Journal of Health and Medical Sciences

Motivation behind choosing the subject: Forensic psychiatry is always a challenge by raising the issue of discernment when committing an antisocial act. The fact becomes all the more interesting as it is not a schizophrenia case, but other diagnoses in the psychotic spectrum, but which maintain a better contact with reality and a greater social functioning. Study Questions: Paranoid schizophrenia can overlap high emotionality, lability, the richness of the affective life being supported by the nature of the delusional idea. Objective: We want to present the life history of a patient with AHC filled with heritability for the paranoid spectrum, whose diagnosis ranged from Polymorphic Personality Disorder with Psychotic Decompensation to Delirious Disorder for ten years, during which he had two prolonged admissions between a hospital of maximum security and special measures. Results: The patient presents disorders predominantly in the register of thought, delirious ideation of persecution, prejudice, with the disorganization of thought and language (predominantly in writing, with jargonophasia and the intrication of the delusional idea totally discordant of context, without neglecting the total absence of empathy, both the patient, as well as that of his brother, related to the disappearance of their mother for several months who suffers from Alzheimer's disease. This, together with the lack of insight, enhances the danger, together with the pathology that dictated the last hospitalization (repeated threats with stabbing to the address to some unknown people). Conclusions: The high doses of antipsychotic and timostabilizing medications acted on the thinking component, but less on the axis II disorder, failing to modulate the affectivity, the aspect of psychopatoidization remaining evident.


General description of the case:
Personal data: • born in 1968, being the youngest of the three children (the older sister is a step-sister) • Mother -professional driver profession, affirmatively diagnosed with Alzheimer's disease; missing from home for several months.
• the father -deceased in 1982 (at the age of 67) -affirmative stroke; teacher of mathematics, physics, and astronomy (the patient was 14 years old at the time of his father's death) • brother -married • sister -deceased -brain tumor; the patient is confused about the year of her death • states that he lives with his mother, in an urban environment, although she has been missing for several months; the brother has the same address as the patient's • both deny AHC for Schizophrenia

Studies:
• starts schooling at the Industrial High School (construction profile) and continues at another Industrial High School (architecture profile) -average Bachelor's degree 7.52 -ends in 1986 with the qualification "gas and sanitary installer." • 1988 -1991 -employed as an installer • 1986 -1988 -satisfies the military internship in transmissions -affirmatively he was "front man" and "detachment chief." • 1988 -waiter courses -bartender -cook • 1990 -1993 -piloting courses -sports aviation, affirmative 220 hours of flight -obligatory to obtain the patent for recreational aircraft -"the best period of his life," in which he also has a cohabitation relationship • 1991 -1994 -works as a taxi driver -with short periods in which he did not work • 1995 -employed  • Divorced parents -when the patient was 9 years old • "Dad said it was not good that my mother was a taxi driver, she was a professional driver, she had been an educator, qualified at work, but gave up." • "Dad was 20 years older than my mother." • "My mother was my father's high school student." • "They did not understand jealousy." • "My mother was late at night, she was smelling of gasoline and diesel." • "The father won the divorce in the court, he proved that mother cheated on him." • "In our family, there was an ordeal, they were arguing all the time, and they didn't have time to take us to kindergarten and school." • "Mother was very beautiful." • "My grandmother loved me, she made me sweets, she took me for walks." • "The mother was previously married, had a daughter from that marriage" -the patient's deceased sister • Affirmative, the brother destroyed the house of some neighbors with the ax "because they took a land that we inherited" • 1991 -1994 had a cohabitation relationship with L., the mother forbidding that marriage ("We lived at my place for a while, we quarreled over my jealousy"); later he stated sporadic relationships ("I was handsome, and women liked me, but I didn't care about having a relationship") • 2017 -states he has a relationship with E. (37 years old), having the profession of a salesman; the patient stating that he is ashamed to reveal to her that he is admitted to the psychiatric service About the mother -in recent years: • "Mother goes on pilgrimages to churches." • "She had Alzheimer's, and she forgot, she got lost, she called me, and she asked people on the street to tell me in what area she is, to come and pick her up." • "She was admitted to psychiatry and neurology." • "She didn't have stability, she didn't stand well on her feet." • "She disappeared in June 2018, I am abandoned and alone." • "I told the police after three weeks -a month to make her disappear, because she sometimes slept in front of Real, where she was selling flowers." • "I and my brother were very worried, it's just my mother, I hope she is okay." • "I think someone stole her pension or she went around to churches." • "I had to be very careful with her, otherwise she would get lost." • "I thought she was still at my brother's place. She went to him sometimes. My mother would be missing from home sometimes, she was sleeping on the street, so that she would not pay taxes in her building."

