Can you describe your most interesting/challenging case?

[ClinPsycMasters]

I am not speaking of most difficult patients--I started another thread about that sometime ago.

I am talking about the patients that were most perplexing to you. Do you recall a particular patient whose diagnosis or treatment really stands out in your mind? The kind of patient who really tested your mastery of psychological/psychiatric expertise and clinical skills?

I'd be interested if you be so kind as to share.

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[whopper]

I wrote about this patient before on this forum...

I had a patient with both factitious disorder and malingering---both. She was also MR, and threatened people daily.

And she wasn't even mentally ill in the psychotic of mood disorder sense. She had gone through about 6 previous psychiatrists, all of whom diagnosed her as psychotic or bipolar. She was given antipsychotics for 2 years including Clozaril.

I stopped all her meds, and she actually got better, and admitted she was faking the entire thing. I stopped the meds because not once did I notice any signs of psychosis despite her constant claims of hearing auditory hallucinations.

There's actually much more to the case...I could go on for several screens, but I already did in past threads.

 

[ClinPsycMasters]

Yes, thank you, I do remember reading your post.

I just can't remember which thread that was....

 

[whopper]

Hmm, another one that comes to mind.

The case itself wasn't so interesting, but the story was.

I had a guy who had OCD, and a serious case of bereavement. His dog died and he was suicidal for a few days.

What made it interesting was he kept referring to his dog as his "symbiont." He said that when he felt something, he knew his dog knew what he was feeling.

Okay, fine...he was real close to his dog. I get that. I respect that. That's cool. I wish I had a dog like that.

But then after 1-2 days, he started saying other things...

"I was closer to that dog than a human could be to another human." Then he kept reiterating that he was closer to his dog than a man could be to his wife. Then he said comments like, "That dog was my soulmate." "It's as if I was inside of him." He said he was closer to his dog than he could've been to a lover, including a wife.

It was getting weird. It got to the point where people in the treatment team suspected he had sex with his dog. His descriptions were so close to as if he was describing sex.

So, we did it. We asked him if there was anything sexual going on. We had to do it in the most diplomatic way possible.

Let's just say he wasn't too happy with us for asking the question....

"What kind of sick bastard do you think I am!?!?!?!?"

Trust me, before we asked the question, he really was pushing the descriptions as if he was sexually in love with his dog all the time. It was like a Three's Company episode. I did consider not even asking the question because what good would've come out of it? But after a long discussion with the treatment team, we came to the conclusion that this guy could've been a real bad sex offender and we had to at least probe the issue. The more we probed the issue, just like a Three's Company episode, the more he gave double messages that just begged us to ask the question even more...

 

[billypilgrim37]

Had a guy with a 30 year hx of schizoaffective disorder admitted, entirely euthymic, declaring he was pretty sure that he was Christ. He had deduced this because his body was being controlled externally by God (and he was constantly seen posturing in bizarre positions, running into walls), and if God cared about him enough to manipulate him, he must thus be the son of God. He had pages of logic written out deducing his conclusions (as in, it looked like a 300-level undergrad philosophy logic course homework assignment). He told us after a few days that he and his research group had just published a very important scientific piece in a journal. After a few days, I went and checked it out, and lo and behold, he was the first author of a pretty impressive bit of scientific research in a high impact medical journal published about a month before. Basically his third psychotic episode in 30 years, responded well to the addition of an atypical to his AED, and was back at work a month later, no doubt continuing to be a lot smarter than me.

 

[Red Beard]

These are fantastic, keep them coming!

 

[ClinPsycMasters]

Had a guy with a 30 year hx of schizoaffective disorder admitted, entirely euthymic, declaring he was pretty sure that he was Christ. He had deduced this because his body was being controlled externally by God (and he was constantly seen posturing in bizarre positions, running into walls), and if God cared about him enough to manipulate him, he must thus be the son of God. He had pages of logic written out deducing his conclusions (as in, it looked like a 300-level undergrad philosophy logic course homework assignment). He told us after a few days that he and his research group had just published a very important scientific piece in a journal. After a few days, I went and checked it out, and lo and behold, he was the first author of a pretty impressive bit of scientific research in a high impact medical journal published about a month before. Basically his third psychotic episode in 30 years, responded well to the addition of an atypical to his AED, and was back at work a month later, no doubt continuing to be a lot smarter than me.

That's what's amazing about brilliant people who develop psychotic disorders. Fear can motivate their powerful brains to focus incessantly and deeply on matters of personal interest, not very different from the ways scientists and philosophers dedicate themselves to a particular subject.

The difference, of course, is their great fear but also lack of reality testing which creates much bigger problems for a scientist but not so much for a philosopher. For people with a firm footing in reality, exploring delusions can be real fascinating window into the powers of human psyche. It also makes you realize that reality and its philosophical foundations are more fragile than many "sane" people like to admit.

 

[ClinPsycMasters]

"What kind of sick bastard do you think I am!?!?!?!?"