29 yr male with psychiatric issues and anhedonia

 NOTE: THIS IS AN ONLINE E LOGBOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HIS / HER /GUARDIAN'S SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR INDIVIDUAL PATIENT'S PROBLEMS THROUGH A SERIES OF INPUTS FROM THE AVAILABLE GLOBAL ONLINE COMMUNITY OF EXPERTS INTENDING TO SOLVE THOSE CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE-BASED INPUT. 

NOTE: Dr. SANJANA has also contributed to the case history

PATIENT HISTORY: Pt is a 29 yr old male, an advocate by profession. 

Since childhood, he claimed to be very mature (e.g he used to console his mother when other men used to make advances on her, used to do accounts, and write checks on his father's behalf while still in class 6. But, also claimed to be immature in some issues (he used to suck his thumb till 10 yrs of age, and used to sleep with a teddy bear named Bunny until he lost it at the age of 14 yrs. After that used to sleep hugging a pillow); slept alone. He had owned a toy in an arcade and used to sleep with it till the age of 24 yrs. 

Since 10 yrs of age used to get involved in serious fights when provoked/bullied by friends. 

At that time his mother used to live alone with pt and his brother. Dad had a transferable job, so often not at home for long. Residents of the flat and random guys used to flirt and hit on pt's mom which made her somewhat harsh in dealing with people. So, when he did any mischief or did not follow her commands, or got involved in any fights, she would punish him by causing burn injury with a heated cooking spatula. That traumatized the pt and he became docile afterward. 

When in class 8-10, he used to chew and swallow stapler pins. While studying in intermediate he suffered from jaundice for 6-7 months.

At the age of 11 yrs, he got molested for the first time on multiple occasions while on his way to attend yoga class early in the morning (pt was forced to masturbate by a man, and touched inappropriately). Pt did not complain to his parents and accepted life as it is.

At the age of 13 yrs, molested by 2 boys who were his best friends (pt reported they used to watch porn which he did not, that is why they molested him). Again did not complain to his parents.

At that age, at school, he used to be beaten by teachers in school about which he complained to his mom, who took no major action. One year later, he changed school.

At the age of 15, he got molested by a girl who was 2-3 yrs older, in his biology tuition. She used to take him to a room and made him remove all his clothes and touched him inappropriately.

While in intermediate, he sued to fall for girls quite easily. Was in 2 casual relationships (not physical) for 1.5 months and 6 months.

At the age of 17, he was in a toxic relationship (his girlfriend did not let him talk to anyone else, used to check his phone, and forced him to give up joining a cricket team) for 3 yrs. After the breakup, he felt liberated.

At the age of 22, again in 3 yrs relationship. 

At the age of 24, pt started c/o hearing voices and commands. Described it to be unknown voices of varied ages and gender. In the past was a vivid reader, but he started c/o losing his mind, unable to think anything clearly or concentrate even on simple tasks. Had a severe headache. He also started c/o of memory loss, and constant tremors in his hands, feet, and back. Couldn't tell how time passed (no sense of time i.e he felt the days drag a lot). All of these made him give up his relationship (claimed his relationship was quite healthy). Pt started talking to himself, and could not sleep. When he used to close his eyes would see vivid imagination even though not sleeping, but could not control his thoughts as per his will.

He told about this his parents but they ignored it. He started hearing commands e.g, kill yourself, die, you are worthless, go to that place, do this and that. Pt found it difficult to always neglect the commands. He self-inflicted burn injury using a hot spatula. Wanted to kill himself. When he burnt himself with a hot spatula, he felt the harsh voices decrease giving him commands, and could hear softer voices appreciating him.

After that, he felt that all this was because of him being indisciplined, so he started hitting himself with a belt, but saw no improvement and stopped. But, as described by him, pt was a docile person and could not take any major attempt (he decide to start smoking heavily again to kill himself slowly). His parents took him to a Psychiatrist, who gave him medications. Pt c/o that the Psychiatrist was harsh, not willing to listen to him, and used to blame him and call him stubborn in front of his mom, which made his mom get more irritated with him. So, instead of improving his condition further deteriorated. The medicines prescribed him made him very drowsy and sleepy. He used to sleep for a long time. Once, when his mom tried waking him from his sleep, he got very aggressive and beat her up The Psychiatrist assumed him to be taking drugs and sent him to the ASHA rehab center where nothing abnormal was found, he was released after 7 days.

His brother who is a Dr. recommended doing family therapy, which helped him a bit.

In 2018, before his symptoms began, the following incident occurred:

He was on his bed with his eyes closed. He wasn't asleep, but couldn't open his eyes or move. He then fell from his bed and rolled towards the wall and hit his head. He then felt a fluid oozing out from the back of his head and drenching his back. When he woke up in the morning, he was still on the floor near the wall, but there was no sign of injury.

In 2018, he went to Isha Yoga Centre for a few days to take some space from his family. There he was able to meditate for 2-3 hrs but his breathing apparently slowed (he says 2-3 breaths/min). When he mentioned this to the people in charge, they took him somewhere else, asked him to meditate, and started a cloud of smoke in front of him while ringing bells behind him. 

2 years later, the daughter of his flat's caretaker was molested by a resident of the same flat. He took up the case and made him file a case. He was very committed to the case. But, the caretaker wanted to withdraw the case. His father also told him not to pursue the case further. He assumed his Dad had taken a bribe from the culprit and pt got very angry, resulting him in hitting his family members.

Pt was taken to another Psychiatrist on May 2021, who prescribed Escitalopram oxalate 20 mg and DON LS (Risperidone and Trihexyphenidyl) and nicotine dermal patches. Pt reported the Psychiatrist patiently listens to what he has to say and that is helping him out a lot.

 Currently, he scored his problem (still can hear voices, though less frequently) to be scored 2, which was previously 10/10 before treatment. Pt also reported in the past he could meditate easily for 1-2 hours. Pt does not blame his parents for his condition.

Four months ago he changed his job. He is quite happy with his new job (no pressure at all, unlike his previous job). 

Pt started smoking at the age of 20 yrs due to peer pressure. At first 3-4/day then 8-9/day. Quit at the age of 22 yrs, after he broke up with his girlfriend (he felt liberated from the toxic relationship; started going to the gym, and gave up alcohol). Started again due to  (1 pack /day). Stopped 43 days ago, since he started using nicotine dermal patches.

Pt started alcohol consumption in 2013. Used to drink once in 6 months (600 ml). He stopped drinking in 2015 because he did not want to get addicted. But in 2017, made some friends who forced him to start drinking again (250 ml, 2-3 times/wk). He tried to motivate his friends to work on some business projects which they declined. He realized they are only meeting up for drinking purposes, so after one month stopped meeting with them and quit drinking. His father started blaming him for losing his friends which resulted in depression. For a year he had started drinking with 4 people including his brother. He says he enjoys listening to different viewpoints during the drinking periods (2-3 times/ wk, 250-500 ml).

Currently, he has no friends and had never discussed his problems with any of his friends, and is not in great detail with his family. He says he had lost the ability to speak with people nicely. He complains all around him drinks, so if he gives up drinking completely he will lose all his acquaintance.

FAMILY HISTORY: 

Father - supportive. Encourages him to grow up

Mom - supportive and caring (feeds him via own hand sometimes)

Brother - not supportive. The relationship is not good. Dr. by profession. Boastful, egoistic, and insensitive towards family members.

CHIEF COMPLAINTS AND PATIENT'S REQ.: Pt still c/o hearing voice commands, which prevents him to concentrate on anything, cannot medicate, and want further advice.

REPORTS: