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Forum Name: Psychiatric Topics

Question: anxitey to psychotic episode to i don't even know...


 chelseabearcouture - Sun Jan 11, 2009 4:46 pm

This is about an 18 year old male, who in good health is 100 lbs.

History:
-born premature
-gets B12 shots every month, because of necrotizing entercolitis
Recently:
-oral surgery to remove wisdom teeth and a growth on his tongue; used a general anesthesia and was given follow up meds(Ibuprofen, amoxicillin, and methylprednisolone)

Day after surgery:
-insomnia (he didn’t sleep at all)
-had to settle for a liquid for his mouth to heal, but then began to lose his appetite completely… when he did try to eat, he made facial expressions that made it seem as though its flavor was unpleasant, but this could be due to the sores
-grew paranoid over his health and insisted on getting multiple tests done, but tests showed no unusual results

Next Day:
-he had lost 9 lbs since surgery. It was to the point where sit was uncomfortable on his tailbone… and this worried him.
-continuation of symptoms above
-discontinued surgery meds, because we felt that he might’ve been having a bad reaction to it

Day 3:
- same as above
-began going around to his friends and family, saying “I love you” in a sad/fearful manner
-pacing around and showing signs of much anxiety

Later that night:
-went up to his brother and said “this is the night, I’m going to die”
-began to have a psychotic episode:
~began to cry
~told us to stay away from him, get out of the house, “get away from me, I might hurt you”, “im going to die”… later…”are the cops coming?”, “don’t do it”, “don’t kill me”… etc…. he was trying to make himself vomit… was making a “dry heave” noise??... like metal music… etc black metal growl noise… ???
~was dragging himself around the room… and at a certain time, was trying to bang his head against the wall
~still no sleep that night

Day 4:
-seemed to have calmed down
-took him to a psychiatrist, and he got nervous…
-difficulty communicating
-rocking…
-blank stare, but responded to his name…
-said he wasn’t hearing voices when we asked
-stiffened up when nervous
-wanted to go home, repeated it, continuously asked “where am i?”..
-responded only to the family and closer friends
-psychiatrist suggested to take him to a college psych hospital
Car ride to ER:
-one of his favorite songs came on the radio, and he started to dance… and began to act like he was at a party and started to get excited and told us to dance with him… we got excited and started to play along… this lasted until the music was turned off… immediately after the music was shut off, he calmed down and was quiet again.

ER:
-nervous… stiff… but able to play tetris on gameboy…
-was given benadryl and atavan(sp?) and calmed down to the point where he could explain to us that he remembers everything. Described the past few days as a dream, explaining that the dream was vivid and at times he even thought of himself as an alien…
-while talking, he seemed to be normal, but a little nervous about being in the ER and was acting a little loopy… possibly due to the meds or the fact that he still hasn’t slept at all…
-psych evaluation member came to evaluate his mental state… wrote down that he was hearing voices even though when asked he said “no”
Taken to the psych hospital:
-anxiety and nervousness stiffened him up a bit, but with comfort from his brother, he calmed down a bit…
-when the family left the psych hospital, he seemed even more normal than how he acted at the ER, except he mentioned that he dreamt of dying in that very place

Day 2 of psych hospital:
-stiffened up, still no sleep.
-we were told that he was pacing around the hospital… probably at an extremely slow pace
Morning visit:
-seemed to have reverted back to an out of reality experience, but did respond to family… however his responses had slight delays…
Afternoon visit:
-we arrived to find that he was taken to the ER because his pulse shot up to 200+
ER visit:
-family to ER, doctors tried to give him meds to calm down, restrained him to bed because he was stiffening up and freaking out and the doctors thought that he was going to hurt them… but he began to calm down when he saw his family..
-they later gave him benadryl and atavan and a tranquilizer in an attempt to make him sleep… at first, he was fighting sleep. While he was still awake, they got a urine sample. A staff member from the psych hospital who was there to monitor threw away the sample “thinking that it was already tested”. He later slept for about 4 hrs… I believe he was also hooked up to an IV, but not positive…
-woke him up for ANOTHER urine sample and CAT scan
-while awake, he was anxious and delusional… most likely hallucinating because he was saying that he was doing things that he really wasn’t…
-once again calmed down once his family talked to him then he was given the same meds to calm him down from before
-he attempted to sleep but he would often wake up every few minutes while they were waiting for the test results from the urine sample
-when the test was finished he got the clear to return to the psych hospital

Day 5
-he was returned to the psych hospital
-When I visited him he was unable to walk w/o help, he trouble
eating, he was back was arched back, very tense, he kept his arms up (in a similar manner to a t rex), he was rigidly bobbing his head, when he tipped over his chair he was unable to help him self back up, he was mumbling to himself the same phrase over and over
-That night he stayed in the psych hospital

Day 6
-He was sent to the ER once again for another CAT scan
-he is going to get a spinal tap to check for brain infection
-afterwards, he was given something to calm him down… I’m not exactly sure what it was, but he got some sleep

Day 7
-spinal tap results came in negative… it did show that he had one extra pus cell

Due to the fact that we aren’t allowed inside until visiting hours, we do not know at this point what his current state is…
 Dr. E. Seigle - Fri Jan 23, 2009 2:20 pm

Hi chelseabearcouture,

Your relative's condition certainly sounds serious and complex. You must be wanting more information as to what conditions are being considered. An important step in a patient such as your relative is to rule-out any medical conditions that can mimic a psychiatric one. It sounds as if the doctors are doing this through tests such as the CAT scan and urine test. I assume that blood tests have been done, and in cases such as this, a neurologic consultation, an EEG (brain wave test for seizures), and perhaps a brain MRI are often done. Once a medical cause is ruled-out the doctors should try to pinpoint the correct psychiatric diagnosis. Doctors usually make a list of the conditions that a patient MIGHT have, and which of these are most likely and why. Then, through testing, gathering data, examinations, observations discussions with relatives, and most importantly, a thorough history of your relative's life, what is called a Working Diagnosis is make, if the diagnosis is not definite. Sometimes, responses to medications helps to make the right diagnosis.

The possible psychiatric diagnoses that may be considered for this young man include:

Bipolar Disorder, with psychotic features, either depressed, manic, mixed, or rapid cycling.
Major Depressive Episode, with psychotic features
Schizoaffective Disorder
Schizophreniform disorder, which is thought to possibly precede schizophrenia
Psychotic Disorder of an atypical type, which can't be better classified

You may want to ask your relative's doctor if he or she can spend the time with you to discuss these issues, as well as other questions you are likely to have. You should feel entitled to have your questions answered, if you are a close relative.

Having a relative or friend in the hospital can be confusing, scary and upsetting. Often, people feel overwhelmed and afraid to ask questions. It can be helpful to spend time with the doctor, letting her know that you need some time so as to ask questions. Often, having someone with you that you trust who can support you or write things down, is helpful. Medical treatments for the psychiatric conditions I have mentioned are usually quite helpful, and sometimes cause full remissions. Many psychiatric conditions can occur in the future, but not always. It can take a few weeks, a month, or even longer in the hospital, to fully treat a condition such as the one you have described, to a point where continued treatment can occur on an out-patient basis.

These are responses to some of the many issues that I felt that you raised by what you shared about your relative. Feel free to respond or ask further questions should you wish.

Good luck! E. Seigle MD

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