CASE 1

The patient was a 19-year-old male university student. His recreational activities
included skateboarding, snowboarding, break dancing, and weight training. The
patient first sought medical attention from a sport medicine physician in January
2006, when he reported right lateral wrist pain since falling and hitting the ulnar
aspect of his wrist while skateboarding in October 2005. Plain film radiographs taken
after the injury were negative, and the patient did not receive any treatment. The
physician found no wrist swelling, minimal tenderness over the ulnar aspect of the
right wrist, full functional strength, and minimally restricted range of motion (ROM).
The patient was given ROM exercises and was diagnosed with a right wrist
contusion.

Over the next 22 months, the patient returned to the same sport medicine clinic 10
times, reporting pain in his wrist, shoulder, elbow, knee, ankle, and neck. He stated
that the elbow, wrist, and shoulder injuries were due to falls while skateboarding and
snowboarding or to overuse during weight training; some injuries had no apparent
cause. Over the course of his medical care, the patient followed up with three
different physicians at the same clinic. He was diagnosed by these physicians, in
order of occurrence, with (1) right wrist contusion and sprain; (2) right wrist
impingement and left wrist strain; (3) right shoulder supraspinatus tendinopathy; (4)
right peroneal overuse injury and strain; (5) disuse adhesions of the right peroneals
and right hip adhesions; (6) right ankle neuropathic pain secondary to nerve injury
and sprain and right-knee patellofemoral pain syndrome (PFPS); (7) neuropathic pain
of the right peroneal nerve; (8) trauma-induced left-knee PFPS; (9) ongoing post-
traumatic left-knee PFPS; and (10) right levator scapula strain, chronic right
infraspinatus strain, right elbow ulnar ridge contusion, and right wrist chronic distal
ulnar impingement secondary to malaligned triangular fibrocartilage complex
(TFCC).

After his tenth visit to a physician, the patient was referred for physical therapy for
chronic right levator scapula strain and right supraspinatus strain. During the
interview, the patient stated that he had right shoulder pain because of a
snowboarding injury sustained 1 year earlier and because of a fall onto the lateral
right shoulder 2 years ago. Aggravating activities to the shoulder included pull-ups,
rowing, and free weights. No position or movement alleviated his pain, and the pain
did not fluctuate over the course of the day. His sleep was disturbed only when lying
on the right shoulder. The patient was in generally good health, but he said that his
right wrist and left knee occasionally felt cold for no apparent reason. He denied
experiencing any loss of sensation, decreased blood flow, or numbness or tingling in
the knee and wrist. The patient said he believed that his knee and wrist became cold
as a result of electromagnetic impulses sent to the joint via an electrical implant in his
body and that this device was the cause of his ongoing shoulder pain.

According to the patient, this device had been implanted into his body 2 years earlier
by a government organization (the Central Intelligence Agency, the US government,
or the US Army) to control his actions. Electromagnetic impulses generated by the
implant had caused his falls and injuries; they also caused his joints to become cold or
painful when he was doing something “they” did not want him to do, such as break
dancing, snowboarding, skateboarding, or exercising. The patient also believed that
many other people unknowingly had implants; he claimed that friends, neighbours,
professors, and strangers were “working with them” and that they “emotionally
abuse[d]” him by giving signs such as kicking a leg back to let him know he was
being watched. Furthermore, he indicated that he often received commands telling
him to harm his friends or family and that these orders came either from the electrical
implant or from the people he claimed were emotionally abusing him. He therefore
distanced himself from some friends because he did not want to follow through with
these commands. I asked the patient if he felt he would harm himself or others
because of his psychotic-like symptoms. He denied any desire to inflict harm on
himself or others. Had he posed a threat to himself or others, he would have been
“formed” (i.e., committed to a psychiatric facility by the appropriate medical
professional).

The patient's past medical and family history were unremarkable. He did not use any
prescription or over-the-counter medications, but he felt his thoughts about electrical
implants were decreased by the use of marijuana, which he used socially. He was a
non-smoker and a social consumer of alcohol. He had a normal gait and appeared
comfortable in an unsupported seated position. He denied any weight changes, bowel
or bladder problems, night pain, or difficulty breathing. Throughout the interview, the
patient did not maintain good eye contact, spoke in a monotone voice, and had an
overall flat affect. Even when he described his beliefs about implants and government
control, his voice and demeanour remained expressionless.

