MEDC 4303
CASE REPORT IN PSYCHIATRY
Brittney Mohammed
CLASS OF 2026
1 DEMOGRAPHICS
Name: J. R.
Age: 25 years old
Date of Birth: 05/05/1999
Area of Residence: Penal Quinam Rd.Penal
Relationship Status: Single
Ethnicity: Indo-Trinidadian
Religion: Hindu
Employment: Unemployed
Date of Admission: 29th January 2025
Date of Interview: 1st February 2025
Date of Discharge: Not yet discharged
CIRCUMSTANCES FOR REFERRAL
The patient was brought into the Accident and Emergency Department by parents
due to aggressive behaviour towards them, insomnia, decreased appetite, heavy
marijuana and alcohol usage.
2 HISTORY
Presenting Complaint
Patient presents with aggressive behaviour, decreased sleep, decreased appetite, heavy
marijuana and alcohol usage for 3 days.
History of Presenting Complaint
Patient is a 25-year-old, single Indo-Caribbean man, unemployed and lives in Penal with
his parents. J. R. has a known history of previous admissions for drug-induced psychosis,
non-compliant on medication and nil follow-up at Substance Abuse Clinic. He smokes 1-2
packs of cigarettes per day and approximately 10 blunts of Marijuana daily. J. R. also consumes
alcohol (Puncheon and Guinness) each day of varying quantities.
Patient stated that his use of alcohol and marijuana began back in secondary school where he used
substances with his school friends which increased over time. He also notes that he felt neglected and
abused in his childhood and as a result is rebelling at present. Patients father noted that he had
previously brought him to A&E for similar symptoms and was discharged one week later on Divalproex,
Benzhexol, Diazepam and Haloperidol.
Father noted that after discharge, patient decreased marijuana and alcohol usage and was
compliant with his medication. They noted that he became calm, but his movements were
lethargic. They opted for rehab, but patient constantly refused. Approximately 2 weeks ago,
patient stopped taking his medications because voices told him that the medications are
stopping him from his calling/ purpose in life. 2 days later began smoking Marijuana and
consuming alcohol increasingly.
Parents stated that patient began sleeping less, approximately 2-3 hours daily, speaking to
himself inaudibly and to things around him. He also stopped bathing for long periods and
sometimes didn’t speak to them. No present suicidal ideations but had in the past, began
having homicidal ideations where he was threatening to kill and bury relatives and became
hyper religious, converting to Islam while simultaneously speaking about Hinduism. They
also stated that patient believed they were against him and wishing him bad and praying
for his downfall to Hindu Gods.
They noticed his behaviour worsened over the past 2 weeks where he became more
erratic, speaking to them aggressively but no physical harm occurred.
Patient stated that parents are doubles vendors and when he was younger, he helped them
with their business and now they are ungrateful towards him. He also noted that his
grandmother promised him a place to live in her house before passing but claims that his
mother said that his uncle and cousin who reside there doesn’t want him there. His parents
said this is not true. He also stated that after being discharged he plans to open a fruit stall
in Penal and make lots of money.
YES NO
o Excessive sleeping
DEPRESSION
o Suicidal Ideation
o Anhedonia
o Feelings of guilt
o Persistent sadness
o Fatigue/ loss of energy
o Difficulty concentrating
o Distractibility
MANIA/HYPOMANIA ✓ Elevated mood
o Thoughtless
✓ Increased energy
✓ Decreased need for sleep
✓ Grandiosity/ inflated self-
worth
✓ Impulsive
✓ Talkative
✓ Restlessness o Irritability
ANXIETY
✓ Sleep disturbances o Muscle
tension
o Excessive worry
o Fatigue
o Difficulty concentrating
PSYCHOSIS ✓ Delusions o Disorganized speech
✓ Hallucinations
✓ Disorganized Behaviour
✓ Negative symptoms
PAST PSYCHIATRIC HISTORY
J. R.’s first psychotic episode was 2 months ago where his parents complained of his overuse of
marijuana and excessive alcohol use, leading to him becoming aggressive and behaving
abnormally. Patient was brought to A&E by his parents as they became fearful and worried
about his condition. He was diagnosed with Substance induced- psychosis and admitted for 12
days in Ward 1 at San Fernando General Hospital. He was treated with a combination therapy
of Haloperidol, Divalproex, Benzhexol and Diazepam. Patient responded positively to treatment
and was later discharged on the same medications
PAST MEDICAL/SURGICAL HISTORY
Nil medical history.
