HISTORY: THREE DIAGNOSES BY AGE 15
Matthew, age 17, has been hospitalized twice for psychiatric treatment. At school, he has no friends, is extremely energetic and volatile, and has paranoid delusional thoughts. At night, he becomes depressed over his inability to “fit in.”
Brilliant and deeply spiritual, Matthew obsesses over sins he believes he committed, yet he is angry with God over his illness, its impact on his life, and his apparently dimmed prospects for the future.
His troubles started early. While in preschool, a teacher said he had “autistic tendencies.” He was shy and larger than most children (>90th percentile in height and weight). He acquired language slowly, beginning at 18 months, and slept poorly, waking several times nightly.
Throughout grade school, Matthew was both bright and eccentric. His Wechsler Intelligence Scale for Children-III scores, taken at age 9, were 133 (full scale), 143 (verbal), and 111 (performance). By the third grade, he struggled with the meaning of the universe and other existential issues. In sixth grade, he believed his mouth stank and frequently used mouthwash, even at school. He also had periods of excessive hand-washing.
In fifth grade, a pediatrician diagnosed Matthew as having attention-deficit/hyperactivity disorder after his teacher complained about his behavior in class (blurting out answers, correcting the teacher, restlessness, questioning authority). The doctor prescribed methylphenidate and dextroamphetamine, but the combination made Matthew feel both “drugged and wired.” He stopped taking the agents after 8 weeks.
At age 15, Matthew saw a psychiatrist. His parents said he was depressed and obsessively afraid of being abandoned. Every day, they said, he kissed both parents twice on each cheek.
The psychiatrist diagnosed Matthew with obsessive-compulsive disorder. A trial of paroxetine, 20 mg/d, caused mild irritability with no symptom improvement. After 2 months, Matthew was switched to fluoxetine, initially 10 mg/d and increased to 20 mg/d, but after 6 weeks he suffered an acute manic episode. He claimed he was one with the universe and reported auditory hallucinations, intense suicidal thoughts, and sleeplessness for days on end.
Matthew was hospitalized for 7 days. Haloperidol, dosage unknown, decreased his psychosis but did not return him to baseline. The psychiatrist stopped fluoxetine because Matthew’s parents feared the antidepressant was causing his suicidality. No other agent was tried at this time.
The authors’ observations
Soon after Matthew began taking fluoxetine for apparent OCD and depressive symptoms, profound psychotic symptoms surfaced. These included command hallucinations, delusions, disordered and disorganized thought, high suicidality, motoric hyperarousal, and marked anxiety.
Although positive schizophrenia symptoms were predominant, mood and affect instability were also pronounced. The admitting psychiatrist diagnosed Matthew with schizoaffective disorder but did not include in the record the basis for this diagnosis.
Matthew’s OCD symptoms did not appear to derive from a delusional system or impaired reality testing. These symptoms were often associated with guilt and were consistent with other excessive behaviors.
HOSPITALIZATION: NEW DIAGNOSIS
Out of the hospital, Matthew’s ability to function declined over several months and he began to look disheveled and dirty. He was acutely suicidal, excessively guilty, isolative, and slept 1 to 2 hours nightly.
Matthew was again hospitalized, this time for 2 months. The psychiatrist revised the diagnosis to schizoaffective disorder, bipolar type, based on Matthew’s psychotic episodes, emerging positive symptoms, social withdrawal, and family history. (A male maternal cousin has paranoid schizophrenia.)
Risperidone, initially 0.5 mg nightly and titrated to 0.5 mg each morning and 1.5 mg nightly, gradually improved Matthew’s psychotic symptoms. The psychiatrist added divalproex, 250 mg bid titrated to 250 mg each morning, 250 mg at noon and 500 mg nightly, to address Matthew’s affective lability. After another 2 months of partial hospitalization, he was discharged. Thought disorder symptoms persisted, but reality testing was intact.
Back in high school, Matthew has gotten into a screaming match with the principal and heated political arguments with his teachers. He shows bursts of energy, agitation, and euphoria and is at times overdramatic and grandiose. His rapid-fire creativity easily shifts to irritability and paranoid delusional thinking punctuated by rage.
Almost nightly, Matthew sinks into depression. He also compulsively washes his hands, binge eats, has difficulty reading social cues and making conversation, and believes he is a “misfit.” He views Internet pornography to relieve sexual obsessions, but this habit leads to guilt-ridden ruminations that trigger suicidal thoughts.
For Matthew, high school’s pattern of alternating regimentation and intellectual stimulation constantly provokes mania. He sometimes disguises these episodes by playing “class clown,” only to sink into despair at night over his dyscontrol. His desperation causes frequent anxiety attacks. Searching for answers, Matthew changes psychiatrists and turns to us for help.