Anonymized Consultation (Patient #0043)
[person] is an individual with a longstanding history of schizophrenia, characterized by both positive symptoms (auditory hallucinations) and longstanding negative symptoms, including social withdrawal, limited affect, and a general sense of resignation. At present, he does not display depressive symptoms; he continues to enjoy his hobbies, maintains full-time employment, and finds satisfaction in his routine. His hopelessness and resignation regarding treatment appear best understood within the context of negative symptoms and his long-term adaptation to persistent hallucinations.
During the interview, multiple treatment alternatives were offered, including an increase in quetiapine, redistribution of the dose throughout the day, or a voluntary inpatient admission for a monitored medication trial. [person] firmly declined all options, repeatedly emphasizing that his main priority is to reassure his mother that he is safe and functioning, rather than pursuing changes to his current treatment.
In keeping with a patient-centred approach, no medication adjustments were made during this visit. Instead, a follow-up appointment was offered for further psychoeducation involving both [person] and his mother, as well as exploration of psychosocial resources in the community—an approach with which [person] was agreeable. Given his positive and trusting relationship with his family physician, I am documenting potential medication strategies here in case an appointment with his primary care provider helps open the door to future discussion about treatment options.
I will reassess [person] in approximately six weeks, again with an ASL interpreter, with the goal of continuing to build rapport and supporting potential engagement in future therapeutic interventions.
Dear Dr. [person],
Please note that there is a possibility that [person] may choose not to continue his care or follow-up with me. Should that occur, I remain fully available for open communication to ensure that we continue to provide him with the best possible care.
Patient Identification
Dear Dr. [person] and Dr. [person],
Thank you for involving me in [person]’s care. I had the pleasure of meeting him today for his initial appointment at the Adult Mental Health Clinic at Hotel Dieu Hospital. I was able to assess [person] in person and in private.
During the visit, I used American Sign Language interpretation services through Voyce Global, available at KHSC. Three interpreters were required due to repeated connectivity issues, which caused the session to be interrupted on three occasions. Despite these limitations, [person] remained cooperative and engaged throughout.
The limits of confidentiality were reviewed, and [person] provided informed consent for the assessment. Information was obtained through a review of his medical records, direct interview with [person], and collateral history from his mother, [person], with whom I met at the end of the appointment.
The information is considered complete and reliable.
Reason for Consultation
Schizophrenia decompensation and medication adjustment.
Chief Complaint
As stated by [person]: "My mother wanted me to come"
History of Present Illness
Consideration was given to the linguistic limitations between the medical provider and the patient. Although a professional interpreter was present, there remains a low risk of loss or distortion of information.
[person] denied having any psychiatric diagnosis but acknowledged that since 2010 he has been hearing voices originating from within his head. When asked about his understanding of the voices’ origin, and after explaining the importance of exploring the nature of this experience given that he is a deaf individual, he was unable to formulate an explanation and continued to sign that he “did not know.”
He described the voices as commenting on the events of his day and at times criticizing what he is doing. He denied any command hallucinations directing him to harm himself or others.
[person] reported no interest in interpersonal relationships. He stated that he maintains only one longstanding friendship with a former teacher he met in high school, with whom he communicates via video call approximately twice a month and visits for dinner every six weeks. He denied interest in romantic relationships, adding that he does not experience romantic or sexual attraction toward others. He stated that this does not bother or concern him. He denied paranoid delusional thoughts, including ideas of persecution, thought insertion or broadcasting, ideas of reference, or grandiosity.
Regarding his mood, he reported feeling “the same as always” and denied persistent sadness, irritability, or anger. He stated that he enjoys his work repairing electronic devices and, in his free time, enjoys researching the mechanisms of various household appliances online. He appreciates having a structured routine and currently does not find it difficult to motivate himself to complete his daily activities.
He stated that he is accustomed to the voices and does not expect these experiences to change. He expressed no optimism regarding potential medication adjustments, noting that he has tried several treatments in the past without benefit. When asked about the burden of coping with these symptoms, he stated that “this is my life” and that he has been dealing with it for many years. He denied suicidal ideation, passive death wishes, and homicidal ideation.
He reported that this past May he experienced increased stress at work due to a colleague “who did not have the best attitude.” His mother—who is consistently attentive to his well-being—became more concerned after seeing him sitting alone at home without engaging in activities. [person] reported that he was “trying to concentrate and not pay attention to the voices.” His mother contacted his family physician, who consulted with Dr. [person], and an increase of 5 mg of olanzapine was recommended.
[person] initially refused the medication adjustment until approximately one week ago, when his mother convinced him by explaining that the change might help his doctors better evaluate his condition. [person] believes he is currently taking the maximum dose of quetiapine and appeared reluctant to explore any changes in medication or dosing. He again demonstrated a sense of hopelessness and resignation.