Nil surgical history.
MEDICATIONS AND ALLERGIES
Nil medications.
Nil allergies.
SUBSTANCE USE HISTORY
Patient has significant history of Substance abuse:
Alcohol: Drinks Puncheon multiple days a week (multiple bottles) along with Guinness.
Smoking: Cigarettes (22 pack-year history – ½-2 pack daily x 11 years)
: Marijuana (1-2 joints every day with an increase to 5 and then 9-10 since the
________age of 16.
FORENSIC HISTORY
This patient has no legal history and has never been involved with the authorities.
FAMILY PSYCHIATRIC HISTORY
The patient states his younger brother attempted suicide via ingestion of Gramaxone,
which was incomplete. He, however, has never been officially diagnosed with a mental
disorder.
FAMILY MEDICAL HISTORY
The patient has an younger brother with nil medical conditions. His father suffers from
hypertension and his mother suffers from Hypertension and Diabetes.
SOCIAL HISTORY
The patient currently resides at home with both parents and younger brother with all
basic amenities. Patient is not currently employed and is relies on his parents for a
financial support.
PERSONAL HISTORY
ANTENATAL AND PERINATAL HISTORY
The patient relays that his mother’s pregnancy was uneventful with no complications and
had all her antenatal checkups. He was an unplanned pregnancy. He was delivered at term
via a normal vaginal delivery with no issues or NICU stays and was discharged the following
day.
EARLY CHILDHOOD DEVELOPMENT
The patient met all his developmental milestones and at the age of 5, commenced primary
school at Penal Presbyterian Primary school and then onto Presentation College, San
Fernando. Patient was a diligent student in his earlier years and his grades gradually
dropped in secondary school as he skipped school occasionally to drink and smoke with his
friends. He achieved 4 CSEC passes with no intention of returning to Form 6. No tertiary
level education pursued.
EMPLOYMENT HISTORY
After finishing school, he remained unemployed for some time and eventually got a job at
18, working in a grocery store for a few months. J. R. found minor construction jobs with
his uncle for some time after that. He then fluctuated between working as a helper at one
of his friend’s vegetable stall and being unemployed from the age of 23 to present.
PSYCHOSEXUAL HISTORY
The patient had a girlfriend at 15 years old while attending Presentation College lasting
about 3 months which ended because her parents did not approve of her having a
boyfriend at the age of 14.
He then had a serious relationship at 19 years old that lasted a year and a half which
ended due to his excessive alcohol consumption and marijuana use.
At 22 years old, he had another serious relationship that ended due to similar
circumstances.
PREMORBID PERSONALITY
Parents stated that before the excessive marijuana and alcohol usage he was a calm, smart,
ambitious and helpful son. He enjoyed playing video games, watching tv and playing cricket
and marble pitch with his friends. He never resorted to violence or aggression and used to
be respectful.
3 MENTAL STATE EXAMINATION
The mental state exam was taken from the patient 3 days after admission and after
the interview. The patient was cooperative, and the Mental State Exam was repeated
the next day as well.
Behaviour, Appearance and Attitude:
The patient was sitting comfortably in at the table in the Psychiatric ward. He was well
groomed, appropriately dressed in a chair in the common area of the Psychiatric Ward.
He appeared his age and was well groomed, of slim built and was dressed
appropriately. Throughout the interview he maintained good eye contact, was very
cooperative and answered all questions without hostility. He also exhibited normal gait,
alertness and appropriate facial expressions. There were no abnormal eye movements
noted. Tar stained lips and fingers were noted.
Speech:
Patient’s speech was of normal rate, speed and volume with a happy tone. It was clear,
understandable, spontaneous without any delay or impoverishment.
Mood and Affect:
The patient reported that he felt happy hi s affect was congruent with his response.
Thought Process:
Upon questioning patient, all answers were direct, logical and coherent throughout.
giving answer that were all coherent
Thought Content:
The patient believed that his parents were praying for him and that they told him his uncle and
cousin didn’t want him to stay in their house. He had no suicidal nor homicidal ideation, no
obsessions, no phobias nor compulsions when comprehensively questioned.
Perceptual disturbances
The patient had no auditory hallucinations, no illusions, no derealization nor
depersonalization.
