July 5, 2023 from Mescape
A 37-year-old man who was injured in a car accident is brought into the emergency department (ED). He doesn’t seem to have any visible physical wounds. He shows considerable annoyance with the existing emergency professionals and police officers, and he throws a cup of water at the hospital staff. The clinical staff notices his unusual agitation and requests a consultation with the hospital’s psychiatry unit.
The patient yells to the doctor repeatedly that the reason he is there is because “that woman cut me off on the highway!” The examining physician is shocked when it is revealed that the collision did not take place on the roadway but rather around an hour afterward.
The patient claims that after closely trailing the other driver home and carefully formulating a plan for retaliation, he purposefully crashed into the woman’s parked car. In his words, “I wanted to show her what happens when she cuts people off.” He started continuously spitting on the terrified woman when she emerged from her house to check what had happened. The woman then made a police call.
The patient shouts throughout the examination about how rude the other driver had been to him and how she deserved to be spit on. He keeps talking about how unfair what happened was and how angry he is about it. He is ferociously upset for the several hours that he spends in the emergency room.
The patient is questioned about what led him to purposefully run into the other driver’s car. He claims that after colliding with her car, he wanted her to drive more cautiously so that she would know better than to do the same to other people.
“I know I shouldn’t hit people.” he responds when asked why he spat on her. “I’ve gotten into trouble for that before.”. When the doctor asked whether he was hearing voices directing him what to do the patient said that there’s always his voice in his head. “It was angry!” he said.
When questioned about his paranoid thoughts, he said “What does that mean?”. “Sometimes, I feel like people are trying to make fun of me. They always have.” he says after giving a brief explanation. Other than his parents’ voices, which he occasionally hears telling him what to do, he is not aware of any other voices. Overall, he shows little understanding of the purpose behind the doctor’s inquiries.
The patient has a low level of patience and seems irritated and irritable. With the emergency personnel and police officers, he is verbally confrontational and uncooperative. There are no obvious physical damages from the car accident.
At 102 beats per minute, the patient’s heart rate is elevated. There are no murmurs, rubs, or gallops heard. He has a regular heartbeat. At 16 breaths per minute, his breathing rate has slightly increased. His lungs can both be auscultated as being clean. His bowel movements are regular, and his belly is not painful or tympanitic to percussion. The nerves in his skull remain unharmed.
The patient is awake and aware of his name and location during the mental status test, but not of the time or date. He exudes an inordinate amount of anger and shows motor overflow. Loud, aggressive, and regularly interrupted by emotional outbursts, his speech is. When compared to his immediate, recent, and distant memories, his recall is sufficient. When requested to perform serial sevens or threes, he struggles and gets irritated more.
He occasionally has tangential thought patterns, but they can be corrected. His main thoughts are of rage and perceived injustices. He shouts constantly about the other driver, claiming that she deserved to be spit on and he reports hearing his parents’ voices in his brain directing him what to do, but he doesn’t have any other auditory or visual hallucinations. He denies having suicidal thoughts. When questioned about his murderous intentions, he merely admits to wanting to spit on the motorist.
The patient has little understanding of the implications of his behavior. He makes poor decisions and struggles with impulse control. The results of an ECG are normal, however, the heart rate is 102 beats per minute. No signs of a large lesion, hemorrhage, or a cerebrovascular event are visible on a head CT without contrast.
Except for cannabis, the findings of a urine toxicological check are negative. The results of a urine analysis are within normal bounds and his total leukocyte count, detailed metabolic profile, and thyroid-stimulating hormone levels are all within reference ranges.
A diagnosis of intellectual impairment (ID) is most significantly correlated with this patient’s presentation and reported history. Identification illness (ID) is a developmental illness that encompasses deficiencies in intellectual and adaptive functioning across conceptual, social, and practical domains, according to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR). ID essentially refers to deficiencies in a person’s daily adaptive mental function when compared to peers who are similarly aged, gendered, and culturally diverse.
Although this case exhibits some symptoms of intermittent explosive disorder (IED), the overall clinical picture most strongly suggests that the patient is experiencing persistent adaptation challenges across a number of domains. Impulsive behavior may be influenced by illnesses like chronic traumatic encephalopathy.
This diagnosis, though, seems considerably less likely. Although it is worth mentioning that these conditions can undoubtedly co-occur with or exacerbate the difficulties present in an individual with ID, the patient in this case exhibits behavioral difficulties that appear to have been lifelong rather than acquired (whether from substance use [e.g., cannabis] or from head trauma).
It is important to notice that the sufferer had a deliberate plan for getting even with the person who had hurt him. According to the DSM-5-TR, the outbursts of people with IED are not premeditated and don’t have a clear goal. Additionally, he was angry for more than 30 minutes, which is unusual for IED and shows he has persistence.
Even if the patient claims to have heard a voice, closer examination reveals that it is more likely that he has confused his own thoughts with outside hallucinations. Instead of having symptoms that blur the distinction between reality and fiction (such as psychosis), he is confused because of a general lack of awareness of himself and how he interacts with his environment.
According to estimates, ID affects 1% of the general population and 1%–3% of the population in Western nations is afflicted. Since mild cases might not be discovered until later in life, it is challenging to determine incidence with accuracy. With a boy-to-girl prevalence ratio of 1.5, the peak diagnostic ages are between 10 and 14 years old.
A thorough assessment of both intellectual and adaptive functioning is necessary for the diagnosis of ID. Although IQ scores have traditionally been the main focus of examinations, modern testing also looks at life skills and adaptive functioning. Because it aids in determining the proper degree of care for each patient, the DSM-5-TR places a strong emphasis on adaptive functioning in ID diagnosis.
It can be difficult to distinguish behavioral impairments brought on by main psychiatric illnesses like schizophrenia or depression from those brought on by developmental disabilities like ID or autism. Furthermore, concomitant psychiatric problems may occur more frequently in people with ID than in the general population. Because there are several treatment modalities, proper diagnosis is crucial. Despite being ideal, complete neuropsychological testing may not always be accessible.
It is critical to collect a complete history in order to distinguish between developmental and primary diseases. A strategy like this could show that there were intellectual and behavioral abnormalities during development and could pinpoint the causes, co-morbid conditions, and relevant intervention strategies for ID. Collateral information about the patient should be gathered from people who are familiar with them, such as their parents, carers, and service providers who are aware of their developmental history, in order to properly take their history. Keeping an eye on the patient’s conduct is also crucial.
Primary mental diseases like schizophrenia should be ruled out in this patient’s evaluation. Schizophrenia is a primary mental disorder that exhibits negative symptoms, hallucinations, incoherent speech, and profoundly disorganized or catatonic behavior, according to the DSM-5-TR. About 1% of the general population is affected, and the onset usually happens in late adolescence or maturity. ID, on the other hand, shows itself earlier in life. According to reports, this patient’s deficiencies persisted throughout his life, which is more indicative of ID.
Because ID symptoms are similar to those of other psychiatric diseases, patients with ID frequently receive the wrong diagnosis. Many severe stress reactions in people with ID could be mistaken for symptoms of other main mental illnesses. As a result, proper identification and effective therapy depend on a thorough evaluation and differential diagnosis.
It might be difficult for people with ID to appropriately convey their inner emotional states and thoughts due to communication, working memory, and insight issues that are frequently connected with the condition. Remember that the patient in this case claims to be “hearing voices” and has delusional beliefs that people are making fun of him.
To distinguish long-term features from the commencement or relapse of an illness, a thorough developmental history is essential. Patients with poor cognitive functioning could have a hard time describing certain symptoms appropriately, like hallucinations and paranoia. Clarification requires probing open-ended questions regarding their experiences, including the cause and persistence of symptoms.
A holistic and interdisciplinary strategy that prioritizes the patient’s special needs and those of the family is necessary for the treatment of ID. Early intervention is essential because it gives people with ID the best chance to realize their full potential. This could involve occupational treatment, speech and language therapy, and specialized educational programs. Improved adaptive functioning may result from interventions that create a nurturing atmosphere that promotes learning and development.
Treatment should attend to the patient’s physical, emotional, and social requirements in addition to providing educational support. For instance, physical therapy can help patients with their mobility and motor abilities, while counseling can help them develop their self-esteem and cope with emotional difficulties. Participating in social events can also encourage inclusion and aid in the development of critical social skills.
Additionally, families must be included in the healing process since their love and support can significantly improve the lives of people with intellectual disabilities. The nature of the disorder should be explained to families, and they should be given tools to assist them in dealing with the difficulties it poses.
The severity of cognitive impairment and the quantity of support offered for it are two factors that affect the prognosis of ID. Early interventions may enhance adaptive functioning, which can occasionally result in notable intellectual advancement.
While those with moderate ID can talk and work under supervision, those with mild ID can live independently and raise families. People with deep ID experience considerable communication and social difficulties, whereas adults with severe ID often require supervised living and employment help. Assessments should reveal if improvements in adaptive skills are sustainable or require continuous assistance and interventions.
Following his evaluation, the patient in this instance was directed to a social worker, who put him in touch with an appropriate behavioral therapist for follow-up treatment. A referral to a psychiatrist was also made in order to weigh the advantages of a medical course of action.
A thorough care plan was developed taking into account the patient’s chronic troubles with his ability to tolerate frustration as well as his social and occupational difficulties. The tailored plan was established with the sole goal of reducing occurrences in the future caused by unchecked rage and frustration.
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