police have arrested Mr. L, age 62, 3 times in 36 hours after spotting him walking naked in public. With the county jail jammed to capacity, police bring him each time to our hospital's emergency room. After his first arrest, Mr. L matter-of-factly tells us, I want to walk naked and starve myself to death. His self-harm exhortations amplify with each visit until--at the third presentation--he reports that he has not eaten for at least 2 days. Mr. L had been living on the streets for nearly 1 month. Before that, he had been in jail for approximately 1 month after attacking a nursing home patient. He has been hospitalized twice in 5 months for severe depression and personality disorder and has engaged in numerous disruptive behavioral episodes and feeble suicide attempts. At this latest presentation, he appears disheveled and lacks judgment and insight into his condition. We readmit Mr. L to the psychiatric unit to re-evaluate his treatment. He had been on citalopram, 60 mg/d, and aripiprazole, 10 mg/d, but he says he stopped taking the medications because they were not improving his mood. What diagnosis do you suspect? a) a psychotic disorder b) depression with psychotic features c) depression without psychotic features d) a personality disorder The authors' observations We readmitted Mr. L with working diagnoses of: * major depressive disorder with psychotic features, based on his suicide threats and complaints of depression * personality disorder not otherwise specified, based on his behavioral episodes, apparent desire to be cared for (Table 1), and refusal to get better during 2 recent hospitalizations. HISTORY His best friends As a child, Mr. L had no friends. His father was physically present but emotionally distant, so he relied on his mother for emotional support. Throughout his teens and early adulthood, his mother continued to do his laundry, buy his food and clothes, and run his life. When he married in his early 20s, his wife assumed this role. Mr. L avoided psychiatric care for most of his but did not socialize outside the house, lacked ambition, and seemed content to depend on his wife. He worked primarily as a janitor or housekeeper but was constantly getting fired and drifted from job to job. His wife told us that when he was supposed to be working, he spent hours staring at the walls and watching TV. Mr. L's recent troubles began approximately 2 years ago, when he suffered a shoulder injury. He underwent physical therapy but refused needed surgery because he lacked money and health insurance. As the shoulder pain intensified, Mr. L quit his job. While out of work, he stopped attending physical therapy sessions when his depressive symptoms began to offset the shoulder pain. He suffered loss of concentration and motivation, increased fatigue with hypersomnia, and decreased appetite. He lost 10 to 12 lb in 1 year. Mr. L also started having trouble focusing on reality and developed obsessive fears of malfunctions around the house, such as the furnace blowing up, the stove catching fire, or the toilet backing up. At one point, he began urinating and defecating in his pants to avoid using the toilet. He began to feel hopeless and several times tried to suffocate himself by placing a plastic bag over his head. He also grew irritable, angry, and aggressive--mostly toward his wife, who increasingly feared him. He started blaming her for everything wrong in my life and began contemplating stabbing her to death or striking her head with a hammer. Five months ago, Mr. L was involuntarily hospitalized for depressive symptoms, suicidality, and continued homicidal thoughts toward his wife. The attending psychiatrist started olanzapine, 5 mg nightly, for psychotic features, and citalopram, 10 mg/d, for depression and anxiety, and ordered one-on-one observation to prevent additional suicide attempts. …" @default.
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• W2994205159 date "2008-03-01" @default.
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• W2994205159 title "The Patient Nobody Liked: Mr. L's Recurrent Suicidality and Aggressive, Disruptive Behaviors Anger Patients and Hospital Staff. What Is His Diagnosis? How Would You Get Him to Stop 'Acting Out'?" @default.
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