assignment

Loren M. Scher, M.D.

Barbara J. Kocsis, M.D.

“Dorothy Franklin, a 54-year-old former waitress, was brought into the psychiatric emergency room (ER) by her husband for escalating delusions and visual hallucinations. Her husband reported that she had been episodically agitated for about 10 years, uncharacteristically suspicious for about 6 months, and complaining of daily hallucinations for weeks to months.

The patient referred to her experience as “my nightmare” and explained, “I see a judge standing in front of me. Plain as day. He is a good judge, but I throw bombs at him and can’t stop. I’m terrified!” The patient and her husband could not identify a precipitating event and denied that she took medications or illicit substances that might trigger these experiences.

Four weeks prior to this evaluation, Ms. Franklin’s husband had taken her to an emergency room because the symptoms had “spun out of control” and “she was tortured by the hallucinations.” At that time, she had a normal physical examination and negative laboratory workup. She was psychiatrically hospitalized, given a diagnosis of unspecified schizophrenia spectrum and other psychotic disorder, and prescribed low-dose risperidone and clonazepam.

The vivid hallucinations diminished markedly within days of starting the medication, and she was discharged from the psychiatric unit after 4 days. For a few weeks, she did not mention the judge. Despite medication adherence, however, the same visual hallucination returned and has been present almost constantly for a week prior to their return to the ER.

Ms. Franklin had been “completely fine” until her early 40s. In the ensuing decades she had seen multiple psychiatrists for agitation, paranoias, and occasional aggression. She had received a new diagnosis of “schizophrenia” when she was 45, but most of the other diagnoses were “not specific.” She and her husband could not recall the names of all of the many psychiatric medications that she had been prescribed over the years, but they included antidepressant, antipsychotic, anti anxiety, and more-stabilizing medications.

Ms. Franklin had smoked half a pack of cigarettes a day for man-years but only rarely drank alcohol and never used recreational drugs. She had worked as a waitress for 20 years but quit 10 years prior to the evaluation because of too many “dropped trays”, misremembered customer orders, and noticeable irritability. Around that time, she was arrested for “hitting someone” in a shopping mall, and she and her husband decided to reduce her stress level.

The patient had two healthy adult children in their late 20s. She had one sister with “depression and irritability.” The patient’s mother had passed away 10 years earlier at age 70. She had been wheelchair bound for years because of severe dementia, postural instability, and involuntary movements. The patient’s maternal grandfather “got sick” in his late 50s and completed suicide with a forearm at age 62.

On mental status examination, Ms. Franklin appeared her sated age, with thin body habitus and good grooming and hygiene. She sateen to her husband, holding his hand and often looking to him when asked questions. She had moderate psychomotor slowing, and noticeable involuntary “dancelike” movements of her trunk and upper extremities. Her eye contact was intermittent but intense. Ms. Franklin described her mood as “not well at all,” and her affect was blunted and minimally reactive. Her speech was soft and slowed, with minimal spontaneity. Her thought process was linear but slowed. She was preoccupied by paranoid

delusions and visual hallucinations. She reported actively hallucinating during the interview. She denied suicidal and homicidal thoughts or plans. On cognitive examination, she was alert and oriented to person, place, and time. She had good attention and concentration, although

she had significant impairments in both short- and long-term memory. Her performance on the Mini-Mental State Examination and clock drawing test revealed moderate impairment in planning and visuospatial tasks.

In the ER, initial test results, including extensive laboratory testing, were all normal. The patient was admitted to the inpatient psychiatric unit for safety and for further workup of her psychotic

symptoms.”

*From: DSM 5 Clinical Cases, Barnhill, J. (Ed.), 2014.