However, no history of increased activity, agitation, restlessness, aimless wandering, increased libido, irrational talk, loss of appetite and sleep disturbances as well as hearing voices, social withdrawal, paucity of self-care, violent behavior, gathering of debris, or any abnormal behavior. Past psychiatric history revealed that there was a positive history of psychoactive drug use, specifically, Cannabis, which he used via smoking of dried leaves wrapped in a strip of paper; he began using it at age 16/17 (17 years ago); he was introduced to it by friends and a desire to experiment and rebel; he used drugs independently and with friends; habit was sustained by his allowance and stealing from his parents; drug use continued for a few years and ceased in his early twenties. In his mid-twenties, in 2006 (9 years ago), he became socially withdrawn, left the house for no apparent reason, and began living alone; then he disappeared for 3-4 months (he later admitted he travelled to Niger in a failed bid to emigrate to Europe) and returned home voluntarily, only to begin living in uncompleted buildings and talking irrationally, with history of provoked violent attack on a shopkeeper after being stigmatized as "a mental case." Subsequently, in 2008, he was admitted to the Neuropsychiatric Hospital, Rumuigbo, and a diagnosis of "Substance Use Disorder" was made; several investigations were done and drugs administered; he was discharged after a month and a fortnight. Follow-up was regular for two months; however, he defaulted because he claimed he was not "mental" and because of the side effects of drugs. There is no history or evidence of a relapse following discharge. In the past medical history, there was no history of hypertension, epilepsy, asthma, diabetes mellitus, sickle cell disease, neurocutaneous disorders, and erectile dysfunction. Family history showed that he is the only male as well as the first of four children in a monogamous setting. However, his mother had 2 children in a later marriage after the divorce of his parents, making a total of 6 children, 3 full sisters and 2 half-sisters. His mother is a middle aged matron with tertiary level of education. His father is deceased, had tertiary level of education, and was a senior civil servant with the Ministry of Agriculture. He was not close to his father and appeared to have had a troubled relationship with him following the divorce of his parents; his father died three years earlier, at age 61, from an unknown medical condition. The personal history revealed that the patient completed his basic education. However, he did not pass the UME with good scores and failed to obtain a university admission, and he was said to be an average student. He enrolled in a part time program, in the National Open University, 2 years earlier, but did not complete the course because of his present illness. Subsequently, he said he has received training as an electrician and construction worker. He claims to be a single father of an 18-year-old boy (with elaborate information about the nonexistent child); however, his mother denies this and he later admitted he told us this so that we would remove his testes since he has a child. Social history showed that, in the past, he occasionally drank alcoholic beverages but has seldom done so for the past seven years. He smoked tobacco in cigarette form occasionally. Patient seldom interacts with people except his family members whom he lives with; he initially said he lives alone but his mother said he lives with her and he admitted this. Psychosexual history as elicited showed that adrenarche was attained at age 14 while onset of nocturnal emissions began at age 17. First sexual activity was with a female partner, experience was pleasurable and exciting, and subsequent experiences have been pleasurable and in almost all cases barrier contraception in the form of male condoms was used. The patient insisted that his sexual orientation and love interest has been strictly heterosexual. He has seldom had any early morning erections over the last 6 years and cannot recall having experienced any nocturnal emissions within the same period. He denies any masturbation as well as orgasm/ejaculation; however, semen for analysis was obtained via masturbation without the use of pornography. In the forensic assessment history, patient has not been convicted for any crime, sentenced to jail, or jumped bail; however, he has been arrested thrice and detained for minor offences such as moving at night during a curfew. Premorbidly, leisure activities included watching football matches; he formed deep ties in relationships, had few friends, and was introverted/quiet. His prevailing mood was happy.
Appearance and behavior showed a well dressed and well groomed young man (with attention paid to minute details such as manicured nails and perfectly styled hair) appearing appropriate for age, maintaining good eye contact, and holding an umbrella with depressed posturing. The tone of speech was low to moderate tone, reactive to circumstances, coherent, and relevant. The mood was sad and affect was depressed. Perceptual abnormalities present included somatic hallucination. There were no disorders of the thought process or formal thought disorder detected. Under cognition, patient was fully oriented to time, place, person, and circumstance. Attention, concentration, comprehension as well as calculator ability, and abstraction were within normal range. In addition, immediate recall, long and short memory are within normal range. Judgement was good and insight was partial (he did not believe the drugs will be of any benefit and his case is hopeless).
Primary diagnosis was hypochondriasis with comorbid secondary diagnosis of severe depression with psychotic features.
Patient was managed using the biopsychosocial model. Drug treatment was done using tricyclic antidepressant (Amitriptyline) and antipsychotic medication (Olanzapine). Psychotherapy carried out involved cognitive behavioral therapy. Finally a letter was sent to SOPD about diagnosis and unsuitability for bilateral orchidectomy as requested.
Initial improvement (evidenced by reduction in pain intensity) was seen for the first 3 weeks; however, pain has been persistent. There was insistence on a bilateral orchidectomy during his last visit.