Cognitive Assessment
ORIENTATION
The patient was able to clearly state his name, age and date of birth. He was oriented
to the place as he knew he was at the San Fernando General Hospital. He was also
oriented to the year 2025, month of February and week but was unsure of the exact
date.
MEMORY AND INTELLECTUAL FUNCTIONS
The patient was able to recall the three words; fish, sea and boat after 5 minutes. He
incorrectly spelt the word ‘limit’ backwards but was successful in subtracting 7 from
100 progressively up to a certain point.
INSIGHT
The patient was unaware that he had a mental illness.
JUDGEMENT
The patient had good judgement as he gave the answer for ‘what would you do if you
saw a child walking in the middle of the road?’ giving his answer, ‘‘to shout to them and
then run to try and help them.’’
PHYSICAL EXAMINATION
On examination:
Young male laying comfortably in nil Cardiopulmonary distress. Mucus Membranes pink
and moist, acyanotic, anicteric and afebrile.
Vitals:
BP - 131
83
Respiratory Rate - 20
Temperature - 36.5°C
Pulse - 58bpm
SpO2 on RA - 100%
CARDIOVASCULAR EXAM:
No pedal oedema. Nil peripheral evidence of any cardiovascular diseases. Pulse was 89
BPM of regular rate, rhythm and volume. No collapsing pulse. Face and neck were
unremarkable. No thrill, parasternal heave or dextrocardia. Apex beat was localized to
5th Intercostal space, mid-clavicular line. Normal heart sounds, S1 & S2 were heard
with no abnormal sounds. No basal crepitations heard.
RESPIRATORY EXAM:
Nil peripheral stigmata of respiratory diseases however tar stained finger tips were
noted. Neck was unremarkable. Nil chest wall deformities with bilateral expansion
adequately. Lungs were resonant to percussion in all lung fields. Normal breath sounds
were heard throughout with normal tactile and vocal fremitus. Findings were the same
at the back. Nil basal crepitations heard.
ABDOMINAL EXAM:
Nil peripheral stigmata of any liver disease noted. Eyes were white, with mucus
membranes pink and moist. Abdomen was non-distended with no striae or caput
medusae. On palpation abdomen was soft and non-tender, no masses, no guarding or
rebound tenderness and no organomegaly. Normal bowel sounds. DRE not done.
CENTRAL NERVOUS SYSTEM:
Patient was alert and oriented. GCS – 15\15.
Nil abnormal movements.
Patient had normal tone- 5/5 in all limbs.
Patient had normal power- 5/5 in all limbs.
Patient had normal reflexes in all 4 limbs.
INVESTIGATIONS
URINALYSIS:
Urine appeared to be clear and transparent in colour.
HAEMATOLOGICAL REPORT:
WBC – 5.9 x 109/L
Lymph% - 43.5%
Mid% - 7.2%
Gran% - 46.7%
RBC – 4.86 X 1012/L
HGB – 13.3.0 g/dL
HCT – 39.5%
MCV – 86.1 fl
MCH – 30.5 pg
MCHC – 34.1 g/dL
RDW-CV – 13.4%
RDW-SD – 44.7 fl
PLT – 227 X 109/L
MPV – 10.5 fl
PDW – 15.4
PCT – 0.258%
CANNABINOIDS: 409 (0-50)
FURTHER INVESTIGATIONS TO REQUEST
1. Liver function tests, Thyroid function tests
2. Radiological studies: CT BRAIN
DIAGNOSIS BASED ON DSM-V CRITERIA
Based on the DSM-V criteria, the differential diagnoses for this patient, J. R., include:
1. Substance induced psychosis
2. Delusional disorder
3. Brief psychotic disorder
DIAGNOSTIC FORMULATION
J.R. is a 25-year-old Indo-Trinidadian male with a history of heavy marijuana and alcohol use who
meets the criteria for substance-induced psychotic disorder. His clinical presentation is characterized
by delusions and hallucinations, aggressive behavior, and hyper-religiosity, which developed in the
context of increased substance use. J.R. has a prior diagnosis of substance-induced psychosis, with a
history of poor treatment compliance and a lack of follow-up care at the Substance Abuse Clinic.
His psychotic symptoms are directly linked to his excessive use of marijuana and alcohol. He reported
consuming up to 10 blunts of marijuana daily, alongside significant alcohol intake, which likely
precipitated his current psychotic episode. His symptoms, particularly persecutory delusions against
his parents and hyper-religious ideation, are consistent with substance-induced psychosis.
