The patient is a 28-year-old man with a history of major depressive disorder, hepatitis C, biliary colic (status postcomplicated cholecystectomy), multiple concussions, and chronic back pain who presented to the emergency department with abdominal pain clinically concerning for acute appendicitis. He localized his pain to the right lower quadrant, complained of right lower quadrant pain with palpation of the left lower quadrant (Rovsing's sign), and indicated his pain was reproducible with extension of the right hip (psoas sign). His vital signs on presentation were notable for the absence of fever or tachycardia and his initial laboratory findings revealed normal chemistries and a normal white blood cell count of 4.2. He received intravenous morphine and an urgent CT scan of his abdomen. Enroute to the CT scanner, the patient mentioned that he had been struggling with sadness and suicidality since his pregnant fiancee had recently been killed in an automobile accident. The emergency physicians felt the pretest probability for acute appendicitis was extremely high and asked the psychiatry consult-liaison team to "evaluate him quickly before he goes to surgery." Ultimately, the imaging was negative for acute appendicitis, surgery was cancelled, and his disposition from the emergency department was left to psychiatry.
Review of the electronic medical record showed that the patient had established care at this institution one month prior to this presentation when he presented with biliary colic resulting in a lengthy hospitalization for a complicated cholecystectomy, challenging postoperative pain management, and a new diagnosis of hepatitis C. During that hospitalization, he was seen by social work who documented that he was baffled as to how he had contracted hepatitis C but offered that he had endured many losses in his life including the death of his mother when he was 6 years of age and the death of his brother when he was 19, so felt he had developed strong coping skills. In terms of his social history, he reported that he was engaged to be married and worked as a mathematics and physics professor at a prestigious university as well as an engineering consultant in the private sector. He also reported that he had sustained a number of musculoskeletal injuries resulting in chronic pain while playing Division I football in college and that he had been drafted by the National Football League. Upon discharge from that admission, he established care with a primary care physician for ongoing management of chronic pain. At his initial appointment he reiterated the social history he provided to the social worker and signed a narcotics agreement.
On initial assessment in the emergency department by the psychiatry consult-liaison team, the patient was observed to be a young, overweight Asian male dressed in a plain white T-shirt and track pants. His hair was greasy, his fingernails were long and dirty, and one of the lenses of his eyeglasses had a small crack. He made poor eye contact and focused his gaze on his tablet computer for most of the interview. His affect was withdrawn and had minimal range. On interview, he began the conversation by requesting placement at an inpatient psychiatric facility for electroconvulsive therapy, reporting that he had been suffering from very low mood since his pregnant fiancee had been killed by a drunk driver eight months ago. Because the electronic medical record indicated that he had been engaged to be married just one month ago, we asked him to confirm the date of his fiancee's death, which he could not recall. He answered all questions in a matter-of-fact tone and showed very little range of affect. In terms of his mood, he did not elaborate on his experience other than to say he felt "depressed and suicidal" with the vague plan of jumping in front of a train. He evaded further discussion of his mood symptoms by spontaneously offering details of his social history. He spoke about his profession as a tenured mathematics and physics professor at a prestigious university although when asked about the nature of his research he could only vaguely describe studying "time bends in space using some of Einstein's old formulae." He spoke in some detail about his career as a varsity football player, citing football injuries as the source of chronic back pain. When asked to provide a collateral contact, he reported that both of his parents, multiple siblings, and cousins had died during his early childhood.
The patient was accompanied by a male friend who was casually but neatly dressed and of approximately the same age. The patient provided us with permission to speak with his friend who appeared uncomfortable, saying "I didn't know I'd have to talk!" He reported that he and the patient were work colleagues who had known each other for a few years but refused to reveal where they worked. He provided no further information, other than saying "He's been really depressed and I just know he needs help before something happens." He then quickly left the hospital without saying goodbye to the patient.
Although, the patient initially reported that both parents were deceased, his father was listed as an emergency contact in his medical record. When confronted with this, the patient said that this was his step-father and gave consent for contact. The father reported that, five years ago, his son graduated with poor grades from a university which does not have a Division I football team. He confirmed the patient had played football in high school and had sustained multiple concussions. The year after graduation, the patient had lived with his parents briefly, but because of escalating narcotic use and lack of employment was asked to leave. Since then, he has suffered from severe opioid use disorder and has been homeless and unemployed. He has travelled to various hospitals within the city and even out of state to seek pain medication and care and has told a similarly fictional narrative to other physicians.
We obtained information from a local emergency community outreach agency which indicated that the patient had presented with the chief complaint of suicidality to multiple emergency departments in the city resulting in two previous inpatient psychiatric stays over the past year. We obtained records from his most recent inpatient psychiatric hospitalization about six months ago, where he presented with depression related to his girlfriend's putative recent breast cancer diagnosis. He was discharged on an antidepressant, a mood stabilizer, and oxycodone for chronic back pain.
When gently confronted with these inconsistencies, the patient appeared unperturbed and easily provided further elaborate details to explain them. However when further pressed, he stated he believed he needed a "dramatic" reason for his depression and suicidality to receive help and asked, "Can I just be depressed and suicidal?" He appeared perplexed as to why we attempted to clarify his previous statements or their relevance for his care. Despite this, he continued to state that he felt very depressed and would not be able to maintain his safety in the community.