CASE 2

A 14-year-old boy, educated up to class 6, belonging to a family of middle

socioeconomic status and residing in an urban area was brought with complaints of
academic decline since 3 years and hearing voices for the past 2 years. The child was
born out of a nonconsanguineous marriage, an unplanned, uneventful, but wanted
pregnancy. The child attained developmental milestones as per age. From his early
childhood, he was exposed to aggressive behavior of his father, who often attempted
to discipline him and in this pursuit at times was abusive and aggressive toward him.
Marital problems and domestic violence since marriage lead to divorce of parents
when the child attained age of 10 years.

The following year, the child and the mother moved to maternal grandparents’ home
and his school was also changed. Within a year of this, a decline in his academic
performance with handwriting deterioration, and irritable and sad behaviour was
noted. Complaints from school were often received by the mother where the child
was found engaged in fist fights and undesirable behavior. He also preferred solitary
activities and resented to eat with the rest of the family. In addition, a decline in
performance of daily routine activities was seen. No history suggestive of depressive
cognitions at that time was forthcoming.

A private psychiatrist was consulted who treated him with sodium valproate up to
400 mg/day for nearly 2 months which led to a decline in his irritability and
aggression. But the diagnosis was deferred and the medications were gradually
tapered and stopped. Over the next 1 year, he also started hearing voices. He
suspected that family members including his mother collude with the unknown
persons, whose voices he heard and believed it was done to tease him. He eventually
dropped out of school and was often found awake till late night, seen muttering to
self, shouting at persons who were not around with further deterioration in his
socialization and self-care.

Another psychiatrist was consulted and he was now diagnosed with schizophrenia
and treated inpatient for 2 weeks with risperidone 3 mg, olanzapine 2.5 mg, and
oxcarbazepine 300 mg/day with some improvement in his symptoms. Significant
weight gain with the medication lead to poor compliance which further led to relapse
within 3 months of discharge. Frequent aggressive episodes over the next 1 year
resulted in multiple hospital admissions. He was brought to the hospital with acute
exacerbation of symptoms and was receiving divalproex sodium 1500 mg/day,
aripiprazole 30 mg/day, trifluperazine 15 mg/day, olanzapine 20 mg/day, and
lorazepam injection as and when required. He was admitted for diagnostic
clarification and rationalization of his medications. He had remarkable physical
features of elongated face with large ears. Non-cooperation for mental state
examination, and aggressive and violent behavior were noted. He was observed to be
muttering and laughing to self. His mood was irritable, speech was laconic, and he
lacked insight into his illness. We entertained a diagnosis of very early-onset
schizophrenia and explored for the possibilities of organic psychosis, autoimmune
encephalitis, and Fragile X syndrome.

His intelligence quotient measured a year ago was 90, but he did not cooperate for the
same during present admission. Initially, we reduced the medication and only kept
him on aripiprazole 30 mg/day and added lurasidone 40 mg twice a day and
discharged him with residual negative symptoms only. However, his hallucinations
and aggression reappeared within 2 weeks of discharge and was readmitted. This time
eight sessions of bilateral modified electroconvulsive therapy were administered and
he was put on aripiprazole 30 mg/day, chlorpromazine 600 mg/day, sodium
divalproex 1000 mg/day, and trihexyphenidyl 4 mg/day. The family was
psychoeducated about the illness, and mother's expressed emotions and
overinvolvement was addressed by supportive psychotherapy. Moreover, an activity
schedule for the child was made, and occupational therapy was instituted. Dietary
modifications in view of weight gain were also suggested. In the past 6 months, no
episodes of violence came to our notice, though irritability on not meeting his
demands is persistent. However, poor socialization, lack of motivation, apathy,
weight gain subsequent to psychotropic medications, and aversion to start school are
still unresolved. Influence of his multiple medications on bone marrow function is an
impending issue of concern.

CASE 3

History: A 25 years old male, the eldest among his three siblings, belonging to a
middle socio-economic class was diagnosed with paranoid schizophrenia (ICD10
classification). His parents and a close relative reported the patient as having been
reserve and shy since childhood, rarely initiating a conversation or any activity and
hesitant to talk to others. Behavioral changes were noticed by members of the family
as he entered adolescence, but were taken in a lighter vain and ignored. His irritable
nature and an anti- social behaviour worsened over the years, and finally, had a
violent bust out on a minor financial issue of the family with a neighbour. There was
no history of any complicated trauma, alcohol and drug dependence, physical or
psychiatric illness of the mother during pregnancy

His formal schooling commenced at the age of four, and completed secondary
education at the age of nineteen. School phobias or any kind of learning difficulty
was not reported. The patient quit his studies in accordance with his parents’ advice.
He preferred indoor/solo games, like cars and video games, rarely indulged in group
activities and did not have a very healthy relationship with the younger siblings. His
activities were mostly sedentary. He at times regretted not being sent to a more
established and well reputed school than the one he had attended.