Current episode
• He is currently talking about a relationship with a partner E. This is integrated in the delirious representations of the patient: "I was passing by Dr. D.'s psychiatric ward, on the way to E., it was her birthday, and she wanted an Airball toy from Noriel, I wanted to give it to her but Dr. D.'s bodyguards, at his instructions, they came after me to beat me, to give them the toy and the money I had with me. When I came out of the store where I had bought the toy, I saw a woman throwing some pots at the garbage. I found the two knives in the trash and took them to protect myself from the guard company, although the police said I had them at my disposal, but I had found them in the trash with the plates and pots. What was I to do? They wanted to take my three mobile phones and the 500 RON I had. The patron of the guard company asked the P.M. bodyguard to beat me with a rake and the two-meter dig. The doctor wanted me to bribe him, because every month he asked for my pension." (Bion, 1904) Delirious ideas last affirmed and sustained on July 25, 2019 • "I got tested by Marius Nasta to make hormones for Băsescu because he needed the pearl of Ardeal, which is the substance they take from my blood sample, it is a very good antidote, I cannot tell you why." • "Melania Trump is my daughter, as well as Mădălina Pușcălău, who is a model." • "The psychologist is Putin's niece, but she does not want to tell us." • "When I was eight, my aunt touched my penis because she wanted my sperm, and she put it in a tube. Carmen and Klaus Iohanis are my children, they are from another religion, and this is why the marriage was allowed." • "I know Melania Trump is my daughter, because when I was in Săpoca, Melania and Donald Trump came to get married in front of me." • "I have more children in the tube, none in the natural way." • "The dolls in the office are made by Mrs. Monica Nicoleta, the daughter of Vladimir Putin, who did not keep her name so that she would have no problems. I met her in high society at the Hotel Royal Constanta, and we are good friends now. Monica Nicoleta was there with Miss Irina, her daughter, and Putin's niece."

Materials and methods
Prolonged hospitalization with compulsory treatment until recovery or elimination of any degree of danger, assessment of the degree of danger, of the mental capacity at various moments of hospitalization, assessment of the discernment in the commission of forensic psychiatric medical expertise, psychological examination, life map tracking the evolution under treatment.

Examination of the present mental state
Observations: the patient, in a hospital gown, relatively uncared for, tense inside, with adhesive and psychic viscosity, insistent, with verbal stereotypes, not always understanding the unavailability of the interlocutor, irritable, potentially explosive, excitable and self-aggressive when it comes to minor frustrations (such as lack of cigarettes). Perception: he denies the auditory and visual hallucinations, or at the level of another analyzer, both at present and in the past, the pathology being present at each hospitalization in the register of thought, which was an argument for supporting the diagnosis of Delirious Disorder. (Trifu, 2017) Attention: voluntary hypoprosexia, with spontaneous hyperprosexia for certain insignificant details, but integrated deliriously or with some significance for the patient. Memory: fixation hypomnesia, with non-selective hypermnesia for certain data, facts, or delusional integrated events. Pseudoreminescences on which the patient builds confabulations and supports his delusional idea. Thinking: accelerated flow and rhythm of ideo-verbal, fast-talking having as its correspondent the graphomania and, sometimes, fast writing (in writing the patient's thinking is disorganized by curbing the jargon-phasia), ideoverbal disorganization in long sentences, but not in short ones. (Cassidy, 2016) Delusional interpretation, coincidence detection, attribution of meanings and allusive meanings, delusional polymorphic ideas not systematized, mainly of magnitude and filiation, as well as persecution and prejudice related to hospitalization, given the absence of criticism. Deficiency of mentalization. Constructions of illogisms, inability to anticipate the consequences of his actions ("I feel like it / I do it!"). (Adler, 2010) Affectivity: potentially dysphoric, excitable, explosive, acting-out manifestations with the breaking of thinking and transposing in a self-aggressive way, primary affections from the register of hatred, anger, revenge, absence of empathy, remorse, inability to feel his depression or guilt, affective switch towards his brother, the affective flattening regarding the disappearance of his mother. Instinctive life: antisocial tendencies, hetero-aggressive acts, compulsive smoking in large quantities, the potential for social danger, minimal risk of self-aggression. Delayed response of pulsation control during highdose psychotropic treatment. (Durkheim, 1997) Activity: the minimum capacity to carry out useful social activities, due to the disorganization of thinking and behavior. Sleeping pattern: sleep is difficult to induce with medications. Disease consciousness: absent Current diagnosis: Persistent delusional disorder (Winnicott, 2005)

