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Alex's story

Alex is a 22-year-old male who has been living alone for the past couple of years. He has a long history of schizophrenia and a complex set of delusions including a belief that he is the messiah (God) and has been crucified. He was admitted to an in patient unit eight days ago after he assaulted a worker at a day programme, which he has attended for the last couple of years. The police and the crisis team were called to assess him. The police arrived first to find that Alex had the day programme assistant in a head lock, and was threatening to punch her. He then assaulted one of the attending police officers. It is unclear whether the assault was directly related to his psychosis. He believes that the programme assistant was preventing him from accessing all of the facilities.

Alex has had no suicidal thoughts over the past few months, does not use alcohol or drugs, and displays no cognitive problems on examination. Since admission, he has complained of abdominal pain and a burning sensation all over his skin. X-rays revealed two cracked ribs but it is unclear how these were sustained. Yesterday he had a gastroscopy, which revealed he has reflux and oesophagitis, and has much improved today as a result of starting medication for these complaints.

Alex has suffered delusions and hallucinations over the last couple of years, and it is doubtful if medication has made any significant impact on these. His preoccupation with these delusions and hallucinations are difficult to assess, but since his admission to the unit it is clear that he is very distressed by some of his beliefs and paranoid delusions. He is isolative and withdrawn. He is troubled with guilt feelings and poor self-esteem. A worker at the day programme has commented that Alex seemed a bit depressed in the last couple of weeks and this became more evident following his admission. Sleep and appetite have been good. We don’t know about his sexual life, however it has been established that he has not had any partners recently.

Alex spends most of his time at the day programme working on the computer, slowly learning programming. He finds this stimulating and looks forward to attending. He also spends a lot of his time in church praying. He has no close friends and only very transient type conversations with acquaintances. He takes reasonably good care of himself and his personal hygiene, although he is somewhat untidy and tends not to change his clothes very often. He seems to manage his day-to-day affairs without difficulty (for example, rent and finances). He likes his current accommodation and gets on well with the landlord. There are no reports of him causing any problems in the community with the exception of the reason for this admission.

Progress notes

Day 1 – initial assessment (in emergency department)
22-year-old accompanied by crisis team following an altercation at Enterprise Day Programme. Appears extremely deluded and agitated. Claims he is God and that he needs to get to a computer because his followers need him. Complains of chest pain, difficulty in breathing and heartburn. He also stated he is being treated for a stomach problem? Hiatus hernia. Sent for X-ray. Crisis team accessing in patient bed at psych unit for further assessment.
James Tribe MBBS

Psychiatric assessment
Alex referred from ED following an outburst of aggression at Enterprise Day Programme. Expressing the belief that he is the one true God and needs to get to a computer to see if his followers still need him. Complains everyone is against him. C/o chest pain on admission – X-ray revealed two cracked ribs – treat symptomatically with paracetomol prn. History of hiatus hernia - referred for endoscopy.
Matt Wizzen FRANZCP

Mental state examination
Dress appropriate and self-care OK. Highly agitated and reluctant to cooperate with admission procedure. During the admission procedure, he is talkative with slight stuttering. States he is not worthy of his followers’ trust and that he has let them down just like he always does. Refers repeatedly to the need to get to a computer to communicate with his followers. Affect appropriate. States he does not hear voices. No apparent impairment of memory. Denies he has an illness and refuses to cooperate with specific testing (for example, serial sevens). Sleep and appetite OK. Denies any thoughts of self-harm. No previous history of suicide attempts. Denies drug or alcohol use recently.
Matt Wizzen FRANZCP

Case entry, day 1 of admission (8pm)
Alex has settled into the ward environment following his admission but remains isolated from staff and patients. When I approached him to find out if there was anything he needed he asked if he could use one of the ward computers to play ‘Doom’. When I said I could leave a note for the day staff tomorrow to follow up his request he seemed to brighten up. Stated he’d enrolled in a course at the local polytechnic programme last week of his own volition. Expressed concern he wouldn’t be able to cope with the course because the other students he saw looked much more intelligent than he was.
Grant Jones RN

Page last updated: 9 December 2008