Problem
CASE
Mr X is a 38-year-old, unemployed, single male with no children and with an elementary level of education. This was his index presentation with a 4-year history characterised by ongoing persecutory delusions, as well as auditory hallucinations. He was brought to the Emergency Department by ambulance because he was found to be bleeding profusely from his scrotum in the toilet of a petrol filling station. He alleged that he had cut open his scrotum to remove his testicles before his 'tormentors' could do so. He stated clearly that he did not want to die because he valued his life. This was therefore not an attempt at suicide.
He was initially admitted to the urology ward and then referred to psychiatry. He responded well to haloperidol 2.5 mg orally in the morning and 5 mg orally at night. A long-acting injectable antipsychotic, flupenthixol decanoate 20 mg intramuscular was also prescribed. No adverse effects were reported. Lorazepam was titrated downwards from 1 mg orally twice daily to 1 mg orally at night, and then stopped before he was discharged. Lansoprazole 30 mg daily orally, tramadol 50 mg three times daily orally and paracetamol 1 g orally were also prescribed as needed.
Upon discharge, on day 44 of the admission, the patient was symptom free with no psychotic or anxiety features.
Task
a) What are the salient features?
b) What are your differential diagnoses?
c) What is your diagnosis?
d) What is your management?