Evolutive Possibilities Of Acute And Transitory Psychotic Disorder

Abstract

Motivation: The presence of isolated psychotic presence is known, characterised by imperative auditory hallucinations, doubled by polymorphous delusional ideation, with sudden, fluoride onset, and full remission in about one month. The patient, aged 38 years, developed two acute and transitory psychotic episodes with a duration of about one month each, at a distance of ten years, schizophrenic? Hypothesis: The episodes are disclosed by triggers in relation to which the patient uses negation as defence mechanism, its structure of narcissist – paranoid type dictating the disorder type. Material and methods: hospitalisation to psychiatry, injectable treatment, psychiatric monitoring under medication, psychodynamic interview, elaboration of life map, identification of coping mechanisms, highlighting the compensatory resources, psychotherapy of Ego strengthening. Results: The patient presents imperative auditory hallucinations, mystical ideation, depressive speech of guilt and sin, with reasons for self-punishment (he wants to give back to the state large amounts of money for a presupposed mistake made many years before). The patient changes bizarrely his attitude, during an airplane flight, being necessary his immobilization because of psychomotor agitation dictated by delusional. Conclusion: As particularity, we encounter the change of thinking in depressive direction, while the thymic function remains flattened in a paranoid functioning. The patient develops adverse reactions from the sphere of dyskinesias in moderate doses of Aripiprazole, sublimating unconsciously the treatment towards which he has only a partial criticism.

Keywords: Transitory acute psychotic disordermystical delirium

Introduction

The patient comes from an organised, socio-economically modest family, his father suffering of diabetes mellitus insufficiently controlled therapeutically, because of his own negligence (at present following to be hospitalised, given the disease complications), his sister is diagnosed with malignant melanoma, extirpated, treated and at present relapsed. Heredo-collateral antecedents are apparently irrelevant psychiatrically.

On his professional training, the patient mentions he graduated a Technological High School, followed by one year at the faculty of Chemistry, where he asserts, he did not go because the admission was facile, needing only one day to learn together with his sister. Subsequently, he abandons it and goes to a private faculty of tourism economics, in parallel being employed in sales, passing successively through many positions, in some years reaching in a top position in sales management, after the completion of the graduated faculty and a master within ASE.

In 2008, he reaches a high position in the sales company, next to a high financial status, relating also a change of his personality, in this sense asserting: “I was an introvert and an inhibited person in high school, but working in sales I had to open myself and to be very persuasive”. On the verge of economic crisis of 2008, he tries to open his own business of footwear, moment when he is accused by the company of unfair competition, he is sued in justice, action charged legally and interpreted subsequently by the patient delusionally. In the period 2008-2011, he works for two smaller companies, also in the sales sector, at approximately one year and a half.

In 2012 he resumes an older passion from adolescence, when he asserts, he made a lot of sport (performance football, arbitration courses) and he enrols to a master programme of management and marketing for performance teams within UNEFS. In 2013 he wins an Erasmus scholarship for six months in Denmark, subsequently extending his resident status. 2013 is also the year when the patient decreases his socio-professional functioning level, choosing to do housekeeping, between 6:00 and 9:00 in the morning to be able to attend courses.

In parallel with the master in sports, he also attends the courses of another faculty of marketing of Denmark that he graduates. The professional route and the option for the extended student status suggest an Adlerian overcompensation of the modest socio-cultural level from which the patient comes (Adler, 2010)

For seven years, the patient is in a relationship from distance with a judge girlfriend, who, during quarrelling moments, reproaches him the precarious status of the provenience family. During the last three years of friendship, he refuses to have intimate relationships with his partner, asserting an ascetic road, on which he says: “I wanted to see if our relationship lasts without it, to convince myself that after we remove sex, there something that remains between us. It is obviously that I frustrated her too, but also myself, it is normal to be so”. He describes this attitude as a “response” to a “tumultuous” period of his past, when, according to his assertions, he had more occasional partners and he enjoyed life (period on which we can infer that it would correspond to the period of financial wellbeing, when it is probable that the patient had a hyperthymic mood for a long time).

In adolescence, he describes an emotionally significant relationship with a girl three years younger, a borderline structure (from the report of events) and who was forced by circumstances to make to abortions at the age of 16 years, approximately, incidents the patient integrates at present delusionally-traumatically and towards which he asserts guilt and remorse (more in the thinking plane then felt in counter transfer).

