A 64-Year-Old Man with Intrusive Thoughts and Fear of Being
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A 64 year old Haitian American man was evaluated at the geriatric psychiatry clinic for chronic depression, intrusive thoughts, and fear of being poisoned. During the evaluation, the patient described his mood as “not that good.” He reported depression, which he rated as 4 on a scale of 0 to 10. He had been having an ongoing “depressive episode” during the past 3 months. He had passive suicidal ideation, questioning whether life was worth living, however he had no specific intent or plan and no thoughts of harming other people. The patient had a history of nightmares, but they had not occurred during the past 3 months. In the 3 years before this evaluation, his startle response had been increased and flashbacks frequently occurred. There were no auditory or visual hallucinations.

The patient’s medical history included diabetes, dyslipidemia, hypertension, seasonal allergies, mild intermittent asthma, eczema, and chronic lower back pain associated with a motor vehicle accident that had occurred 20 years earlier. Medications included bupropion, quetiapine, aspirin, atorvastatin, ezetimibe, amlodipine, fosinopril, hydrochlorothiazide, metformin, and vitamins B12 and D3, fexofenadine, naproxen, sildenafil, and inhaled albuterol as needed.

Quetiapine was stopped because of persistence of persecutory thoughts; risperidone was administered, with no effect on these thoughts. The patient described his mood as “up and down,” with loneliness, which he attributed to the pandemic of coronavirus disease 2019. The dose of bupropion was adjusted. Self-guided and therapist-led exercises of mindfulness and meditation were helpful.

Cultural consultation was requested from a Western psychiatrist familiar with the Haitian culture and belief systems, and efforts are being made to obtain spiritual consultation from the patient’s Vodou and Santeria community. In the meantime, the patient’s relationship with his therapist and geriatric psychiatrist continues. Post traumatic stress disorder and major depressive disorder was diagnosed in the context of culturally and religiously derived beliefs and behaviors.

source: https://www.nejm.org/doi/full/10.1056/NEJMcpc2004981