Psychotic Symptoms:
Hallucinations: He experienced auditory hallucinations, with voices instructing him to smoke in order
to fulfill his purpose in life.
Delusions: J.R. holds persecutory delusions, believing that his parents are against him, praying for his
downfall, and that they are ungrateful despite his contributions to their business. He also has fixed
false beliefs about his entitlement to his grandmother’s house, which his parents dispute.
Disorganized Behavior: His aggressive behavior, erratic speech, and threats to harm relatives indicate
disorganized thought processes. His hyper-religious behavior, including a sudden conversion to Islam
while simultaneously discussing Hinduism, reflects his unstable mental state.
Negative Symptoms: J.R. exhibited poor insight into his condition and lack of motivation, as
evidenced by his unemployment and dependence on his parents for financial support.
Substance Use Disorder:
J.R.’s heavy and prolonged use of marijuana and alcohol, starting in adolescence, has contributed to
his mental health deterioration. His substance use likely served as a maladaptive coping mechanism
for childhood trauma, feelings of neglect, and unresolved family conflicts. His dependence on
substances is evidenced by his resistance to attending rehab and his rapid relapse into substance use
following non-compliance with his medication regimen.
Contributory Factors
1. Psychosocial Stressors: J.R.’s strained relationship with his parents, their frustration with his
lack of employment, and his perceived sense of betrayal regarding his grandmother’s home
contribute to his delusional beliefs.
2. Lack of Support Systems: His history of isolation, poor family dynamics, and absence of
external social support have perpetuated his condition.
3. Non-Compliance with Treatment: J.R.’s decision to stop taking his prescribed medications,
believing they interfered with his "calling in life," directly led to his relapse.
J.R.’s presentation aligns with substance-induced psychotic disorder, with a significant influence from
his substance use history, familial conflicts, and lack of adherence to treatment. His condition is
further complicated by poor insight, delusional thinking, and his reluctance to engage in substance
abuse rehabilitation. Effective management will require a multidisciplinary approach, addressing both
his psychotic symptoms and his underlying substance use disorder, with a focus on long-term
compliance and psychosocial support.
DSM-V CRITERIA FOR SUBSTANCE-INDUCED DISORDER
A. Presence of one or both of the following symptoms:
1. Delusions.
2. Hallucinations.
The patient exhibited persecutory delusions, believing his parents were against him, and experienced
auditory hallucinations, with voices instructing him to smoke in order to fulfill his purpose in life.
B. There is evidence from the history, physical examination, or laboratory findings of both (1) and
(2):
1. The symptoms in Criterion A developed during or soon after substance intoxication or
withdrawal or after exposure to medication.
2. The involved substance/medication is capable of producing the symptoms in Criterion A.
The patient's symptoms occur exclusively in the context of marijuana overuse.
C. The disturbance is not better explained by a psychotic disorder that is not substance/medication-
induced. Such evidence of an independent psychotic disorder could include the following:
The symptoms preceded the onset of the substance/medication use; the symptoms persist for a
substantial period of time (e.g., about 1 month) after the cessation of acute withdrawal or severe
intoxication; or there is other evidence of an independent non-substance/medication-induced
psychotic disorder (e.g., a history of recurrent non-substance/medication-related episodes).
The patient’s psychotic symptoms were temporally related to marijuana overuse, with no history of
psychotic episodes outside of substance use. His symptoms were resolved fully within a short period
following cessation of marijuana, with no evidence of persistent psychosis or a history of recurrent
psychotic episodes independent of substance use. Additionally, there were no prior psychiatric
diagnoses or family history of primary psychotic disorders, supporting the conclusion that his
symptoms were substance-induced rather than indicative of an independent psychotic disorder.
D. The disturbance does not occur exclusively during the course of a delirium.
The patient did not exhibit signs of delirium, such as fluctuating levels of consciousness,
disorientation, or disturbances in attention and awareness. His psychotic symptoms, including
persecutory delusions and auditory hallucinations, were consistent and not associated with
confusion or a waxing and waning mental status, indicating that the disturbance did not occur
exclusively during the course of a delirium.
