Case Studies

Case 3 - A 22-year-old man who dropped out of college

While working in a Community Mental Health Team, you are asked to visit a 22-year-old man, Tom, at home. His concerned mother has contacted services. She reports that he dropped out of college two years ago and has become increasingly withdrawn since. He spends most of his day in his bedroom with the curtains drawn, muttering to himself about cars which stop outside the house. He is reluctant to talk to you, but eventually confides that he believes red cars follow him whenever he goes out, monitoring his movements because they want to kill him. He recently saw a red car parked at a bus stop and believed this was a message from MI5 telling him to ‘watch out’. He has smoked cannabis regularly since the age of 14, but less so in the last year. The longest he has abstained from cannabis use was three months, but this made little difference to his symptoms. His mother tells you worry about her son is driving the family apart.

• a. What psychotic symptoms are described?

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  Correct answer:

  Persecutory delusions, delusional perception and delusions of reference.

• b. What is the most likely diagnosis?

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  Correct answer:

  Schizophrenia. The psychotic symptoms have been present for over a month, as required by ICD-10 criteria for schizophrenia. Although he has smoked cannabis, his symptoms do not occur in the context of cannabis use alone.

You discuss the patient at the next CMHT meeting and a care coordinator is allocated. She wishes to discuss a care plan for him.

• c. What do you think are the priorities for his treatment?

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  Correct answer:

  Engaging Tom and encouraging him to accept antipsychotic medication. Psychoeducation regarding the likely role of cannabis in exacerbating his symptoms. Returning to social, academic or work commitments is an important component of recovery, and encouragement to do this when he is able can be given. Family therapy and CBT may be appropriate.

Tom reluctantly agrees to take antipsychotics. He has no relevant medical history. You decide to prescribe olanzapine.

• d. List three important side-effects of this drug.

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  Correct answer:

  Weight gain, glucose intolerance, sedation.

• e. Tom's mother is concerned to know whether he will get better. What can you tell her about the prognosis?

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  Correct answer:

  After a first psychotic episode there is a 90% chance of being well within a year, but about an 80% chance of a further episode within five years. His psychosis has been untreated for up to two years which may worsen prognosis (see Chapter 7).

• f. Tom's mother asks what she and Tom can do to maximize the chances of him getting and staying well.

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  Correct answer:

  The main factors likely to influence the outcome will be whether Tom takes his antipsychotic medication consistently, refrains from smoking cannabis and avoids undue stress; there is some suggestion of high levels of stress in the family and family therapy to address this might also improve outcome.