The mental status examination revealed that, his eye contact was not continuous and
he moved his eyes suspiciously and furtively. He tried a little hard to change the body
postures and lethargic movements of the limbs (particularly) were also noticed.
Quantity of speech was reduced, and the patient became hesitant on expression of
some of his views and beliefs. During conversation, there were blank intervals and
tangentiality in his train of thoughts, with changes in pitch. Generalizations based on
in-appropriate or limited information were also present. He was not able to
understand and use the concepts easily. His attention and concentration were intact to
an extent. Reaction time was normal and no compulsive acts or habits were present.
Orientation to time, place and person were intact. The patient’s insight into the illness
was ‘grade one’, as he completely attributed it to others around him.

Clinical features: The patient presented with the complaints of restlessness and
irritability at the time of admission, and an incident of a violent attack on his mother
just before the arrival in the health care centre. The dominant symptoms at the time of
admission and during his stay in the health care centre were: suspicious behaviour,
delusions of reference and persecution (such as: sound of blasts, a relative inflicting
him with some mantras), sounds of people talking about him and thought people
poisoning of the air. On investigation it was learned that, in the prodromal state the
patient presents non specific symptoms like: loss of interest, irritability,
oversensitivity, lack of appetite and insomnia. The parents reflected on his non-
compliant behaviour regarding the medication and reported that which makes
administration of medication a difficult for the parents (who then resort to tricks, like:
these drugs are for your psycho-sexual disorder, as the patient once had a hallucination
that his penis nerve is being cut). In addition to the presence of the atypical clinical
features, a history of head injury was reported when the patient was 10 years old, when a
metal rod pierced his fore brain. Deterioration of psycho-social functioning was observed
and reported by the parents.

Treatment history: Investigations included the general physical examination and the
routine investigations, along with the formulation of case history in the health care
centres he visited or where he was admitted since diagnosis. There were no positive
findings on CT scan and EEG records. The client first saw a psychiatrist in April
2006, after his first violent episode. The client was prescribed regular medication
after this to alleviate the symptoms of the disorder. Some of the prescribed drugs
(from 2006 to 2014) were: Olanzapine, Divalproex sodium, Espazine plus
trifluoperazine, Trihexyphenidyl, Aripiprezole and Trihexyphenidyl hydrochloride.
He was given drug therapy along with instructional therapy. Parents and a caregiver
were psycho-educated about the disorder of the client, as psycho-education has broad
potential for many forms of mental health problems

CASE 4

Paul is a 17-year-old White boy, who presented for treatment of schizophrenia. He

came to our specialized outpatient treatment clinic at the urging of his psychiatrist
and his parents who were concerned about his behavior. Paul reported previous
inpatient treatment at a local psychiatric hospital in the Midwest, at the age of 16.
He reported that his symptoms were increasingly debili-tating and negatively
impacting his personal relationship with his parents, particularly his step-father.
He had been diagnosed with undifferentiated schizophrenia (295.90), and his
global assessment of relational functioning was 60.

Paul’s self-reported symptoms were also observed by his parents and are
consistent with a diag-nosis of schizophrenia. He experienced lack of pleasure and
interest throughout each day, and severe difficulty empathizing with other
people’s feelings. He had periods of withdrawal and isolation in his room during
the week, right after school, and the majority of the day during the weekends. He
also reported ongoing suspiciousness and distorted perceptions. Paul’s symptoms
have been consistent and have encompassed his daily life for years. For example,
he was pre-occupied with oversleeping and running late to school, and feeling
severely stressed that he would start hearing voices again that tell him to hurt
himself. He reported that he had struggled with delusions since his sophomore
year of high school.Paul reported difficulty in forming meaningful relationships
with parents and peers.

Due to his medication, he had a low libido and had no interest in a romantic
relationship. He also described eeling powerless over handling his own affairs and
had difficulty trusting that his parents would not commit him to a hospital again.
He had difficulty expressing his feelings and would act out as a bid for attention.

