The patient is a 42-year-old African American male, retired professional basketball player, single, has a daughter, currently unemployed, living in a homeless shelter, with a psychiatric history of schizoaffective disorder, bipolar type diagnosed seven years ago, and a medical history of hypertension. The patient was escorted by the police to the psychiatric emergency room because of his disorganized behavior in the streets. Upon evaluation, the patient was noted to be agitated and restless, evidenced by pacing the emergency room and being uncooperative with psychiatric emergency room protocol. He was verbally aggressive, loud, and hyper-verbose, with a lot of profane words directed at the staff. He was making inappropriate, bizarre gestures by waving his hands in the air and blinking his eyes intermittently. He appeared disorganized by singing and dancing to an unknown sound. He stated: "Look at my teeth. I'm eating pepper seeds." The patient was also noted to be putting a metal piece in his mouth, refused further searches, and became threatening toward staff, eventually requiring intramuscular psychotropic medication. He was then admitted to the inpatient psychiatric unit for safety and stabilization. The patient's onset of symptoms dates back seven years before this current presentation due to non-adherence to medications and outpatient care.
During his hospitalization, he admitted to poor sleep hygiene, stating, "I've not slept well for years since I started playing basketball professionally, and it's my usual pattern." He described his sleep as just taking random naps during flights and said he had been sleep-deprived for the past ten years due to lots of professional traveling across different time zones during regular-season competitions. The patient also stated that he had been "stressed," which he described as dealing with "physical pain and emotions" his whole life. He stated his problems started about 20 years prior when he suffered a lower back injury two years following the start of his college basketball career. After suffering the injury, he refused treatment, which worsened his back pain. Eventually, due to the worsening pain, he had surgery but was sidelined from further participation in sports for two years, during which he reported depression, fear, and anxiety owing to the uncertainty of his future. He followed up with his school physician but reported no improvement in his mood symptoms. In addition, he had poor pain management, which delayed his return to active play and led to his release. After his release, he transferred to another college, but playing time was again limited. During that time, he reported that despite worsening frustration, pain, and anger, he still had a passion for playing because basketball was the "only way out."
Subsequently, he suffered another hip injury at his new college. He underwent another surgery and was sidelined again for another six months, which ended his season prematurely. Furthermore, he reported playing professional basketball overseas two years after, and his daughter was born three years later. The patient described a problematic relationship with his daughter's mother and subsequently engaged in a custody battle that continues to date. Although the patient did not give a clear timeline of events, the patient reported that his symptoms worsened following the start of his custody battle and was subsequently referred to a general psychiatrist; however, he reported he had three hospitalizations due to non-adherence to medication and outpatient follow-up. In addition, the patient reports that he had to travel between home and abroad for court hearings during basketball competitions, which further disturbed his rest time and worsened his mood and his sleep. He denied any history of violent or threatening behavior but reported a history of intermittent anger outbursts. He denied any history of self-injurious behavior or suicide attempt, denied perceptual disturbances, denied use of any illicit substances, and denied any family psychiatric history of any mental illness.