E. The disturbance causes clinically significant distress or impairment in social, occupational, or other
important areas of functioning
The patient's psychotic symptoms led to significant impairment in his daily functioning. He became
socially withdrawn, experienced strained relationships with his parents due to his persecutory
delusions and was unable to engage in usual activities. His auditory hallucinations contributed to
distress and interfered with his ability to focus, resulting in a noticeable decline in his social and
occupational performance.
Predisposing Factors
• J.R. grew up in an abusive household, experiencing physical and verbal mistreatment. This led to
insecurity and anxiety, and he began using marijuana early to cope with emotional pain.
Following a recent confrontation with his parents, his marijuana use increased, triggering
psychotic symptoms.
• J.R.’s uncle, a heavy marijuana user, influenced his substance use. Witnessing his uncle use
marijuana to cope with stress likely normalized it for J.R., contributing to his own use as a way to
manage emotional struggles.
• J.R. has had limited family and social support, with strained relationships and isolation. Combined
with excessive alcohol consumption, this has increased his reliance on marijuana as a coping
mechanism for emotional distress.
Precipitating Factors
• J.R.’s excessive use of marijuana and alcohol, particularly during periods of stress, significantly
contributed to the onset of his psychotic symptoms, including hallucinations and delusions. His
substance overuse triggered a heightened state of vulnerability to psychosis.
• A stressful confrontation with his parents, who expressed frustration over his continued smoking,
drinking, and failure to secure stable employment at 25, led to increased emotional distress. This
conflict exacerbated his paranoia, particularly regarding his parents' intentions.
• He missed a crucial follow-up appointment at his substance abuse clinic, which may have led to a
lapse in treatment and exacerbated his substance use. This contributed to the worsening of his
psychotic symptoms, including persistent delusions.
Perpetuating Factors
• Continued heavy marijuana and alcohol use prevents the resolution of psychotic symptoms and
reinforces his delusions.
• J.R.’s failure to comply with medication, and consistently attending therapy and substance abuse
treatment contribute to the persistence of his psychotic symptoms.
• Unresolved Trauma: Ongoing emotional distress from childhood abuse remains unaddressed,
perpetuating his reliance on substances and reinforcing his psychotic beliefs.
Protective Factors
• He has some insight into his symptoms, which may help him recognize when his condition is
worsening.
• J.R. has access to a medical team that can offer psychiatric care and support for substance use
treatment.
• While strained, J.R. still has the possibility of rebuilding relationships with his parents, which could
reduce his isolation.
• J.R. has expressed some desire to improve his life circumstances, such as finding a stable job and
reducing his substance use.
MANAGEMENT
J.R. will be managed with a focus on stabilizing his psychotic symptoms and addressing his substance
use. He will continue his care at San Fernando General Hospital, where he is currently warded, with
follow-up appointments at the substance abuse clinic for ongoing support. Coordination between the
psychiatric and substance abuse teams will be essential to ensure comprehensive management.
Additionally, J.R. will be encouraged to engage in therapy and build a support network to address
underlying emotional distress and improve his coping mechanisms.
PHARMACOLOGICAL
J.R.'s treatment for substance-induced psychosis will begin with antipsychotic medication, primarily
Haloperidol, to address his persistent delusions. The dosage will be carefully monitored and adjusted
based on his response and tolerance to ensure adequate symptom control. If necessary, a second-
generation antipsychotic like risperidone or olanzapine could be considered as alternatives.
Benzodiazepines, such as Diazepam, will be used on an as-needed basis to manage any anxiety,
agitation, or insomnia that J.R. may experience, especially during the acute phase of his psychosis.
To address any potential mood instability and prevent further episodes of substance-induced
psychosis, Divalproex, a mood stabilizer, will be maintained. This will help regulate J.R.’s mood and
reduce the risk of mood swings that could lead to further psychotic episodes. Benzhexol will be used
to manage any extrapyramidal symptoms (EPS) that may arise as a result of the antipsychotic
treatment, such as tremors or rigidity, ensuring J.R.’s comfort and adherence to medication.
In addition to pharmacological treatment, J.R. will receive ongoing care at the substance abuse clinic,
which is crucial for managing his substance use and preventing relapse. Psychoeducation for J.R. and
his family will be a key component of his treatment plan to improve understanding of substance-
induced psychosis and promote medication adherence. Cognitive behavioral therapy (CBT) may be
introduced to help J.R. develop healthier coping mechanisms, and regular follow-up visits will be
essential to monitor his progress and adjust the treatment as needed.
