Psychiatry & Psychosomatic Medicine

This is a case report of an 18-year-old male who presented with first episode psychosis (FEP) with symptoms of catatonia, negativity & religious delusions and was admitted in our unit for 2 months. This was a case in which we had difficulty in diagnosis, difficulty in treating & for those of us who were closely involved in his care, had difficulty dealing with a myriad of emotions, including helplessness and anger. Differential diagnoses of NMS, malignant catatonia & NMDA encephalitis was considered. We were limited in the use of antipsychotics as the patient developed EPS & increased CPK, along with unstable vital signs on 4 different antipsychotics. He neither responded to high doses of up to 22 mg Lorazepam; nor did he respond to i/V Solumedrol. There was a pattern of high expressed emotion amongst the family; so much so that their visits would become a major trigger for the patient’s aggressive outbursts. There were also some cultural barriers that contributed to communication gaps during family meetings. Religious themes had to be considered with highly religious family members and religious delusions in both patient and his sister. During his inpatient stay there were repeated episodes of assaultive behavior towards multiple staff members leading to a high tension atmosphere in the unit and a non-nurturing milieu. In this case report we would like to discuss the diagnostic uncertainty in FEP; the control of aggressive behavior when one is limited in the use of antipsychotics & influence of psychosocial factors on patient’s stay in the unit. We also want to concentrate on what we could have done differently or better. Although the patient is now improved on Clozapine,

considering the family dynamics, we would also like to discuss how we can work on preventing a relapse.