The first episode of diseases occurred in 2009 and has as possible real trigger the financial failure in which the patient shows massive negation (“Me, trauma? No way of such things, I am not the type!”). the manifest trigger in relation to which the patient develops a “fixation” is represented by an incident potentiated by subcultural beliefs, in which together with his mother and sister buy a bulb from the internet, with the conviction that it has effects of increase of immunity. The patient exposes himself extendedly and at small distance to the ultraviolet rays, developing a non-specific erythema, he interprets delusionally, which subsequently progresses to ideation in the network from the spectrum of relationship and influence, with consecutive change of behaviour. (He wears very thick clothes, he endows his house with specific transparencies and even shutters against natural lighting, and, finally, he refuses to leave domicile of ear of sunrays. He takes interest in the type of radiations the respective bulb could have emitted, he writes emails to NASA, from where he receives a neutral response to which he assigns delusional significance) (Robins, Oliver, & Pervin, 2010)

During these months, he develops a psychotic episode in which delusional relationship ideation dominates, next to proprioceptive and tactile hallucinations, systematised delirium supported by somato-tactile feelings and fed by coincidences, in parallel being present the negative phenomenology of the socio-cultural activity and self-care deficit type. He undergoes a psychiatric consultation, and he is indicated a moderate medication, after a few weeks the patient presenting a suicidal attempt by ingestion of medicines, affirmatively because of mood change in depressive direction by the exhaustion given by the persistency of hypochondriac delirium.

Problem Statement

Patient aged 38 years, has psychiatric antecedents recorded within “Alexandru Obregia” Psychiatry Hospital since 2009, when he was hospitalised for ten days for a suicidal attempt by the ingestion of 15-20 tablets prescribed by the psychiatrist, affirmatively for insomnia (“I took the respective pills. I said to sleep more and I apologized to God. I took them outside, because I did not want my family to see me. I knew I could die. I renounced to fight anymore.”)

In relation to the present episode (March 2019), he declares that the symptoms started three days before hospitalisation “with panic attacks and emotional lability”, exhausted (we conclude) by the psychotic phenomenology at the basis. He comes to hospital voluntarily, travelling emergently from Denmark to Bucharest. During the flight, it is needed that the crew on board content the patient, who was in a visible psycho-motor agitation condition.

From the patient’s accounts, we find out that the psychosis pushed him to this direction, taking the form of some imperative voices with mystical-divine character, during the current episode obliging him to leave the domicile from Denmark, to throw the key of his apartment in which he was living and to go in the search of the nearest church, where to take off his clothes to see God: “I thought I had to be naked, in my purest form”. The patient interprets the key finding in the place where it was thrown as a sign he acted correctly listening to the voices: “God left the key there, it is clear that this was meant to do. Therefore, the key would not have been in the same place!”. Upon the remission of symptoms, the patient “resumes” the hallucinations inside his being, calling them “my consciousness, not an external voice”.

Research Questions

The present case is interesting through the evolutionary possibilities of an acute psychotic episode. The present patient is in the second episode of this type in his life, the first being about ten years ago, with high-quality inter-psychiatric functioning, maintaining the complete remission after treatment about six months ago with ten years.

Given the structure of the premorbid personality of the patient (characterized by inhibitory, sensitivity, polite manners, degraded behavior in emotion expression, modest empathy, religiosity, asceticism - refused intimate relationships outside of marriage, developing neurotic inhibitions) To that extent, evolution will be towards a recurrent depressive disorder with time-spanning episodes and complete inter-episode remissions or a quality remission schizophrenia, enhanced by high compliance with treatment and by the warm and empathic support environment.

Also, the risk of hereditary transmission of psychiatric suffering is not neglected, the patient's partner being around the age of 40, wanting to have children, genetic counselling as well as constellation couple advice hereditary (both biological and pulsatile).

The questions of the case are directly related to the defense mechanisms used by the person concerned, such as repression, isolation and displacement, regarding sister skin cancer, fears being disguised as paranoid fears and delusional ideas of the patient during the course of his episode psychotic.

