However, features of Mr. O’s illness are not typical of a chronic psychotic illness. He recalls psychiatric hospitalizations in his youth and recently, but not for the 40 years in between. Mr. O says he has never experienced auditory hallucinations. For these reasons, our treatment team obtains old medical records to investigate his early history (Table).
Table
Mr. O’s clinical course
| Age | Symptoms/behaviors | Diagnosis |
|---|---|---|
| 17 | Temper tantrums and destructive behaviors. No delusions or hallucinations but a flat affect and hostile attitude | Primary behavior disorder, simple adult maladjustment |
| 22 | Returned to the psychiatric hospital when his welfare payments stopped; “psychopathic” symptoms; described as defiant and resented authority and regular work | Primary behavior disorder |
| 24 | His mother complained that he stole from her and carried a weapon; while hospitalized, described as manageable and without overt psychotic symptoms | Primary behavior disorder |
| 26 | Arrested for causing property damage while intoxicated on alcohol; silly laugh, loose associations, irrelevant and incoherent speech, and believed hospital staff were against him | Psychosis with psychopathic personality |
| 66 | A fire that he set accidentally while smoking in bed after taking zolpidem destroyed his home | Diagnosis unknown |
| 68 | Transferred from a homeless shelter to the ER after he took 30 to 40 mg of zolpidem and exhibited bizarre behaviors | Schizoaffective disorder |
| 69 | More spontaneous, remains logical and relevant after haloperidol is discontinued; no delusions or hallucinations, still complains of pain | Substance use disorder and personality disorder |
| ER: emergency room | ||
HISTORY: Destructive and defiant
Mr. O’s mother reported that he had been a nervous, restless child who would scream and yell at the slightest provocation. At age 10 he became wantonly destructive. His mother bought him an expensive toy that he destroyed after a short time; he asked for another toy, which he also destroyed. When such behavior became more frequent, she took him to a city hospital, where he was treated for 6 weeks and released at age 13. He was sent to a boarding school but soon was expelled for drinking and selling beer.
Mr. O was admitted to long-term psychiatric facilities 6 times in the next 10 years, from the late 1950s to the late 1960s. He was first admitted at age 17 for temper tantrums during which he fired an air rifle and smashed windows in the home he shared with his mother. During examination he had no delusions or hallucinations but did have flat affect and a hostile attitude. Doctors documented that almost all his tantrums were as a result of interactions with his mother.
Records from this psychiatric admission state that Mr. O showed no unusual distractibility, “psychotic trends,” or paranoid thinking. After approximately 6 months in the hospital he was discharged home with the diagnosis of primary behavior disorder, simple adult maladjustment. Mr. O, who was age 18 at the time, and his mother were eager for him to complete high school and learn auto mechanics.
Nine months later, he returned to the psychiatric facility because of excessive drinking and inability to secure employment, according to his records. In the hospital, he was productive and reliable. When he was discharged home 3 months later, doctors wrote that his determination to stop drinking was firmly fixed. They encouraged Mr. O to complete high school as a night student and find employment during the day. His mother was delighted with his improvement.
A third admission, less than 2 months later, occurred after he broke a window during an argument with his mother. He had a job but quit. After 5 months he was discharged with the same diagnosis of primary behavior disorder, but his mother would not let him back in her home. He was referred to the social service department to be placed on welfare.
A year later, Mr. O had trouble managing his welfare allotment and moved repeatedly. He said he returned to the psychiatric hospital because his welfare payments had been discontinued. During this admission, doctors noted “psychopathic” symptoms; Mr. O was defiant and resented authority and regular work. Mr. O eloped from the hospital several times and brought beer into the building. After 18 months he was discharged with the same diagnosis, with plans to apply for welfare. He was not prescribed medication.
Mr. O’s fifth admission came nearly 2 years later after his mother complained that he stole from her home and carried a weapon. In the hospital he was described as manageable and without overt psychotic symptoms. When he was discharged a little more than a year after being admitted, doctors wrote that he was a psychopath who had a history of drinking, stealing, and delinquent tendencies as a teenager. His diagnosis remained primary behavior disorder.