Case 1: A woman who will not leave home for fear the neighbours will kill her

01The case

A 26-year-old woman is admitted to hospital because her husband asked for it. For the past two weeks she has refused to leave the house, afraid that the neighbours mean to kill her. Twice she has tried to telephone the President of the Republic, to offer her help in stopping a dangerous virus from spreading. When her husband tried to talk her out of it, she told him that a transmitter in her brain tells her what to do.

02Summary

Diagnosis

An acute paranoid psychosis, a first psychotic episode, in ICD-10 an acute and transient psychotic disorder.

What points to it

• Persecutory delusions: the neighbours want to kill her, so she stays at home.
• A delusion of being controlled from outside: a transmitter in her brain gives her orders. Delusions of control are first-rank symptoms of schizophrenia.
• The grandiose wish to help the President stop a virus.
• A short history: two weeks is too short for schizophrenia, which needs a month of symptoms in ICD-10 and ICD-11.

What else it could be

If the symptoms last beyond a month the diagnosis becomes schizophrenia, and if a manic or depressive episode comes with them, a mood disorder with psychotic features or schizoaffective disorder. A first psychosis also calls for a search for an organic cause or a drug: a physical examination, blood tests, a drug screen and, where the history suggests it, brain imaging.

Management

• Admission, since she cannot be cared for at home while she believes she is in danger there.
• An antipsychotic, at a low starting dose in a first episode.
• Psychoeducation for her and her husband.
• Treatment as an outpatient for a long time once the acute symptoms have gone, usually at least a year after a first episode.

Outlook

Guarded. It is a first episode, so how she responds to treatment and how the illness runs are not yet known: some acute psychoses resolve fully, and some turn out to be the start of schizophrenia.