Purpose of the Study

The case presentation is dedicated to young specialists in order to make them more attentive to a correct assessment of a psychiatric patient with good inter-paradigm evolution, as there is currently a modern trend in psychopharmacology to institute high-dose therapies with therapeutic combinations from various classes of medication, to cover the entire spectrum of psychiatric disorders. This may seem beneficial for the time being, but over time there is the risk of a desensitization of the receptor, the occurrence of unnecessary side effects, in which the present patient was also exposed (he developed extrapyramidal reactions at moderate doses of atypical antipsychotic - Aripiprazole, given the sensitivity of a paranoid-type structure, sensitivity that also has a receptor-related correlation with neurotransmitter function).

Thus, a pertinent psychiatric and psychological evaluation, a correct and fully established differential diagnosis, avoids unnecessary medication, devoted to the rapid restoration of patient functionality.

It is worth mentioning the feelings of its extrinsic guilty exteriorization, the psychotic-modified religious mystic behavior, symptoms that converge to the diagnostic hypothesis according to which the mood was initially changed in a depressive sense, subsequently overlapping with the psychotic phenomena (hallucinations and delusional ideas), but the time was short-lived between the two moments.

The delusional interpretation of the individual in question is supported by acoustic synchronicity, which makes it even more difficult to support the diagnosis of schizophrenia. The high operating level previously achieved, as well as the possibility of maintaining a couple relationship, are positive prognostic factors. The present study aims to highlight the patient's compensatory resources for a better quality of the therapeutic act.

Research Methods

Examination of the present psychic state:

Remarks: The patient is conscious and cooperating, tranquil from a psycho-motor point of view, with a hypomobile facial expression of beatitude (in the absence of an adequate stimulus) and fixed gaze. He is oriented to time and space, auto- and allo-psychically. His posture is neat, with preserved hygiene. The speech is slightly incoherent, tachyphemia is noticed, with jerky voice. Psycho-verbal contact is achieved easily. Throughout the medical interview, the patient keeps tightly in his hands an icon.

Perceptions: From the sphere of quantitative disorders, we identify a hyperesthesia focused on tactile sensorial register. From the sphere of perception, the following are recorded as qualitative disorders:

-imperative auditory hallucinations: “It told me that I must go to church. The voice was telling me: Throw the key and go to church! I believe it was God and he was sending me there for my sins.”;

-pseudo-hallucinations: “The voice was as a inner process for my sins”

Attention: Voluntary hypoprosexia is acknowledged, with spontaneous hyperprosexia, insufficient functioning of attention filter, difficulties of concentration, stability and selectivity of attention.

Memory: A selective hypermnesia is present, with extraction of certain data, facts and events integrated in an interpretatively delusional way. The patient fixes and retains elements that present a “significance” that contributes to the augmentation of his delirium: “I bought a bulb from the internet. I was very cold and there was written that the bulb cleans the air within the room, and it is beneficial for breathing. I felt my teeth are drying […] I could not leave the house. I was feeling more and more the heat on my skin.”

Thinking: Analysing the central cognitive function of psychic life, we acknowledge both quantitative disorganisation disorders, and qualitative ones, subsuming psychotic thinking. The ideo-verbal flow is accelerated, with flight of ideas and speech sliding, which is focused on marking content (professional failure, abortions of his former life partner), intercalating sometimes with hypermnesia for non-significant details and incapacity to differentiate the general essential. Weakening of logical associations is noticed, with sliding from one real plane to the metaphorical one. We also note the existence of circumstantial discourse and tangential responses (to the question: “How did you reach to the psychiatry hospital” the patient answers: “The symptoms continued until July. A friend recommended me a psychiatrist to be able to sleep”).

I addition to quantitative thinking disorders, we also draw the attention of the qualitative ones:

-delusional ideation of follow-up, persecution, and damage, carried out on the background of a basal suspicion: “In Denmark, one shall find out of my failure in Romania. And when one shall hear there on my trial, nobody will employ me”, “I feel followed-up.”

-mystical delusional ideation: “At church, during the last years, I was praying only for others, because I did not consider myself important. I was saying the names of the persons I know and after that I was praying for all beings on Earth. I felt better during praying.”, “I pray 6-7 times a day.”

-delusional guilt ideation: “I have two children with whom I am not in a relationship because my girlfriend underwent abortion when I was 18-19 years old. I feel guilty because I didn’t even care.”

