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Ah, a topic made for me. I needed a break after going through study material that uses vorbeireden to illustrate vorbeireden. I suppose this example helps me shore up my understanding of the differences between delusional perception, delusional memory, and delusional misinterpretation. It seems to be the last one in this case, the patient has a pre-existing delusion which causes him to interpret "neutral" stimuli in a negative context. I think. I am not sure if being accosted by three cops is strictly neutral, even for the neurotypical.
Let us stick to facts and base rates for a moment.
https://jamanetwork.com/journals/jamapsychiatry/fullarticle/2787197
The authors note that this seemed relatively stable between countries, so it is fair to assume it holds in the States. This means that, statistically speaking, a man with schizophrenia is about 4.5 times more likely to perpetrate violence than a man without it. This is a significant number. It is not 450 times, but it is also not zero.
The same study notes that the relative risk also depends on the presence or absence of substance abuse:
Taking your testimony to Hassan's clean living standards at face value, he should be at the lower end. We can assume he is probably around 350% more dangerous than the average person, with wide error bars. The conclusion that he is, in fact, more dangerous than average seems almost certain from a statistical perspective.
(The more cynical would invoke FBI crime stats at this point)
But this is the classic base rate problem. We are not just interested in the average person with schizophrenia, we are also interested in Hassan. So I'll go ahead build a quick and dirty risk profile based on your account:
What works in his favor:
What works against him:
Human men have a wide variance in their propensity towards violence. I would personally class Hassan as moderate risk, but take my opinion with a massive dose of salt since I have never met the guy, I'm hearing the story secondhand, and I clearly lack the opportunity to run reasonably validated scoring systems across the gentleman. It's far from ideal. Good thing that nobody listens to me.
In the UK, where social services and the cops have more power in such matters, Hassan would likely have regular welfare checks from a social worker. If he demonstrated severe self-neglect, they'd have the right to bring him in for treatment, which would be given if he was deemed to lack capacity. Whether or not he meets that bar is unclear to me. I presume he'd react better to an unarmed social worker, but that's a luxury in the States, where gun violence is much more of a risk. Here, they'd probably try and shank you first, or hit you with a beer bottle. The matter would be expedited if he resorted to violence or criminality, but he's not there yet.
You mention the man who attacked the FBI office believing in an "LGBTQ white supremacist pedophile" cabal. His thought process seems totally divorced from reality. We can comfortably call that "broken hardware." But where is the line? As you note, is believing the police kill 10,000 unarmed black men a year (the actual number is closer to a dozen) a delusion, or just a political perspective fed by bad information? Is believing Obama is a gay Kenyan married to a man a delusion, or just a conspiracy theory?
(If I was in an OSCE setting, this is where I'd mutter something about the distinction between over-valued thoughts and delusions, and also the fact that delusions need to be carefully interpreted in terms of their commonality in the patient's socio-cultural milieu. If we could commit Evangelicals who spoke in tongues or spoke to Jesus, we'd be filling a lot of psych wards very quickly. The erroneous beliefs mentioned above have millions of adherents, so from a pragmatic point of view we can't treat them all)
I suppose after all that hedging, I should say something mildly actionable. If I were you, I'd refrain from asking for another wellness check unless you note clear and obvious deterioration on his condition. If you could gently nudge him towards a checkup, well, that might help. He seems to trust you, as he should, since you're clearly looking out for him.
At the end of the day, the US's approach to psychiatric services for the insane (who need it the most, I'd say) is rather suboptimal. This is probably the best way of avoiding suicide by cop or homelessness, while also balancing violating his rights. If only there was a way to bring him in for a few weeks to an impatient clinic and starting him on some antipsychotics. That would probably be best, but it's not on the cards at the moment. @Throwaway05 correct me if I'm wrong here.
I mean it depends on the where. Usually you can get someone to a psych ED through a wellness check, the police, etc (at least in a blue state). But then if it's a city this guy is absolutely going to get cut loose. So you need non-urban (save for the real acuity) or non-rural (not enough resources) for their to be any chance of really catching this guy and sending him to inpatient - which is what you'd have to do since he won't meet the criteria for involuntary outpatient and doesn't likely want treatment himself. Inpatient is not really appropriate either.
This is the system we have unfortunately (or fortunately - it's very rights forward which can be a good thing, but is pretty American).
Thanks. I wasn't aware that there was a Community Treatment Order equivalent in the States, which would likely be a better for this gentleman.
I mean I'm aware it exists but I've never actually seen it which says something unfortunate.
Some places have "ACT/PACT/Whatever" teams that follow people in the community so they don't need to go to appointments but that requires sufficient patient engagement.
Usually that means lots of commitments and you get them with "you wanna stay out of the hospital bro?"
But we let a lot of people wander who dont want treatment and stay out of trouble.
Usually drugs is what gets people involved because it makes them erratic enough for the police to get involved.
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What can be done here?
The best option would be to bring him in and commence him on antipsychotics, at least for a few weeks. In an ideal world, that would reduce his symptoms enough for him to make an informed decision around continuing treatment, and he could be followed up in the community and even treated with long-lasting depot injections to reduce the compliance burden.
This would be relatively easy in the UK (it's still a major pain in the ass), much harder to achieve in the States, at least as I understand it. It might be easier if his condition worsened, severe self-neglect or violent tendencies would allow for expedited care. He's in an awkward state where he's too high-functioning to really justify institutionalization or imposed treatment, while clearly not being in his right mind.
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He's in his late 30's, if that changes things. The "young Denzel" line might have given a different impression, but there's a high degree of "black don't crack" going on. He has excellent skin condition.
I don't have any clues from things he's told me, but as we've covered his is pretty functional. Is it possible he's already on medication? I don't have a good sense of what modern anti-psychotics do. Would you expect a notable improvement on the delusions?
It's also worth noting that there's a small chance that he was previously on medication, but desisted. The drugs don't always work, and an unfortunate number of patients quit them either due to a lack of efficacy or the side effects becoming unbearable.
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That's good context to have, but his situation will still likely decline with time.
Antipsychotics are modestly effective in schizophrenia. They're not... pleasant drugs to be on, but they do meet the bar of being better for you than going untreated. The most significant benefit they provide is a roughly 50% reduction in mortality rate, which is a pretty big deal. Even so, they're very unlikely to restore normalcy, but they have decent odds of at least helping improve his QOL. It's complicated, and I find it hard to translate things like improvements in PANSS scores to actual tangible benefits.
I would strongly bet against him being on meds. The profile just doesn't fit, he lacks insight into his condition, and he hasn't complained about medical professionals messing with him, which is the usual presentation for people who are coaxed or coerced into treatment. The US medical system is awful about such things.
Of course, you could just ask him next time you see him. If he doesn't know he has a diagnosis or doesn't remember taking pills or getting shots, then he's almost certainly not on medication.
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