Cases That Test Your Skills

The sailor who won’t follow orders

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Mr. L is rehospitalized 9 times in 3 months but repeatedly fails to adhere to outpatient treatment. What is the cause of his exasperating behavior?


 

References

CASE: An unlikable patient

Mr. L, age 56, is admitted to the psychiatric unit at our Veterans Affairs Medical Center for active suicidal ideation; he has a history of self-injurious behaviors that include mutilation and overdose. He also has a history of alcohol dependence and multiple inpatient psychiatric admissions. He has never married and conflicts with his siblings—in whose home he has been staying—have led to frequent homelessness.

On presentation, Mr. L meets DSM-IV-TR criteria for borderline personality disorder, alcohol dependence, and bipolar disorder, current manic episode. He is unable to correctly assess social cues and lacks empathy—he speaks indifferently of the sequelae stemming from removal of his twin brother’s “golf ball”-sized benign brain tumor.

His affect is silly and shallow. He also shows signs of haughtiness, disinhibition, grandiosity, and confabulation. For example, he says that while in the Navy he had 82 sexual exploits and developed a drug that cured herpes.

We start Mr. L on divalproex, 1,500 mg/d, and quetiapine, titrated to 200 mg/d. After 3 days he is discharged, but this begins a cycle of repeated suicide gestures and readmissions—9 within the next 3 months. Each time he is discharged, Mr. L fails to follow through on treatment recommendations and is indifferent to our staff’s annoyed reactions.

The author’s observations

Some of our staff members regard Mr. L’s suicidal gestures as manipulative and feel angry and demoralized by his poor adherence to outpatient treatment plans. Their negative countertransference might have impacted how they evaluated Mr. L through repeated admissions and discharges. During Mr. L’s ninth admission, we decide to reevaluate his longitudinal history for clues to his noncompliant behavior.

History: Undocumented injury

Mr. L says he began drinking alcohol at age 16. He reports that he has grown marijuana but has not smoked it since 1991. He denies using heroin or other drugs.

Mr. L reports that he completed a bachelor’s degree in chemical engineering and served as a lieutenant in the Navy from 1973 to 1976, working in the radiation health/medical division within the medical service corps. He says he completed a master’s degree in public health and held several industrial hygiene and radiation safety jobs. His last employment was approximately 3 years ago.

Mr. L states that he suffered a head injury in 1975 after falling off a ladder on a Navy ship. He describes losing consciousness for a brief but uncertain duration. He reports that he has developed a seizure disorder since this fall and a history of amnesia secondary to past seizures. His medical records contain no witnessed seizures. Mr. L also says he was hospitalized a few years ago and placed on a ventilator for 7 days for an undetermined reason.

The authors’ observations

Based on Mr. L’s report of a possible traumatic brain injury (TBI), we order a neurologic evaluation. A year earlier, MRI of the brain without contrast demonstrated minimal, nonspecific periventricular and subcortical, punctuate hyperintensities on flair and T2 weighted sequences that are nonspecific. Overall, the impression was “diffuse involutional changes and mild nonspecific periventricular and subcortical white matter hyperintensities,” which might reflect covert vascular brain injury.

Mr. L’s neurologic workup and EEG are essentially normal, except for abnormal tandem gait. CT indicates mild generalized atrophy and an area of low attenuation in the left temporal region that could represent an old infarct or cyst. MR angiography is interpreted as normal. Overall, these data suggest that Mr. L’s cognitive deficits are not the result of focal brain pathology.

Our frustration over Mr. L’s repeated readmissions for suicidal gestures led us to seek outside evaluation and consultation from a senior psychiatrist for assistance with discharge and treatment planning. Unlike our staff, the consulting psychiatrist did not harbor strong negative feelings toward the patient.

Mr. L’s history of deterioration in psychosocial functioning prompted this psychiatrist to perform a thorough mental status examination that focused on cognitive elements and request formal neuropsychological testing.

Evalutation: Cognitive Deficits

During mental status examination, Mr. L has difficulty recalling 3 items and uses a memory strategy to assist himself. He fails to recollect in reverse order the last 5 U.S. presidents. He spells “world” backward, but has difficulty repeating 6 digits forward and 4 backward. He is unable to do serial 7 subtractions from 93 to 65 correctly. He adequately copies interlocking pentagons and draws a clock with the correct time. He achieves a score of 28/30 on the Folstein Mini Mental State Exam, missing the date by 4 days and recalling 2 of 3 words.

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