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Hallucinations/Disordered Thinking Case Study

Sample Case

Mr P is a 21 year old university student. He was referred to a psychiatrist by the University Health Service as he was complaining of hearing voices. During an outpatient interview, he told the psychiatrist that he had been upset for the last year as he had been hearing someone talking about him when he was alone. He said he would typically hear two male voices discussing him on average three times a week. These voices would also sometimes comment on his actions. He had put off going to see his GP for over a year because he was afraid of being spied on by M15 security agents, who he was convinced were plotting to kill him.

Mr P lives alone in rented accommodation. He told the psychiatrist that his father was “sectioned” to a psychiatric ward many years ago because of a similar problem. He has no past medical history of note. He admits to having smoked cannabis regularly for 2 years when he was 17 years old but denies any illicit drug use since coming to university.

During the interview, Mr P kept scanning the room and appeared very suspicious. At one point he became distracted, suddenly stopping in mid-sentence, looking over his right shoulder and shouted: “You shut up!” He went on to say that he felt low in mood and frustrated as he did not understand why the security agents were after him. He admitted that he had thought of jumping in front of a car so that he could escape this “torture”. When asked what he thought the problem might be, Mr P denied that he had a mental illness or that he needed medication.

What symptoms does Mr P have and what is the differential diagnosis for him? Discuss possible aetiological factors and the important management issues in this case.

Cause

Schizophrenia

Management

Olanzipine, or other anti-psychotics.
Consider an SSRI if depressive symptoms persist.

Common Questions

Define the terms hallucination and delusion

  • A hallucination is an incorrect perception - There is an elephant standing in the corner of the room.
  • A delusion is an incorrect belief - All the elephants in the world worship me as their king.
  • They can both exist together - That elephant in the corner worships me as his king.

The above example may, unfortunately, cause problems if your patient happens to be King of the Elephants, and you are holding a clinic in a zoo. Use your discretion, in other words.

Describe the different types of hallucination and delusion that psychiatric patients may present with.

Hallucinations:

  • Auditory - Most common, I hear voices
  • Visual - Also fairly common, Look at that spaceship!
  • Tactile - Less common, but seen after cocaine use, I feel bugs crawling all over me!
  • Olfactory - Rare, but can occur just before epileptic attack, I smell coffee, can you smell that?

List the possible differential diagnoses for patients presenting with hallucinations and delusions.

Describe the first rank symptoms of schizophrenia.

  • Audible thoughts
  • Arguing voices in their head
  • Running commentary in their head
  • Feel like being controlled by outside forces.
  • Thought withdrawal
  • Thought insertion
  • Thought broadcast
  • Delusional perception

Nice way of rememebering it is ABCD: Auditory hallucinations, Broadcasting of thought, Controlled thought (delusions of control), Delusional perception.

Be able to appropriately investigate the causes of psychotic symptoms.

Be able to assess risk in patient with psychotic symptoms.

  • Suicide - The voices are telling me to kill myself
  • Risk to others - The aliens want me to kill Welsh people
  • Self neglect - If I eat anything the world will explode

Understand when and how to employ the Mental Health Act.

That is a tricky one, but generally, the Mental Health Act is only used when a patient is

  • a danger to himself
  • a danger to others
  • deteriorating to the point that he will be one of the above

The above conditions must be attributed to a mental illness.

Understand the treatment options for psychosis and the basic pharmacology of antipsychotic drugs.

Mainstay of treatment is antipsychotics, such as olanzipine and clozapine. They work by increasing reuptake of dopamine, and blocking dopamine receptors; basically they stop dopamine acting so much in the brain.

Know how to screen for common psychotic symptoms (including First Rank symptoms)

Using the ABCD from earlier:

  • Auditory hallucinations - Do you ever hear voices that no-one else can hear?
  • Broadcasting of thought - Do you ever feel people can hear your thoughts?
  • Controlled thought (delusions of control) - Do you ever feel you are not in control of your body or actions?
  • Delusional perception - Seen anything odd recently?, or maybe not, but just try to assess through conversation if they have got some.