By far the majority of patients whom we treat on our inpatient psychiatric unit are people with chronic mental illness who have experienced many recurrences of their severe symptoms of depression, mania, psychosis, or combinations of these.
Their worsened symptoms might be because they have been subjected to unusually stressful circumstances or because they stopped taking their medications, or perhaps it is simply the natural course of their recurring illness.
Occasionally, however, a young adult will be admitted with what may be described as a "first psychotic break." Recently, we treated a young man who had no psychiatric symptoms prior to this episode. About one week before his admission, he began acting oddly. Initially, only his parents noticed some subtle changes but, as the days progressed, everyone around him knew that something was drastically wrong.
He became alarmed that something bad might happen. He developed peculiar beliefs about other people and himself, and his speech often didn't make sense. At times, he was extremely agitated and seemed to be responding to auditory hallucinations. He was unable to sleep and he purposely moved furniture around all night. Ultimately, he was brought to an emergency department by the police after he began breaking objects at home.
Diagnosing patients with new psychotic symptoms can be challenging. That's because there are no blood tests or reliable psychological tests to confirm a diagnosis of a particular psychotic disorder. Thus, when making a diagnosis, we always try to consider someone's past history.
An important consideration in these cases is the possible influence of substance abuse. Although several different types of substances could contribute to a patient's abnormal behavior, perceptions, and beliefs, the use of amphetamines could have produced exactly the symptoms experienced by our patient —especially the paranoid delusions, hallucinations, and sleeplessness.
But there was no evidence of any substance abuse by this young man, and the emergency department's toxicological screen confirmed that he was not abusing any drugs.
Our patient's high energy level and bizarre thinking led us to consider the possibility of bipolar disorder, with his current state representing a manic episode. At times, he did seem rather elated and occasionally described himself as feeling "great."
A past history of depressive or manic episodes would help establish whether our patient was experiencing the first episode of this mood disorder. But his past history was of no help.
The other major possibility is that our patient's symptoms were the first manifestation of schizophrenia. His thoughts and behavior were rather bizarre, and it seemed that he was having auditory hallucinations.
The constellation of these symptoms for less than six months would be classed as a schizophreniform disorder. If they persisted for over six months, a diagnosis of the chronic disorder schizophrenia could be made.
In the hospital, we can provide a safe environment and treatment for this patient's psychotic symptoms. We can make sure that he is scheduled with appropriate outpatient follow-up appointments with a psychiatrist. But in his case, we may not be absolutely certain about the diagnosis for some time — only retrospectively will it become clearer.
