Case 11: A young woman who says her phone is tapped, after a break-up

01The case

A 24-year-old woman is brought to the psychiatric clinic by her parents after they saw her GP. For three weeks part of what she says has been impossible to follow. She has said that she is being watched and her phone tapped, because she has access to top secret information. For a short time she was agitated, and for the last three days she has not slept at all. It started with a short spell of low mood after she split up with her boyfriend.

Treatment is started at once, as an outpatient, and within a few weeks all the acute symptoms have gone. She talks about what happened to her readily and agrees to stay on treatment for at least a year.

02Summary

Diagnosis

An acute psychosis with schizoaffective features, a first psychotic episode.

What points to it

• A sudden onset over three weeks, after a stressful event.
• Sleeplessness, restlessness and partly incoherent speech.
• Delusions of persecution (watched, phone tapped) and of grandeur (access to state secrets).
• Marked swings of mood: low at the start, then signs that look like mania (no sleep at all, agitation, grandiosity).

What else it could be

One short first episode cannot settle the diagnosis. The choice lies between schizoaffective disorder, manic type, and a manic episode with psychotic features, the start of bipolar affective disorder; only the course will show which. Schizoaffective disorder needs the symptoms of schizophrenia and those of a mood episode in the same episode, at the same time or within a few days of each other, for at least a month, so it cannot yet be called that. Exclude drugs and physical causes as in any first psychosis.

Management

• An antipsychotic, which treats both the psychosis and manic symptoms; add a mood stabiliser if a manic episode is confirmed.
• Not valproate for her unless nothing else will do and a pregnancy prevention programme is in place: she is a woman who could become pregnant.
• Hospital or home: older teaching treats her as an inpatient, but the case shows that outpatient care works when the family is supportive and she is willing.
• Psychoeducation for her and her parents, including early signs of relapse.
• At least a year of treatment, as she has agreed, then a gradual reduction under close review.

Outlook

Good. In her favour are the acute onset, a clear precipitating event, prominent mood symptoms, a quick response to treatment, her cooperation and her parents' support.