Lesson 1: Clinical Disorders – Part C

Description

Brandon, a 42-year old postal worker, was brought to an emergency room because of his belief that there was a contract out on his life (someone wanted him killed). Approximately four months previously, Brandon had been accused of tampering with a package at work. He denied this accusation, and because his job was in jeopardy, he filed a protest. At his formal hearing he was vindicated (proven innocent), which in his view humiliated his boss and made his boss angry.

About two weeks after his hearing, Brandon began to notice that his colleagues were avoiding him. He noted they would turn away as he was walking toward them and he believed they were talking about him. While he was unable to clearly hear what they were saying, he was sure they were avoiding him because his boss had taken out a contract on his life.

Brandon was functioning fairly well until he began to notice large white cars driving up and down the street on which he lived. He became increasingly alarmed and was certain “contract killers” were in these cars. At this time he refused to leave his apartment without an escort and would panic and run home when he saw the white cars. After one such incident, his wife insisted that he accompany her to the local hospital.

Both Brandon’s wife and brother described Brandon as a basically well-adjusted man who liked spending time with his wife and two children.

Brandon had served (with distinction) in Vietnam and while he did not see much combat, he was pulled from a burning vehicle moments before it blew up. Aside from his belief that there was a contract on his life, Brandon’s speech and behaviour were ordinary. Although he admitted he was anxious, Brandon denied having hallucinations and other psychotic symptoms (apart from his belief in the contract killers) and noted that he was not depressed, and had no change in appetite, sex drive, energy level, or concentration.

Diagnosis

Brandon’s anxiety resulted from his belief that contract killers had been hired to kill him. Because there was no reason to believe his boss had arranged such a contract, it was evident that Brandon was delusional. In reality, because contract killers are sometimes hired, the delusion was non-bizarre. Apart from his delusion, Brandon’s behaviour was not odd - he did not experience any hallucinations nor did he have symptoms of depression, bipolar disorder, or drug abuse (a potential organic cause of delusions). Because of this, a diagnosis of delusional disorder was made. The content of his delusion involved the theme of danger and harm such that the diagnosis was further classified as persecutory.

His DSM diagnosis is Axis I: delusional disorder, persecutory type

Follow-up

Brandon was hospitalized and given an antipsychotic drug, but, unfortunately, he remained delusional for the first week of treatment. He even became convinced that a few of the other patients on his ward (the ones with Italian names) were contract killers sent to kill him. Over the next month, with continued treatment, Brandon’s delusions faded. Upon discharge, Brandon announced “I guess my boss has called off the contract. He couldn’t get away with it now without publicity.”

Brandon had two relapses over the following 18 months, each involving the same content and both occurring after he had stopped taking his medication. Each relapse was quickly and effectively treated with the continuation of his medication.