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CASE: Sleepless and paranoid
Ms. V, age 16, is referred to our psychiatric hospital from a juvenile detention center after she is charged with killing her sister with a hammer. She reports paranoid delusions, including believing that her sister was poisoning her food. Ms. V’s troubling behavior increased in the 6 months before the murder. She began to ask her mother to smell her food for possible poison. Her school grades dropped and she experienced decreased sleep and appetite. According to her mother, Ms. V’s insomnia worsened recently because of her paranoid thinking, which was evident when she noticed that her daughter slept with a hammer. Ms. V stopped socializing with her peers and no longer went to the gym.
Ms. V’s mother describes her daughter’s negative symptoms as consisting of social isolation and a flat affect. There was no evidence of auditory or visual hallucinations. After noticing the change in her daughter’s behavior, Ms. V’s mother attempted to schedule an appointment with a mental health professional, but there was a 2-month waiting list.
Ms. V cleaned her room before the murder, which was uncharacteristic of her routine behavior. On the day of the murder, Ms. V approached her sister while she was sleeping on the sofa and struck her on the head several times with a hammer. After the sister died, neighbors spotted Ms. V washing blood off her hands in their backyard with a sprinkler. Soaked in blood, she approached one of the neighbors and said that someone had been killed in the house. The neighbors called the police and Ms. V was arrested. She did not express remorse. She did not exhibit physical aggression toward others before the murder. Ms. V’s sense of entitlement and grandiosity persisted after the murder.
The authors’ observations
Paranoid delusions are fixed false beliefs with severe fears of others that may impair functioning at school or work, in personal relationships, and in other social dimensions. Paranoid thinking can have diverse presentations, ranging from social concerns such as fear of rejection to severe threat perceptions of people trying to cause substantial physical harm.1 Paranoid thoughts can be a result of misinterpretation of language, a personality disorder, anxiety, or psychosis.
Feelings of low self-esteem2 and anger1 may develop in a patient experiencing paranoid ideations. When anger begins to escalate, it may erupt into violent behavior. In Ms. V’s case, her paranoid ideations increased until she killed her younger sister. Ms. V’s case is similar to a mass shooting near Tucson, AZ on January 8, 2011 in that it possibly could have been prevented with earlier psychiatric intervention (Box).3-6
Tucson, AZ mass shooting: Could it have been prevented?
On January 8, 2011, a mass shooting occurred near Tucson, AZ that killed 6 and wounded 13. The suspect, 22-year-old Jared Lee Loughner, refused to cooperate with authorities by invoking his right to remain silent.3 Although the motives behind this crime remain undisclosed, mental illness appears to be a contributing factor.
Reports indicate that Mr. Loughner was abusing drugs and those close to him had noticed personality changes.4,5 The college he was attending advised Mr. Loughner to undergo a mental health evaluation, but he refused and dropped out of school.4,5 While in custody after the shooting, Mr. Loughner was diagnosed with paranoid schizophrenia, deemed incompetent to stand trial, and ordered to receive psychiatric treatment.6
This tragic mass shooting and similar incidents have led to questions regarding the adequacy of the mental health care infrastructure in United States. Experts suggest that this tragedy could have been prevented with more aggressive psychiatric prevention and intervention. Critical analysis of similar recent cases and expert opinions are needed to address this problem effectively.
EVALUATION: Remorseless
At admission, Ms. V’s affect is restricted and, at times, inappropriate. She is guarded about discussing the homicide but describes paranoid thoughts about her sister poisoning her. She is eager to learn if the police had found poison in her food. Her speech is soft with good articulation. Based on her presentation, her intelligence is average. She shows no evidence of remorse and is preoccupied with her sister poisoning her.
The Rorschach Inkblot Technique reveals positive evidence for a severe thought disorder. Ms. V’s thinking seems regressed. Ms. V’s medical workup, including MRI, electroencephalogram, and laboratory tests, are all within normal limits.
In the 5th grade, Ms. V’s primary care provider prescribed amphetamine and dextroamphetamine for attention-deficit/hyperactivity disorder, but she discontinued the drug after 1 year. Ms. V has never been hospitalized for psychiatric illness. She had no chronic medical conditions and no developmental delays.