Can someone please give a DX ? What if client was 28 yrs old. Will that make a difference?

Question

A single, unemployed, college-educated 28-year-old African-American woman, Ms. Fielding, was escorted to the emergency room by the mobile crisis team. The team had been contacted by the patient’s sister after she failed to persuade Ms. Fielding to visit an outpatient psychiatrist. Her sister was concerned about the patient’s increasingly erratic work patterns and, more recently, her bizarre behavior since the death of their father 2 years ago. The patient’s only prior psychiatric contact had been brief psychotherapy in college.

The patient had not worked since losing her job 3 months ago. According to her boyfriend and roommate (both of whom live with her), she had become intensely preoccupied with the upstairs neighbors. A few days earlier she had banged on their front door with an iron for no apparent reason. She told the mobile crisis team that the family upstairs was harassing her by ‘accessing’ her thoughts and then repeating them to her. The crisis team brought her to the emergency room for evaluation of ‘thought broadcasting.’ Though she denied having any trouble with her thinking, she conceded that she had been feeling ‘stressed’ since losing her job, and might benefit from more psychotherapy.

The patient presented as attractive, stylishly dressed, but somewhat disheveled. She greeted the emergency room psychiatrists with a courteous, if somewhat superficial smile. She related to the doctors with nonchalant respectfulness. When asked why she was there, she ventured a timid shrug, and replied, “I was hoping to find out from you!”

Ms. Fielding had been working as a secretary and attributed her job loss to the sluggish economy. She denied having and recent mood disturbance, and answered no to questions about psychotic symptoms, punctuating each query with a polite but incredulous laugh. Wondering if perhaps the crisis team’s assessment was of a different patient, the interviewer asked, somewhat apologetically, if the patient ever wondered whether people could read her mind. She replied, “Oh, yes, it happens all the time,” and described how, on one occasion, she was standing in her kitchen planning dinner in silence, only to hear, moments later, voices of people on the street below reciting the entire menu. She was convinced of the reality of the experience, having verified it by looking out the window and observing them speaking her thoughts aloud.

The patient was distressed not so much by people ‘accessing’ her thoughts as by her inability to exercise control over the process. She believed that most people developed telepathic powers in childhood and that she was a ‘late bloomer’ who had just become aware of her abilities and was currently overwhelmed by them. Although she had begun having telepathic experiences 2 years ago, they had become almost constant in the 3 months since losing her job. She was troubled most by her upstairs neighbors, who would not only repeat her thoughts but would bombard her with their own devaluing and critical comments, such as “you’re no good!” and “You have to leave.” They had begun to intrude upon her mercilessly, at all hours of the night and day.

She was convinced that the only solution was for the family to move away. When asked if she had contemplated other possibilities, she reluctantly admitted that she had spoken to her boyfriend about hiring a hit man to ‘threaten’ or, if need be, ‘eliminate’ the couple. She hoped she would be able to spare their two children, who she felt were not involved in this invasion of her ‘mental boundaries.’ This concern for the children was the only insight she demonstrated into the gravity of her symptoms. She did agree, however, to admit herself voluntarily to the hospital.

Answer 1

There are several possibilities, but let me stress that despite the amount of info and history you provided, there is still not enough info to conclusively rule out some things so as to definitively identitfy the dx.
I would probably rule out schizophrenia however for a couple reasons: her age for starters-schizophrenia rarely shows that late of an onset and requires far more info, including evidence of a prodromal phase, for which there is none. However, further history from family might reveal that there was in fact an earlier episode, perhaps untreated, in college-she may have had similar symptoms in college which had prompted her to seek the brief psychiatric treatment she did. However, she denies any occurrence of these psychotic sx prior to her Father's death.
I would be suspicious of a Major Depression, Single Episode, Severe with Mood-Incongruent Psychotic Features (complicated bereavement) or a Bipolar Disorder. I don't have enough info to even say Major Depression for certain, since she is denying mood symptoms and there is no info about any vegetative sx, like sleep patterns, appetite changes, energy level, etc. which would help to make the diagnosis. The Bipolar piece comes in because we cannot rule out that this episode is a manic one-she's denying depression, but she may actually be manic. Again, info is needed on sleep, energy level, etc. Her initial denial of depression may be true or just a denial, so it is hard to know. Collateral observations of her mood and other symptoms would help, especially if she is just denying mood symptoms despite their presence.
She has shown evidence of psychotic sx for 2 years, so we can rule out a Brief Reactive Psychosis. That leaves the only plausible dx given the info available as a Delusional Dosorder, Persecutory Type which may in fact be the answer as it would account for the fact that her behavior appears strikingly normal apart from the delusional symptoms. My money is on that one without further information. Again, drug use and organic factors need to be conclusively ruled out, but it sounds as though there is little evidence to suggest either may play a role. Without my DSM on hand, this is the best answer I can give you going from memory.
A great place to pose a specific dx question is James Morrison's site for his book "DSM IV Made Easy". He enjoys dx dilemmas as much as I do and usually responds to questions posed relatively quickly. Let us know when you find out the actual dx, I'd be curious to hear what further evaluation revealed!
Thanks for posing such a thoughtful question.

Answer 2

A DX? According to a shortwave listener, a DX is an acknowledgement that your broadcast was received. It has been. DX stands for "distance."
According to a doctor, DX is diagnosis. Given that I am not a doctor and do not specialize in psychiatry, I can't give you one of these. The symptoms sound like schizophrenia may be a part of the problem experienced by this lady.

Answer 3

paranoid schizophrenia is my dx