-somatic delirium: “My physical pain started because of the ultraviolet bulb... I felt my teeth are drying. I slept with it and when I woke up I had the eyes swollen, I was red on my throat and on my face, I was a little tanned.”

-delusional interpretativity: “At the conference of Denmark, I had the impression it is spoken about me”

-ideation of xenopathic control (Dewitt, Parker, Frankena, & Wiliam, 2012): “It told me I must go to church. I was told: Go there. Throw the key and go to church! I believe it was God, who was sending me to Church for my sins.”.

Affectivity: Patient’s mood is marked by anguish with psychotic roots, described by the person in question as “a triggering of panic, fear, anxiety”. Affective flattening is acknowledged, with hypomobile facies and reduction of body language (Trifu, Drăgoi, & Andronache, 2018).

Activity: He presents low useful yield: “I could not leave the house”, and throughout the last years he did not carry out any socially useful activity because, wanting to stabilise in Denmark, he learnt the language and he was permanently in contact with an adviser who had as purpose to facilitate his social-professional integration in the environment from there. He asserts that loneliness and the lack of a job affected him significantly, this being the reason for which he accepted for a while to carry out an activity below his academic training.

Behaviour: He is psychotically changed (the patient keeps an icon in his hands as “anchor” and he assert he prays 6-7 times a day). He is unpredictable, instable, with dromomania tendencies.

Instinctual life: he presents food appetite disorder and low preoccupations for erotic life: “I had sexual relationships at the beginning, but it did not seem normal how they were running, so that I renounced three year ago. It seems normally to me this way, not to have intimate relationships until marriage.”

Circadian rhythm: He complains of mixed insomnias, sleeping interrupted by nightmares.

Personality: A bizarre aspect of personality can be noticed, suggesting that the patient faced a psychotic process (Symington & Symington, 1996).

Insight: Partially preserved.

Feelings induced in counter transfer: He suggests grandiosity (involving both grandeur and narcissism, narcissist – paranoid area in which patient functioning carries out at present) (Bowlby, 1988).

Findings

Conclusion

References

1. Adler, A. (2010). Understanding Human Nature. Eastford: Martino Fine Books; Tra edition.
2. Ansbacher, H., & Ansbacher, R. (1964). The Individual Psychology of Alfred Adler: A Systematic Presentation in Selections from His Writings. New York: Harper Perennial.
3. Bion, W. (1904). Second Thoughts: Selected Papers on Psychoanalysis. New York: Karnac Books.
4. Bowlby, J. (1988). A Secure Base: Parent-Child Attachment and Healthy Human Development. New York: Basic Books.
5. Cassidy, J., & Shaver, P. (2016). Handbook of Attachment, Third Edition: Theory, Research, and Clinical Applications 3rd Edition. New York: The Guilford Press.
6. Dewitt, H. P., & Frankena, W. K. (2012). The Psylosophy of Value. Whitefish: Literary Licensing, LLC.
7. Fromm-Reichmann, F. (1974). Psychoanalysis and Psychotherapy Selected Papers. Chicago: University of Chicago Pr (T).
8. Gabbard, G. (2014). Tratat de psihiatrie psihodinamica [Treatise of psychodynamic psychiatry]. Bucharest: Trei Publishing House.
9. Kohut, H. (2009). The Analysis of the Self: A Systematic Approach to the Psychoanalytic Treatment of Narcissistic Personality Disorders. Chicago: The University of Chicago Press.
10. Robins W. R., & Oliver, P. J., & Pervin, A. L. (2010). Handbook of Personality, Third Edition: Theory and Research. New York: The Guilford Press.
11. Symington, N., & Symington, J. (1996). The Clinical Thinking of Wilfred Bion (Makers of Modern Psychotherapy) 1st Edition. Oxford: Routledge.
12. Trifu, S., Drăgoi, A. M., & Andronache, D. (coordinators) (2018). Psihiatrie Psihodinamică. Studii de caz [Psychodynamic Psychiatry. Case studies]. Bucharest: Medical Publishing House.
13. Trifu, S. (2014). Elements of antisocial personality in major psychiatric pathologies. Saarbrucken: LAP Lambert Academic Publishing.