Our patient was 21 years old when he was first hospitalized. This single, Caucasian, right-handed man was living with his mother and had finished high school five years earlier. During this period, he did not pursue any goal-oriented projects; he did not work or try to go back to school, and spent most of his time withdrawn in his bedroom. He had no siblings and very little contact with his father. He had been drug free for the past year and his family history for neurological and psychotic disorders was negative.
He was admitted to the emergency ward of a psychiatric hospital about four years ago after a court order was issued to evaluate his mental state. Three days earlier, our patient had been arrested after his mother called the police to report being assaulted and threatened by him. The fight took place after she had scolded him for being lazy and aloof. His initial psychiatric evaluation revealed a very fragile mental state for at least the five previous years. After quitting school because of a lack of motivation, our patient started to spend most of his time reading about subjects related to spirituality. Previously, he had been a relatively good student, with no disruptive behavior and above average marks. He seemed obsessed with developing new concepts to reach a more ‘perfect’ existence and thought that studying anything but these subjects was simply futile. The initial mental examination, performed at the time of his admission, revealed coherent speech but a perplexed attitude and what sounded like loose associations. He seemed suspicious, but he had no suicidal or homicidal thoughts. He claimed feeling odd sensations in his mind and in his body that could be linked to some sort of ‘evolutionary’ process resulting from spiritual uplift. He also reported non-specific visual hallucinations (seeing odd shapes and colored lines) and what sounded like auditory hallucinations and telepathic powers. There was no hypergraphism and hypermoralism. His medical history was not contributory. The initial diagnosis was a possible schizophreniform disorder and our patient was admitted. His Global Assessment of Functioning (GAF) scale score was marked at 25, and a dose of risperidone 1mg at bedtime was initiated.
An electroencephalogram (EEG) was performed shortly after his admission and revealed a background symmetric alpha rhythm of about 10Hz, predominantly in the posterior and temporal regions of the brain, coupled with an important subcortical epileptic activity with 3 to 5Hz of slow, pointed waves outbursts. The results of a thorough neurological examination were perfectly normal. However, our patient reported having frequent ‘déjà vu’ sensations and depersonalization tantrums over the past few years to the consultant neurologist. The neurologist concluded our patient was a case of partial complex epilepsy with psychosensorial and psychotic symptoms and prescribed levetiracetam 500mg twice a day. Meanwhile, the risperidone was ceased since our patient showed worsening of certain symptoms. A neuropsychological evaluation showed important deficits in executive functions (especially working memory and concentration) and lack of motivation, probably secondary to intellectual understimulation for a long period of time. However, since our patient had no developmental delay up to the middle of high school, his intellectual potential was probably superior and was enhanced with proper management and stimulation. A control EEG performed one month later showed no improvement and carbamazepine continued release was progressively increased to 400mg twice a day (blood concentration stabilized at 40μmol/L). The results of a computed tomography (CT) scan and cerebral magnetic resonance imaging (MRI) study were both normal. Follow-up EEGs (performed six months after his first admission) continued to show the same epileptic activity and carbamazepine was stopped and replaced by valproic acid (up to 500mg twice a day with blood concentration stabilized at 452μmol/L). In spite of this, his EEG results remained practically unchanged.
Even though abnormal epileptic activity remained, our patient showed significant improvement during this period. Three months after admission, our patient left the hospital and started an integrated psychological therapy (IPT) group three times a week, a program that combines neurocognitive and social cognitive interventions with social skills approaches for patients who are schizophrenic. IPT has been shown to be an effective rehabilitation approach for patients experiencing psychotic disorders . In addition, he was also integrated into a rehabilitation home in order to practice these skills in a protected and proactive setting adapted to his strengths and weaknesses and willing to follow his pace of learning. Monthly individual cognitive-behavioral therapy (CBT) sessions, adapted for psychotic patients [14, 15], were also initiated by the treating psychiatrist to further potentiate the treatment. In a matter of months, our patient realized his deficits in social interactions. When confronted with them, he tried to isolate himself by going back to his old thoughts on spirituality and pursuit of a perfect world. However, these beliefs were found to be primitive psychological defense mechanisms and our patient himself knew this. The previous visual and tactile hallucinations became much more scattered and were more the fruits of odd interpretations of reality. Almost a year and a half after being hospitalized, he started a job reinsertion program and is looking forward to moving into his own apartment. The final psychiatric diagnosis was a psychotic disorder and personality change due to a general medical condition (epilepsy). However, despite active epilepsy, non-responsive to medication, he has managed to control a lot of symptoms deriving from the intertwining of his organic and psychiatric disorders. A control neuropsychological evaluation performed more than a year after the first one revealed steady scores for executive functions, but significant improvement in speed of information processing. His most recent GAF scale score was 65.