CASE RECORDS of the MASSACHUSETTS GENERAL HOSPITAL. Case 14 2016. A 37 Year Old Woman with Adult Onset Psychosis.
Dr. Maureen M. Leonard: A 37 year old woman was admitted to a psychiatric hospital for adult onset psychosis. The patient had been healthy and studying for a doctoral degree when she began having symptoms of psychosis. Her first symptom was a belief that "people were talking about her" as part of a larger "conspiracy" in which family, friends, and random people were part of a "game" and acting out "scenes" for her. She had had stress associated with her schooling and had contemplated changing schools. However, she had not had other symptoms of anxiety or depression, neurovegetative symptoms, or auditory or visual hallucinations. A few months later, the patient's apartment was burglarized and vandalized; her parents were the only other people with a key, and she believed they were involved. Because of threats she made against family members, she was admitted to an inpatient state psychiatric facility. A diagnosis of psychotic disorder, possibly paranoid schizophrenia, was rendered. An evaluation for causes of the disorder revealed evidence of marked iron deficiency anemia, including an iron level of 18 mg per deciliter (3 mmol per liter; reference range, 45 to 182 mg per deciliter [8 to 33 mmol per liter] a ferritin level of 6 ng per milliliter (reference range, 11 to 306) and a transferrin saturation of 3.7% (reference range, 11.0 to 50.0) The evaluation also revealed vitamin deficiencies, including a vitamin B12 level of 167 pg per milliliter (reference range, 182 to 803) and a vitamin D2 level of 10 ng per milliliter (reference value, >32) Before admission to the state psychiatric facility, the patient had had no history of psychiatric disease. She had a remote history of a left foot fracture and had undergone a right oophorectomy at 17 years of age for torsion of the ovary. She took no medications. Her mother recalled her being a "perfectionist," especially during her late teenage years. The patient had reported an unintentional weight loss of 9 kg over an unspecified period of time, despite self described polyphagia and some hair thinning. She did not have diarrhea. There was no history of head injury or seizure, menopausal symptoms after the oophorectomy, or social withdrawal. Her mother had systemic lupus erythematosus, her sister had hypothyroidism From the Departments of Medicine (H.K.D. Pediatrics (M.M.L. A.F. and Pathology (V.N. Massachusetts General Hospital, and the Departments of Medi cine (H.K.D. Pediatrics (M.M.L. A.F. and Pathology (V.N. Harvard Medical School both in Boston.
The New England journal of medicine