'Mr. C' is a 58-year-old Navy veteran with a history of substance use disorder in sustained remission, traumatic brain injury (TBI), mild neurocognitive impairment, and a 15-year diagnosis of schizophrenia. Importantly, his sister indicated that Mr. C suffered his first psychiatric break during adolescence. He was prescribed medication, but his parents, who indicated their preference for treating his condition with prayer, refused these. He has been living with his sister for the past 20 years and participates in all activities of daily living. He is a widower and is currently unemployed. His TBI history includes a single episode approximately 25 years ago when he fell off a moving train, requiring extended hospitalization. Mr. C was brought in to our Veterans Affairs (VA) hospital by his sister after calling the Veterans' Crisis Line with SI. One week earlier there was an altercation with his brother-in-law resulting in Mr. C attacking him with a crowbar and the sister intervening. On admission, the family reported that Mr. C was taking venlafaxine and quetiapine.
Upon initial interview, Mr. C was grossly oriented, with psychomotor agitation, mildly pressured speech, anxious mood, and restricted affect. Thought process was tangential, and his cooperation was poor due to his preoccupation with delusions that he was dead, that nothing existed. He felt his body was being energized by demons: "These demons are my energy, I am dead, how can I have any energy?" He perseverated on this content despite attempts to engage him: "How can you help me, I am dead." When asked about suicidal ideation (SI) he indicated, "I am dead, how can I be suicidal?" When providers commented on the novelty of speaking with a dead person, he replied, "Maybe you are dead too." Importantly, his nihilistic beliefs included strong religiously mediated content not shared by his family. Mr. C. made the comments: "That physical God is alive because he has a physical body, but the demons inside me keep me dead, keep me from being alive." "It is not nice meeting the devil, all the demonic spirits are tormenting me and raping me." He believed his insides were being corroded by demons and indicated that he had repeatedly sodomized himself to try and purge himself of the demons. Mr. C's sister indicated that the onset of his religiously themed delusional symptoms began after his TBI when he became convinced that a miracle had occurred during the accident and he became aware of his "dead nature."
Magnetic resonance imaging (MRI) performed in April 2015 revealed mild global volume loss for age with widening of the Sylvian fissure bilaterally. Neither evidence of past acute TBI or white matter abnormalities were noted on fluid-attenuated inversion recovery (FLAIR) imaging (Figure 1). Neuropsychological testing administered during the index hospitalization was significant for impairment on tasks of processing speed, simple attention, verbal learning and memory, aspects of executive functioning (set-shifting, verbal fluency), facial recognition, and affect naming and recognition. Aspects of visuospatial discrimination and construction, confrontation naming, and visual memory were intact (Table 1).
Upon initial presentation, given the patient's aggressive and activated behavior as well as sleep difficulties, venlafaxine was discontinued and quetiapine was titrated to 700 mg. Divalproex was added during the admission for mood stabilization and titrated to 750 mg. During his 2 weeks on the inpatient ward repeated inquiry about his religious experience and his relationship to God led to changes in the content of Mr. C's delusion from literal and concrete beliefs that he was physically dead to more abstract and metaphorical descriptions of spiritual death. His belief that only God was physically alive remained, and his belief that demons possessed his body persisted. Continued probing about the patient's existence demonstrated further amelioration of the nihilistic content. A month into his admission when asked if his daily activities (eating, drinking, showering) were evidence that he was in fact physically alive, he indicated that he was 'probably alive.'
Mr. C continued to be alert and oriented to person, place, and time, with evidence of increased insight into his preoccupation with his belief that he was dead. Approximately 1 month into his admission he recognized when the content of his speech began to focus on death, demons, and self-negation, at which point he would stop and remark, 'There I go again talking about all that dead stuff.' He was ultimately discharged after 5 weeks of hospitalization. On discharge, the patient's brother noted that he was less delusional and more linear than at baseline.