Patient: Crichton, John Robert
Date: May 28, 1999
Length: 60 minutes
History of Presenting Illness: Patient is a 30 year old single white male who was referred for evaluation by IASA. Pt is an astronaut for IASA and has worked without difficulty there for 3 years. Pt has been working on a project which is well documented elsewhere (see Farscape mission). IASA referring officials have provided the following information. The pt was ordered to abort his experiment due to an electromagnetic wave in space. The pt did not do so and as a result landed in a controlled crash which destroyed the Farscape module. Pt was evaluated at the Emergency Department for medical clearance. Upon waking, the pt became violent and attacked his father without provocation. Pt was placed in restraints, sedated, and allowed to regain control. Upon calming, pt displayed insight into his actions and verbalized the inappropriateness of acting in a violent manner. Pt was then released from treatment in the custody of his family. Pt is now referred for full evaluation by attending physician Dr. Bettina Fairchild.
Mental Status Exam: Upon my initial arrival to my office, I found the patient already in the room. He was seated behind my desk and was using my telephone to order a pizza. He displayed an alert state of consciousness. He maintained strong eye contact. He displayed significant levels of wariness and paranoia.
His thought content revealed evidence of markedly delusional thinking. The patient reported multiple delusional ideations including reporting that I am a plant from Delfya and that my name is actually Zaan, even suggesting that we have had intercourse despite the fact we have never met before this occasion. ( I am currently unaware of the meaning of this…is Delfya a company competing with IASA??) He makes references to a ship of aliens from Moya and is focused on someone named Erin. The patient also displays evidence of marked paranoia about the integrity of his body, reporting that people want to attack his mind/brain (scorpio?? Astrology? Planets Delfya/Moya? Something called Maltus). The delusions appear somewhat entrenched and may be fixed in nature. The pt also appears to be racially preoccupied in his thoughts and is very concerned over working with me. (Am I first blue person pt has seen…watch for ethnic/racial transference issues)
The pt’s thought processes reveal loose associations at times but are largely logical overall…discounting the incomprehensible delusional material. Pt also displayed evidence of psychomotor agitation, during first session it was the constant movement around the room. Second session, the pt continued to clutch a pillow as if needing something to ground him in this reality. He described his mood as “I don’t know” but his affect was fearful and hypervigilant. His concentration was intact. No overt evidence of responding to internal stimuli and the pt denied auditory or visual hallucinations.
Assessment: The pt appears to be displaying psychotic symptoms of paranoia, delusions, and LOA. While history does not support a diagnosis of schizophrenia, a diagnosis of psychosis NOS is appropriate. Psychosis secondary to head trauma appears to be ruled out with the serial CT scans from the ED but a post-concussive syndrome remains a rule out diagnosis. Given the pt’s focus on people being replaced by these aliens, a diagnosis of Capgras Syndrome may be appropriate as well.
Plan: Weekly insight oriented psychotherapy sessions. Consider trial of antipsychotic medication…preferably Risperdal with its low incidence of sedation and weight gain. Pt does not wish medication intervention at present. Will continue to monitor symptoms and for any further signs of assaultive or aggressive behaviors. If they reoccur, may need to consider a trial of a mood stabilizer such as Depakote.
Addendum: Pt.’s violent behavior escalated, resulting in the assault and near death of a police officer. While reviewing and discussing treatment and possible return to duty with IASA Director, Douglas Logan, Col. Jack Crichton, Douglas Knox, and Dr. Bettina Fairchild. Pt arrived, clearly distracted as he circled the room saying he did not have a future in our ’reality’, his delusions clearly taking a more active role in his mind. Speaking of the person named Scorpius once more, and claiming this man needed to release him. (Pt did not state what he needed released from.) Pt then pulled out a firearm and shot his father, then each person in the room. Security arrived and restrained the pt who is now under heavy sedation in the psychiatric wing at the Brevard Co. Hospital awaiting treatment.
Loose Associations or LOA as it is abbreviated is a way of thinking found in psychotic patients. It means the patient makes jumps in topic in which he is following what he is talking about but you have no idea what he is referring to. You ask about his weekend and he replies I like that Goatboy. His thought process was this: weekend=Saturday=Saturday Night Live=character sketch comedy=my favorite character=Goatboy.
Psychomotor Agitation or PMA means he was physically moving all around as opposed to PMR psychomotor retardation when the pt appears almost catatonic.
Responding to Internal Stimuli or RIS…when the patient looks like he is talking to someone or hearing voices that you can’t hear.
NOS - Not otherwise specified
Capgras Syndrome - The delusion that others, or the self, have been replaced by impostors. It typically follows the development of negative feelings toward the other person that the subject cannot accept and attributes, instead, to the impostor. The syndrome has been reported in paranoid schizophrenia (see schizophrenia) and, even more frequently, in organic brain disease.
I had to wait to get some 'technical' help with this. Krazeedr, went above and beyond what I asked of her, even adding Dr. Cominsky's little notes as to John's fixation with her color. So she should get the credit for almost all of it, cause I sure as hell couldn't find this information on my own. I couldn't even find a decent case study after over two hours of searching the other day. Tweeks will be made of course.