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Thank for letting me see your patient Michael about his condition; this has been a unique opportunity for me to encounter and observe some of the psychiatry-related theoretical concepts in real-life surroundings.
In my opinion, Michael clearly shows some of the symptoms of autistic spectrum disorder, which is however, has not yet surpassed the boundaries of mild form. Michael also has some learning problems as outlined in his recent psychological assessment. The matter is somewhat complicated by the patient’s reported behavior; namely, some of experiences recounted by Michael slightly distort the overall clinical picture, however, I would not coin them as such that would qualify as “psychotic symptoms”. Instead, we are basically dealing with strong addiction of the patient to science fiction imagery, the examples of which he often recounts as such that are closely intertwined with reality.
Another symptom that can be easily defined here is obsession which is characterized by his frequent repetition of ideas at occasions that are definitely inappropriate in social terms. On the brighter side, I am content with the fact that Michael acknowledges himself as one an only source of the ideas he articulates, meaning that at the moment we can exclude the possibility of schizophrenic underpinning to the patient’s condition. He did not report any occurrences of external channeling of ideas or imagery into his consciousness.
Another aspect that needs to be pointed out is that Michael is not happy with all of the ideas and thoughts that he has; I presume some of those are regular adolescent fantasies with might cause natural disturbance and uneasiness in the patient. Thoughts such as this frequently make him look derailed as he thinks over them, attempting to cope with them by means of engaging into repetitive rituals. This often makes Michael angry and lost in case if these rituals become interrupted by others for whatever reason. Generally, it appeared to me that the clinical picture of Michael is well-consistent with definition of obsession thinking present in adolescent with insufficient self-expression and social skills. However, we can be sure to discard the possibility of schizophrenic illness of any type.
I do have little doubts that that Michael’s condition needs a direct and timely treatment; I fully understand the preoccupation of his parents with his condition which is apparently associated with numerous inconveniences for a young man of 20. They are also not fully convinced that all the possible treatments have been tried while the effect of the ones that have been already tried was very insignificant.
Michael has had all the appropriate investigations and assessments for all of these, plus just about every treatment it is reasonable to try. However, their anxieties about Michael go back a long way, as you know, and I suspect that the recurring breakdown they have in their relationships with professionals is because their sense of bitterness and loss and their fears for the future have never been entirely taken up. I think it is important that someone tries, although it can be difficult to pursue this when they are thinking more in terms of medical diagnoses and solutions. As Dr X said in the report you have kindly provided for my information, the few drugs that seemed to help him a little also made him drowsy, but it does seem that the most help was with the milder tranquillizers at low dosage, which confirms my impression that anxiety rather than a psychotic condition is one of his key problems.
I think it would be best for Michael and his parents to stay with Dr X and her team, and for him to remain a boarder at X-College for as long as they will have him, despite their feeling they aren’t quite set up for his needs. I have told Michael and his parents that I don’t advise any tests or new drugs, and there is indeed nothing I could advise specifically for Michael that hasn’t been tried adequately already, but that I did think it would help if they talked over their disappointment with the social worker on Dr X’s team. I have to say that they didn’t think much of this suggestion, but thanked me for my time. I would be surprised if they don’t come back to you again about seeing Dr Y, whose clinic has had some more publicity recently. I’m sorry that there’s nothing more I can suggest.
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