The evolution during the last hospitalization
Patient T. has been admitted to psychiatry for about two months. We mention that he came to the hospital with a crew of the Police Station, for a marked psychomotor agitation behavior (threatening with the knife several people on the street), for his acquisition and hospitalization, it was necessary to immobilize and handcuff him. From the Police report, the patient was incoherent ideo-verbally, with marked hetero-aggressiveness.
It is under the incident of art. 109 Penal Code, in the psychiatric dispensary at the Mental Health Center, after the last discharge from the Safety and Special Measures Hospital. The attending physician in his dispensary found that he was not compliant with the prescribed pharmacological treatment, notifying the Court in this regard, which is why after decommissioning the non-voluntary hospitalization procedure in the emergency room. The court cites the patient in the court in order to replace/cease the measure of compulsory medical treatment (art. 568 / NCPP) and to replace it with the measure of the provisional medical hospitalization until the recovery or improvement of any danger state (Kernberg, 1995).
It is worth mentioning that during the entire hospitalization in our clinic, the patient was in the surveillance room, he was presented every time in front of the Court, as well as at the National Institute of Legal Medicine, where he refused psychiatric expertise. At the beginning of the hospitalization, high doses of medication were required, both classical neuroleptics and atypical antipsychotics (Clopixol Acuphace superimposed over 8 mg Risperidone), due to the manifestations of hetero-aggressiveness that persisted for more than three weeks.
Throughout the hospitalization the patient was adhesive, insistent, with verbal and physical aggression towards the staff and the other patients, with graphomania (multiple petitions filed both in the attention of the Hospital Management and in the attention of the Court, the current doctor sending to the Court the majority of the patient's documents). In most of the documents, he requested to be released from the incidence of non-voluntary medical hospitalization and to transform the hospitalization into a voluntary one. He also states that he is aware of his rights and that he does not want to be evaluated by the expert committee of the National Institute of Legal Medicine, but by a party expert, whom he will designate himself (Bowlby, 1976). He was visited on several occasions by his brother, who had a manipulative behavior (asking for the keys of the apartment in which they both live, against the patient's will, as well as numerous papers related to his brother's health, not presenting any legal document from which it would result that he is the patient's guardian). In this regard, the opinion of the legal lady of the Safety and Special Measures Hospital was requested, who stated that there is no document referring to the patient having a designated legal guardian in the medical file of the hospital.
We mention that throughout the hospitalization, the pathology of the patient was manifested mainly at the behavioral level, with marked violence and heterogeneity, as well as in the thinking area. As a result of the treatment, after about a month, the ideo-verbal incoherence was partially restored, but delusional ideas persisted, mainly of filiation, as well as of persecution and prejudice. (Klein, 2011) The absence of the emotional resonance was observed, the psychological examination highlighting an antisocial personality line, the potential for marked danger, acting out type reactions with a mentalization deficit, the inability to understand the consequences of his aggressive actions, the lack of empathy, the absence of remorse, the lack of insight, the lack of criticism. Regarding phenomenology that determined the hospitalization (including in the present moment he considered that "It is not great that I had in my hand two knives, it seemed to the police that I was threatening people").
All the necessary investigations were carried out, the psychological examination insisting on the delusional ideas of persecution and grandeur, on the interpretations and delusional behavior, developed on a lower average intelligence level IQ -95. The personality is imprinted by paranoid tendencies, impulsivity, and heteroaggressive decompensations, with poor overall operating efficiency (GAFS = 40). The EEG describes a hypovoluble route, with an alpha rhythm of 10 cycles/second, poorly represented, symmetrical, reactive, without pathological graphs (Trifu, 2015).
To mention the patient's graphomania, all the citations issued by the Court, which were communicated and handed to him, being filled with multiple patient's writings, partially legible, partly highlighting fragments of delusional ideas ("I was decorated in April 1990 by General Lafayetet Trueman ... ") later the speech was disorganized and suggested jargonophasia, by mixing English words in the text, later writing that he refused all psychiatric and psychological expertise. He notes in the court citation: "I specify that Melania Trump is my daughter, and her children are my legal grandchildren." The writings bump multiple references to older psychiatric expertise, performed in another county court, intricate with legislative concepts from the patient's past (former student at the faculty of law), wrongly understood and used outside the context ("Decree 14 of Protocol 114 of 14.11.1994. Strasbourg. Extra-judiciary.") (Kohut, 2009) The attending physician, the department head doctor, the resident doctors and the psychologists of the clinic performed repeated anamnesis throughout the hospitalization, one of the subjects discussed being the absence of the patient's mother's from home (it was understood that she was old, suffering from Alzheimer's and disappeared about eight months before), neither the patient nor his brother showed any emotional feelings of concern about what might have happened. We emphasize once again the lack of emotional resonance capacity, the total lack of affect, the only forms of externalization in this register being impulsivity, excitable discharges, irritability, irascibility. (Gabbard, 2014) During the hospitalization, despite the high doses of medication (the last treatment followed was Risperidone 8 mg, Tiapridal 300 mg, Levomepromazine 25 mg and neuroleptic Fluanxol 20 mg depot a vial every two weeks) and being in a ward supervision, the patient presented multiple aggressive behaviors, both to the staff and to other inpatients. (Freud, 2014) Accordingly, we are of the opinion that at the present time the high degree of danger regarding the patient is maintained, which is why it was considered a necessity to continue the provisional medical hospitalization until the Decision of definitive medical hospitalization by the Court, within the Sapoca Special Safety and Measures Hospital, because a current psychiatric hospital does not offer sufficient protection measures regarding such a patient, his behavior endangering the integrity of the other patients admitted.