A 20-year-old homeless white male (JO) was informally admitted to a psychiatric unit after reports of fire-setting behavior (eg, laughing while setting individuals on fire with lighter fluid). As a child, he had set fire to a hillside barn, which would have had significant consequences for a village further up the hill had it not been extinguished. When admitted to the unit he was found to be grossly cognitively impaired. However, collateral information indicated that previously he was an average student, completing 10 years of education. He did not exhibit behavioral problems during the last several years of his education. The patient had brief periods of manual labor employment, the longest lasting 3 months. He denied having had any long-term relationships. He has had limited contact with his mother. The patient's father was a heavy drinker and committed suicide two years previously, several months after losing his business. Police databases did not show a formal forensic history for the patient.
On admission to the ward, JO was noted to have low mood associated with anhedonia, reduced motivation, and cognitive depressive symptoms. He also had persecutory delusional ideas; thinking that others talked about him and mocked him. He admitted to fleeting visual and auditory hallucinations. These consisted of hearing "breathing" in his bedroom and seeing blood on the wall. In addition, he stated that he had seen "ghost-like people that looked like water". During a diagnostic interview the patient indicated that he had problems with memory, including difficulty remembering names, phone numbers, appointments, directions, and recent events.
Routine cognitive examination revealed difficulty with word finding and reading retention. Manual motor tasks were adequate. He was casually dressed, but dishevelled and had a blunted affect, paucity of facial expression, and poverty of speech. Significantly, he scored in the impaired range (18 correct of 30 items) on the Mini Mental Status Examination (MMSE), doing poorly on measures of short-term memory, concentration, and orientation in time. He seemed to be making a genuine effort to complete the tests, and he appeared perplexed at his inability to answer questions. From the diagnostic interview it was apparent that fire setting did not occur as an accident during a confusional state such as alcoholism or drug intoxication. Moreover, fire setting did not occur during an acute manic episode or psychotic episode in specific response to a delusional idea or commands from hallucinated voices. The patient did not meet the criteria for conduct disorder, as most of his behavioral problems were limited to verbal outbursts. As a child he did not make the association between fire setting and the potential harm it might present to others.
His characteristic ward behavior was described as being withdrawn with poverty of speech. However, during an interview, a rapid change in affect occurred when questioned about what he did for entertainment. The patient began to laugh and smile indicating that he "enjoyed putting lighter fluid on people and setting them on fire". The patient continued to be animated while discussing violent topics (eg, what it would be like to drop objects from motorway bridges to cause an accident). He was also at times sexually inappropriate toward female staff and talked of his wish to travel to a foreign country for "loads of sex". On another occasion, he asked a female mental health worker if she could arrange for prostitutes dressed as nurses to visit the inpatient ward.
Previously, JO had experienced two episodes of collapse for which he was admitted to hospital. On both occasions he had normal CT scans and a normal EEG. These collapses were attributed to illicit drug use, probably opiates. He had experimented with other drugs including marijuana but did not evidence signs of dependence. During the current admission, however, nursing staff observed 2 generalized tonic-clonic seizures. Routine bloods were normal as were lumbar puncture (including testing for new variant Creutzfeldt-Jakob disease [nvCJD]), HIV screening, and EEG. Testing for nvCJD was undertaken due to the severity of JO's cognitive impairments. An MRI examination demonstrated evidence of generalized cerebral atrophy. JO was initially treated with an anticonvulsant sodium valproate (300 mg bd, increased to 800 mg bd; serum levels confirmed dose in therapeutic range). No further seizures were observed. Olanzapine was commenced 5 days after sodium valproate. Neuropsychological tests were administered on admission and were repeated 5-months later. Olanzapine 10 mg was started after baseline testing and maintained throughout the 5-month psychiatric hospitalization. Perceptual abnormalities and paranoia resolved following the introduction of olanzapine. While behavioral disturbance gradually abated, cognitive function gradually improved (see below).
The neuropsychological test battery was designed to assess multiple domains of cognition including premorbid intelligence (National Adult Reading Test), sustained attention and concentration (Continuous Performance Test), cognitive flexibility and executive function (Verbal Fluency), language (Boston Naming Test), verbal memory (Rey Auditory Verbal Learning Test), visual memory (Rey Complex Figure Test), and visuospatial function (Parietal Lobe Test). Frequency of serious clinical incidents (eg, self-harm, threatening behavior, and verbal abuse) were noted by the treating psychiatrists, nurses, and mental health workers and documented in the medical charts.