Collateral:
In speaking with [person], his mother and current co-resident, she confirmed [person]’s account. She noted that the increase in hallucinations she observed in May improved after a few weeks but recurred recently, which she associated with [person]’s probable anxiety about an upcoming psychiatric appointment. She reported that after starting olanzapine 5 mg nightly, [person] did not show significant improvement in his hallucinations, though his sleep has improved.
She stated that she has no concerns regarding [person]’s safety and denied ever hearing him express suicidal thoughts or death-related fantasies. She did express worries about her son’s long-term future, given that she and her husband are older adults, and fears that [person] may not have adequate supports available when she is no longer able to provide care.
Past Psychiatric History
[person] reports that since approximately 2010 he began hearing voices that others could not hear. When questioned further, he was unable to provide a rational explanation for the origin of these voices. Due to these symptoms, he required a psychiatric admission at KGH in 2010 and again several years later. Despite having previously received a diagnosis of schizophrenia, [person] denied having any mental health diagnosis. He stated that he has not had psychiatric follow-up at HDH since 2010 and that he had instead been followed by ACTT in the community.
He reported having undergone several therapeutic trials with psychiatric medications but was unable to recall the names or doses. He stated that most medications caused bothersome side effects, including significant sedation and stiffness, which interfered with his ability to carry out daily activities.
For at least the past five years, he has been treated with quetiapine 800 mg nightly (two 400 mg tablets). He stated that although the voices remain present, he has remained adherent to this medication. His mother confirmed his medication adherence.
Psychiatry Assessment/ Follow up: ACTT [phone]
Psychotherapy: Has joined some support groups.
Psychiatry admissions: two
Suicide Attempts: [person] denied any suicide attempts; however, his mother reported that in 2010 she found him in the shower under cold water with signs of hypothermia, after which she took him to the ED and he was admitted for the first time.
No-suicidal self-harm behavior: denied.
Trauma history: [person] stated that his biological father and his mother’s first partner after their divorce were emotionally abusive toward him, although he did not provide further details.
He denied any history of bullying during his school years. He denied history of physical or sexual abuse.
Substance History
Alcohol: denied
Nicotine: denied
Cannabis: denied
Other substance use: denied
Comments:
Risk Assessment
Risk to self: moderate
Suicidal ideation, intent, and/or plan: denied.
Prior suicide attempt(s): once stated by mother.
Self-harm behavior: denied.
Risk factors for suicide: male, chronic mental illness, psychotic symptoms, negative symptoms, hopelessness.
Protective factors against suicide: the patient expressed future-oriented planning, stating that he wishes to continue working and engaging in his hobbies. Additionally, he identified his desire to avoid placing his mother and stepfather in a difficult situation as another important protective factor.
Comments
Risk to others: low
Homicidal ideation, intent, and/or plan: denied
Prior history of violence: denied
Risk factors for violence: male, chronic mental illness, psychotic symptoms.
Protective factors against violence: no previous history of aggressive behavior.
Comments:
Patient currently certifiable under the Mental Health Act?: NO
Mental Status Exam
Apearance: [person] is a middle-aged man who appears his stated age. He was appropriately dressed, with good hygiene. He is deaf and communicates through American Sign Language with the assistance of a certified interpreter. He has a left eye enucleation.
Behaviour: Cooperative, calm, and engaged throughout the interview. Tearful when expressing no hope on symptoms changing.
Motor activity: . No psychomotor agitation or retardation observed.
Speech: Communication conducted entirely through ASL. Signing was fluent, coherent, and appropriately paced. No evidence of thought blocking or disorganized communication.
Mood: Described his mood as “the same as always.” Denied sadness, irritability, or persistent anger.
Affect: Affect was appropriate, stable, and congruent with stated mood. Mild constriction noted but no emotional lability.
Thought process: Linear, coherent, and goal-directed. No loosening of associations, flight of ideas, or tangentiality.
Thought content: He denied suicidal ideation, passive death wishes, homicidal ideation, paranoid ideation, ideas of persecution, thought insertion, thought broadcasting, ideas of reference, or grandiosity. He expressed a sense of resignation and limited hope regarding treatment options.
Cognition: Alert and oriented to person, place, time, and situation. No gross deficits noted in attention or concentration during the interview. Long-term memory appears intact based on history; short-term memory not formally tested but functionally adequate.
Perception: Reports ongoing auditory hallucinations experienced as voices originating from within his head, providing commentary and occasional criticism. Denies command hallucinations.
Insight: Limited. He acknowledges hearing voices but denies having a psychiatric diagnosis and has difficulty articulating the origin or significance of his symptoms.
Judgement: Fair. He remains adherent to medication and employed, and he seeks support from his mother when needed. However, he shows reluctance to consider medication adjustments and demonstrates resignation about his condition.