The client’s family is composed of mother (Sue), 35 years old; stepfather (Jack),
48 years old; and Paul, 18 years old. On the telephone, the mother reported that
Paul is very aggressive, throws things, and yells for no apparent motive.
Historically, Paul grew up as an only child in a family with his mother and
stepfather, in a middle-class, rural community. He excelled in school and
participated in sports and Boy Scouts until he began hearing voices at age 13. He
refused to attend school reporting that he was concerned that his teachers were
“out to get him” and that there was a plot to discredit him around his peers. He
stopped bathing, brushing his teeth, and failed to show any emotional expressions
when around his parents. He became impulsive and took action without thinking
about the consequences. He reports being arrested for hitting a pizza delivery boy
on the head with a frying pan because voices instructed him to steal the delivery
boy’s pizzas and his car. After this incident, Paul was committed by his parents to
a psychiatric hospital for 6 weeks and monitored on the antipsychotic medication
Risperdal 75 mg. After returning home, he experienced diminished ability to
experience pleasure, which resulted in him becoming more defiant and distant.
The ensuing negative impact on his relationship with his parents was
significant.Paul’s mother reported that her son thinks she needs therapy, not he;
that it is his life and he can do what he wants alone, without the help of doctors;
that doctors do not understand or help; that it is not his fault; and that others or
circumstances are to blame. His stepfather related that Paul’s ambition is to be a
rock star and that he is very self-centered and puts a lot of demands on his mother.
As a child, Paul was very demanding in getting his needs met, and Paul’s mother
would sacrifice her own needs for the needs of her son. Mother dedicated the
majority of her time to Paul as a way to keep him close and safe. The stepfather
reported that he resents his wife for babying her son and sees her as “incapable of
letting her son grow up.” Paul’s stepfather disen-gaged by isolating himself at
home physically and emotionally and avoiding interaction with both Paul and his
mother, due to feelings of frustration and powerlessness.

CASE 5

The case of S.L.R., single, male, retired and inmate of the Complexo Hospitalar do
Juquery. Accord- ing to the police, the patient (48 years) struck iron shots to the head
of his father (73 years) who was sleeping and caused his death. He would have
discussed with the victim who asked the son to leave the house and not having
accepted such request he decided to kill him. The defendant reported that on the day
of the crime, his head was “a thousand degrees”, he heard voices of his father and
neighbors, he thought that people wanted to kill him, a woman would have voodoo to
kill his father, he couldn’t sleep, he was agitated and without re- ceiving haloperidol
decanoato injection for four years. According to reports from his family members, the
patient’s father was psychotic and violent. There are many relatives who suffer from
mental illness and others committed homicides.

The patient is coming from the countryside and with unfinished basic education. He
was engaged twice for a few years. One of the his women was assaulted often by him,
once he threw her from a ravine and she fractured her skull. He had the habit of
killing animals. He changed his behavior at age 25 after his mother’s death. He
became aggressive and began to have hallucinations, incoherent thought and
persecutory delusions. He was admitted to the psychiatric hospitals and he followed
treatment outpatient irregularly. The patient lived with his father for more than ten
years, the relationship was bad, they attacked each other and he always talked about
killing his father. The patient violently assaulted his father a year before the murder.
Some days before the murder, father and son were fighting, the patient was seen with
er- ratic behavior, disorganized speech, delusions, hallucinations and repeatedly said
he wanted “blood and kill”. After the murder the patient told a neighbor: “I killed that
damn old man and still turned on the light to see if he was dead”. Then he said he
wanted to kill his neighbours and killed a dog. He was found by a brother-in-law and
he said that he wished to kill the whole family. He was captured by the police in a bus
station in a near town, he was quiet and wait- ing his brother arrives. At the present,
the patient occasionally has periods of intensification of productive symptoms with
homicide and suicidal ideation even hospitalized and in regular use of depot
antipsychotic. Currently the patient reveals mannerisms, residual persecutory
delusions and inappropriate affect. He meets diagnostic criteria for Paranoid
Schizophrenia.

Parental homicide or parricide is defined as murder of the fa- ther or the mother or
any other legitimate ascendant and patricide is defined as murder of the father
(predominantly committed by sons). It is a rare crime, represents 2%-3% of
homicides in general and 20% to 30% of psychotic murders 1,2,4. The relationship
between mental illness and violence has been controversial, for some authors
schizophrenia is associated with an increased risk of violence while other authors
claim that this mental illness must not be considered dangerous 1-3. Several studies
show that the subtype paranoid schizo- phrenia, persecutory delusions, auditory
hallucinations, a history of violent acts, the association of use of alcohol or drugs and
stopping the use of antipsychotic medication or absence of treatment increase the risk
of violent behavior1-5. The case reported is congruent with the literature described.

