Guide Questions:
1. What are the salient features?
2. What are your differential diagnoses?
3. What is your diagnosis?
4. What is your management?
CASE:
A 24-year-old man presents to casualty having got into a fight as he thought he was being watched and felt threatened. He appears to have fractured his thumb but is reluctant to let you examine him or order an X-ray. He looks suspicious and wary. When asked about his concerns he says that over the last few months he has been carefully monitored by government agencies. He has been hearing a voice out loud giving a running commentary on his thoughts and these are being broadcast to the government. Any machine enables the government to get inside his head and the voice is telling him it would be unwise to face the X-ray machine. The voice is not one that he recognizes and it is sometimes derogatory telling him he is stupid for giving his thoughts away for free. Initially the voice came and went but over the last few weeks it is present almost constantly and he cannot always sleep because even when he sleeps the voice comments on what he is thinking. He is exhausted.
The man is absolutely convinced that the government is after him but he cannot explain why. There is no previous history and he denies any substance use. Until a few weeks ago he had been working as a kitchen assistant but was sacked for leaving jobs unfinished. There is no family history of any psychiatric illness.