PSYCHOLOGICAL MANAGEMENT
The psychological management of J.R. will focus on addressing the underlying factors contributing to
his substance-induced psychosis, including his childhood trauma, substance abuse, and strained
family dynamics. Given J.R.'s history of trauma, particularly physical and verbal abuse during
childhood, it is essential to initiate trauma-focused therapy to help him process these past
experiences and their impact on his current emotional state. Cognitive-behavioral therapy (CBT) will
be central to addressing his delusions and paranoid beliefs, especially those regarding his parents.
Through CBT, J.R. will be supported in identifying and reframing his irrational thoughts and learning
healthier coping mechanisms to manage stress and anxiety.
In addition to individual therapy, family therapy will be crucial to improving the relationship between
J.R. and his parents. His parents have been a primary source of support but are currently strained
due to his aggressive behavior and refusal to adhere to treatment. Involving the family in therapy will
educate them on the nature of substance-induced psychosis, help them understand J.R.'s behavior,
and equip them with strategies to support his recovery. Reconnecting J.R. with his family will be vital
to building a stronger support network and improving his long-term prognosis.
Given J.R.'s isolation and lack of a reliable social support system, social skills training will be
implemented to enhance his ability to interact with others, rebuild relationships, and reduce feelings
of isolation. This will also help him improve his social functioning, which has been significantly
impacted by his substance use and psychosis. Additionally, cognitive rehabilitation may be considered
to address any cognitive deficits resulting from prolonged substance abuse, with the goal of helping
him regain functional abilities and reintegrate into society.
Overall, J.R.'s treatment will involve a combination of therapy aimed at addressing his psychosis,
substance abuse, and past trauma. Engaging in therapy, rebuilding family support, and learning to
cope with stress and emotional difficulties will provide J.R. with the tools necessary to improve his
psychological functioning and support his recovery. Regular follow-up and close monitoring of his
progress will be essential to ensure that he remains on track with his treatment and continues to
make strides in his recovery.
PROGRESS NOTES
30/01/2025
The patient was verbally aggressive, shouting profanities to the nursing staff the night prior
while refusing to take his medications and was given Haloperidol 10mg IM STAT and placed
in seclusion room. When his parents came to visit, he was verbally silent, laying down with
his arms folded on his chest and not responding. On MSE, he was uncooperative,
aggressive and upset, with a restricted speech and congruent affect. Patient still believed
parents were against him and did not want to speak to them. No homicidal/ suicidal
ideations.
31/01/2025
The patient was noted to be less aggressive and wanted to come out of seclusion and use
the washroom. He was seen standing at the gate of the seclusion room calmly stating that
he would behave himself and take his medications. He was not aggressive and took his
medications. He had normal tone and volume and denied any hallucinations or delusions.
Patient was given a trial out of the seclusion room and all care and management
continued.
01/02/25
The patient was seen on the ward with the nurses reporting no aggressive behaviour and he
was compliant with all medications. Patient was talkative and happy with congruent affect. No
delusions, hallucinations, suicidal/homicidal ideations were noted. Plan continued as before with
all medications and care.
02/01/2025
The patient was comfortable with nil complaints and no aggressive behaviour. No complaints
noted by the nurse. Patient compliant with all medications. Speech was normal and patient was
talking about plans for when he leaves. Affect was congruent with his mood. Nil delusions or
hallucinations and no homicidal/ suicidal ideation. Plan to continue all care and management
continued.
PROGNOSIS
The prognosis for J.R., who presents with substance-induced psychosis secondary to heavy
marijuana and alcohol use, will be influenced by several key factors, including symptom severity,
treatment compliance, social support, and access to resources. Here are the critical factors to
consider:
1. Severity of Symptoms: The severity of J.R.'s current symptoms, including his ongoing
delusions and aggressive behavior, will significantly affect his prognosis. If these symptoms can
be effectively managed with medication and psychological support, there is potential for
improvement. However, if his substance use continues to exacerbate his symptoms, his
prognosis may remain guarded. Substance use is a major contributor to his psychotic episodes,
and ongoing consumption may prevent full resolution of his symptoms.
2. Treatment Compliance: For J.R., treatment adherence will be crucial for a positive prognosis.
His history of non-compliance with medication, particularly after discharge from his previous
hospitalization, suggests that maintaining treatment plans will be challenging. However, with
consistent medication, substance abuse treatment, and psychological support, his prognosis can
improve. Overcoming barriers to treatment adherence, such as the belief that medications
interfere with his "purpose in life," will be essential in stabilizing his condition.