The most common diagnosis among the patricides is schizo- phrenia and a review of
the literature reveals that such offenders are usually male, young, unmarried,
unemployed, living with his father in the countryside, have low education and low
socio-economic level. The victim is usually dead in his bedroom and the attacker
using sharp objects1-4.

These crimes are not premeditated and can be precipitated by some

misunderstanding, are brutal and abrupt, with affective indif- ference and often
caused by persecutory delusions and command auditory hallucinations. Classically
has been described an apparent “calming” the murderer after the crime and about half
of them at- tempted suicide after the act 1-4. The crime reported shows similarity to the
revision of several authors and it can be concluded that adherence to psychiatric
treatment, continuous use of antipsychotic medication (preferably in the form depot
in cases of little cooperation), con- stant supervision of their acts, family support and
hospitalization if necessary are actions more effective in reducing violent behavior or
homicide among people who suffer from schizophrenia.

CASE 6
The patient Ms. K (40 years old) was a poor historian and was unable to recount what
occurred immediately prior to her admission. According to patient care team at her
residence, about two weeks prior to admission, she had run out of food stamps and
there was some difficulty in renewing them. She became agitated, hostile and
aggressive towards people at her residence and reported to her social worker that she
felt like committing suicide and homicide. Emergency Medical Services (EMS) was
activated and she was taken to the psychiatric emergency room. Upon evaluation, she
was observed to be expansive, internally preoccupied reporting nonspecific homicidal
and suicidal thoughts. She was subsequently admitted to the inpatient unit to treat her
becase of hearing voices. She stated that she would hear anywhere from ten to fifteen
different voices, both male and female, that were constantly fighting with each other
and talking about her. When asked to elaborate what the voices would say, the patient
responded: “stupid stuff” and would not elaborate further. She denied the use of drugs
or alcohol, and her urine toxicology was negative on admission.

Throughout the course of her admission she was noted to verbalize several somatic
complaints some of which were exaggerated, unrealistic and bizarre. Specifically she
reported that her bone was “sticking out” and that her wrist was twisted. She was
further convinced that her arm was dysfunctional as the veins in her arm were not
going in the “right direction.” Of note, she would wince of pain when her arm was
examined, but when she was distracted and her arm was touched, she did not react.
An X-ray taken after the onset of this complaint was negative. She became frustrated
as her continued attempts for a cast were denied as there was no indication, and
eventually stated “I just need a cast, I keep saying it. Nobody pays attention to me.
You know what I’m going to do? One day, I’m just going to say ‘My arm just fell
down on the floor. I am dying’ but it doesn’t matter, because I don’t have a cast.”
When asked why she felt like she was dying she replied “I could die of it” and that
her broken arm gave her fever and chills.

The patient exhibited many somatic complaints in various other parts of her body.
After she was hit by an orange following a verbal altercation with another patient, she
described the pain as it “feels like my head was cracked open,” and believed that she
had a huge bump on her forehead, which she did not. The patient also described a
pain in her right leg after reporting that she fell down some stairs about two years
ago. She felt that her leg was broken and that the two bones in her lower leg were
“broken and twisted,” yet had no difficulty ambulating and exam did not indicate any
abnormality. After getting her last intramuscular injection of Invega Sustenna prior to
discharge, the patient reported that she felt like “all my little tendons and ligaments
are like, all standing up” and if “[the injection] would had been placed in my bone, I
wouldn’t have a bone because it would’ve been a broken arm.” At one point, the
patient stated that she felt as if she had an abortion because her “stomach got big and
hard and then got soft and small.” She continued by saying that she did not want to go
to the hospital to the gynecologist because they are going to “hospitalize me and
induce the labor and I’m not due yet.” A beta-HCG test on admission was negative.
When told that she was not pregnant, the patient replied: “Well they will induce it.”
She went on to reiterate that she felt as if she had an abortion and it then “grew back.”
The patient was noted to still be hearing voices on and off and her dose of
antipsychotic was thus increased. Her third week on the unit, the patient began to
show some improvement, continued compliance with her medication, but still
remained internally preoccupied and preoccupied with various somatic delusions

According to her records, between July of 2009 and March of 2014 the patient had 27
emergency room visits and three brief inpatient medical admissions. Over that time
period she visited five different New York City hospitals requesting treatment for
extremity pain/ myalgia, unspecified chest pain, Gastroesophgeal Reflux Disease
(GERD)/dysphagia, and abdominal pain/gastritis. Her three inpatient admissions were
twice for esophageal reflux, and once for “other chest pain.” These complaints are in
parallel with many of the patient’s complaints during her most recent psychiatric
hospitalization.