3. Social Support and Family Involvement: J.R.'s prognosis will be heavily influenced by the
support he receives from his family, particularly his parents. The involvement of his parents in
therapy and treatment is crucial to prevent further isolation and ensure he follows his prescribed
regimen. However, strained relationships with his family, due to his substance use and
aggressive behavior, may complicate his recovery. Strengthening family dynamics and
addressing communication within the household can have a significant positive effect on J.R.'s
mental health.
4. Access to Resources and Rehabilitation: J.R.'s access to comprehensive mental health
services, including drug rehabilitation programs and regular psychiatric follow-up, will
significantly impact his prognosis. His location in Penal and the availability of the substance
abuse clinic at San Fernando General Hospital provide opportunities for ongoing support and
care. Integrated treatment approaches that address both his substance use and psychotic
symptoms will be vital for his recovery. Without consistent follow-up and rehabilitation, J.R. is at
high risk of relapse and persistent psychotic symptoms.
In summary, while J.R.'s prognosis is challenging due to his substance abuse, family dynamics,
and history of non-compliance, there is potential for improvement with consistent treatment,
social support, and rehabilitation. His ability to manage substance use, adhere to therapy, and
engage in family involvement will determine his long-term functioning and recovery.
DISCUSSION
J.R. is a 25-year-old single, unemployed Indo-Trinidadian man presenting with aggressive
behavior, decreased sleep and appetite, and heavy marijuana and alcohol use. His symptoms
began two weeks prior to admission, following a period of medication non-compliance and
increased substance use. He exhibited persecutory delusions, believing his family was praying
for his downfall, and displayed hyper-religious behavior, converting to Islam while
simultaneously referencing Hinduism. His erratic behavior, including threats to harm relatives
and speaking inaudibly to himself, aligns with substance-induced psychotic disorder. According
to the DSM-5 criteria, his psychosis appears to be closely linked to his increased substance use,
with no evidence of primary psychotic disorders persisting in the absence of substances.
J.R. also meets the criteria for substance use disorder, characterized by his heavy and prolonged
use of marijuana and alcohol. He smokes 10 blunts of marijuana daily, alongside significant
alcohol consumption, including strong spirits such as Puncheon rum and Guinness. His substance
use began during secondary school and escalated over time, leading to impaired functioning,
strained family relationships, and repeated aggressive episodes. His past history of substance-
induced psychosis with previous admissions, coupled with his refusal to engage in rehabilitation
and inconsistent medication adherence, underscores the chronicity of his condition. His
substance use is not merely recreational but appears to serve as a maladaptive coping
mechanism for unresolved childhood trauma and perceived familial neglect. The psychosocial
background of J.R. is crucial to understanding his presentation. He reported feeling neglected
and abused during his childhood, which may contribute to his current rebellious behavior. His
perception that his parents are ungrateful for his contributions to their business and his belief
that his grandmother's promise of a place to live was undermined by his family add to his sense
of betrayal. These delusional thoughts, combined with his hyper-religiousness, indicate
significant cognitive and emotional disturbances. Additionally, his social isolation, poor
employment history, and lack of stable relationships highlight his difficulty maintaining functional
roles in society. His aggressive behavior towards his parents, driven by his delusions and
substance use, further stresses the need for a comprehensive treatment approach.
J.R.'s prognosis depends significantly on his engagement with a multidisciplinary treatment plan.
Effective management would involve antipsychotic and mood-stabilizing medications, likely
continuing with agents such as Haloperidol, Divalproex, Benzhexol, and Diazepam to manage his
psychotic symptoms and mood instability. Equally important is psychological intervention,
including cognitive-behavioral therapy (CBT) to address his delusions, substance use counseling
to reduce dependence, and family therapy to rebuild trust and improve his support system.
Given his history of non-compliance, measures to enhance adherence, such as long-acting
injectable medications or structured outpatient programs, may be beneficial. With consistent
medical and psychological support, along with strong family and community involvement, J.R.
has the potential to achieve stability, reduce the risk of relapse, and improve his overall quality
of life. However, his prognosis remains guarded, given his history of medication non-compliance,
substance abuse, and limited insight into his condition.
