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Dr. Steve
Dr. Steve, Psychologist
Category: Mental Health
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Experience:  19 years conducting therapy; book author; newspaper columnist; former co-host of radio show
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I was wondering if anyone could help me with research for my

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I was wondering if anyone could help me with research for my fantasy novel. There's a situation and I was wondering if someone could suggest possible responses to it, both in terms of where a psychiatrist or psychologist might focus their attention, and possible diagnosis routes that would be on his mind.
Sadly I don't think there's quite enough space in this box for the scenario, but please could someone let me know if they would be willing to help. It's not especially complex and I really just need a list of lines of enquiry, things a psychiatrist or psychologist might ask, and possible diagnosis that will lead to further research I can do in order to make it fairly believable.
I guess you could either email me on***@******.*** or give me your email address... though perhaps that breaks the rules on this site! I'm not sure. In any case, I'm happy to pay for the information.


Geez... this is an excellent question. I have written a couple novels myself and know the importance of good research. Unfortunately, your email address gets blocked when you try to post it on JA, as would mine, as you were correct to note that contact outside of this forum breaks the rules we agreed to. Is there a way for you to condense the information such that I might have a good idea as to what you need? My answer can be as long and rambling as it needs to be... but I don't know if your question space is restricted.

Anyway, let me know - glad to help. And depending upon the amount of time I spend on the answer, please bear in mind that bonuses are appreciated here at JA :).

Dr. Steve

Customer: replied 7 years ago.

Thanks for the reply. I really appreciate the help!

It looks like there's more space in the reply box than in the initial question box, so I should be able to post all the information here.

A 17 year old boy is brought into his headteacher's office. He has no idea why that is and he's done nothing wrong as far as he's aware. The real reason is that he's being congratulated for an award he's won, but before they get that far in the conversation the 17 year old grabs a pen from a holder on the desk and tries to stab the teacher with it. It seems to the teacher to be an aggressive action, rather than out of fear. They restrain the boy and get him under control, and shortly after he stops struggling, but he's unresponsive for a short time. When they finally get a response from him he claims he doesn't remember anything that happened since he walked into the office. He shows shock when he's given an account of his actions, which at least appears to others as genuine.

There's no prior history of any episodes, issues, depression or obvious problems at school or home. He's sleeping well (loves to sleep, in fact, though not in a depressive way at this point). He also claims he hasn't taken any drugs and his parents think it would be out of character; he's very much a nerd and isn't in a bad crowd of any kind as far as they're aware.

The first therapy session occurs with no other obvious symptoms. At this point, what would the thought process be? What kind of questions would be asked? And what possible diagnosis might be floating around the head of the psychiatrist or psychologist (haven't decided which it will be yet)?

Later the boy starts having extremely vivid dreams of a medieval-ish fantasy world, and enjoys the dreams so much that he starts to sleep for longer when he has the opportunity. He's never had especially vivid dreams before, and certainly not with the same frequency. He's also been feeling increasingly down about life in general, but he thinks it's mostly because people are talking about him at school, and both he and his parents are worried.

Again, with this added possible symptom, how would that change the line of thought?

The final issue that comes up is an apparent delusion that he's being followed, culminating in actually seeing a cloaked man looking at him on a bus. The cloaked man eventually gets off the bus at the same time as another group of people, but by the way nobody else seems to be noticing such a strangely dressed man, it's possible it's purely hallucination. As time goes on he seems to be getting increasingly down and depressive, but that didn't start until after the attack on the teacher and seems to be more related to the consequences of that event.

That's all I've got for the moment. Suggestions of the thought process towards diagnosis would be helpful, along with suggestions of possible diagnosis at each stage. Another question I have is whether a psychiatrist would approach it differently to a psychologist?

Thanks again!

Hello again:

Listen, I have clients all night... let me get to this tomorrow and you will have a thorough answer, okay? Thanks for including me... this is cool.

Dr. Steve

Customer: replied 7 years ago.

Okidoke. No rush :) I look forward to reading your answer.

Customer: replied 7 years ago.
A psychology student on a forum somewhere mentioned that they hadn't heard of anyone blacking out without any obvious cause like drug-use or a head trauma. I thought therefore I'd mention that I could change the plot so that he attacks the teacher out of a sudden irrational fear, which later makes no sense to him. The important part is that he doesn't understand why or how he attacked him, so if removing the "black out" makes the diagnosis path easier then feel free to go with that.


Okay... first thing's first. A psychiatrist and psychologist would approach the diagnostic tree the same way, although the psychiatrist would be moving ahead more directly, and with no room for any therapeutic interventions - i.e., his interview would last about 15-20 minutes, and be solely delivered for the express purpose of figuring out which medication to prescribe. Now I will say this, unless the kid was already in therapy (apparently not, given your scenario), he would probably be sent to a psychiatrist first - especially because the authorities seem to have been involved. With an act of violence like that, he would have been ordered to undergo a psychiatric evaluation, regardless of whether he was ever adjudicated for the attack - in other words, his lawyer (at the very least) would have arranged a psychiatric evaluation to make him appear more sympathetic in the eyes of the judge.

But onto the diagnostic process...

FIRST SCENARIO (the attack): Following this one, my questions would flow through BOTH an examination of acute stress (bullying, dropping grades, extreme parental pressure for academic performance, losing a girlfriend, drugs, suicidal ideations) AND a look at a family history - this would be to assess a possible genetic link to a psychological malady (i.e., looking at family substance abuse, depression, stress, history of violent behavior). Lastly, I would take a close look at (a) diet and especially over-use of caffeine, and (b) sleep patterns and potential for frying himself through not sleeping well or not sleeping enough. Now, I recognize that you covered a few of these in your scenario, but a shrink would not know that, and (frankly) would want to ask the questions himself anyway.

Here are the diagnoses that would be floating around in my head: substance abuse, even if acute; a bipolar episode (this would require some history of similar behaviors, even if they are not to this extreme); a dissociative disorder (this would be the primary course of my inquiry - a history of trauma would almost have to be present to create this mental landscape, but this is easily the most apparent); brief psychotic disorder (pretty rare in teenagers, but on the table because the scenario fits).

SECOND SCENARIO: With the addition of the vivid dreams and the apparent withdrawal into a world that does not parallel reality, I would be more aggressive at going after trauma, either in his history or in the present tense. So I would put more pressure on inquiry regarding his relationship with his caretakers, any potential for abuse at the hands of others during his developmental years... or, perhaps being victimized right now by a bully at school or maybe sexually abused at the hands of an adult. Because schizophrenia does not "come on" like this (I can tell you more about this if you are interested), and truly does not affect school-aged kids in this manner, my mind would not be moving in that direction.

Diagnostically, I would look more closely at a dissociative disorder - given your storyline, this would not be accurate within the context of the story, but as the therapist, I would not be completely privy to everything that a reader would be aware of - therefore, I would pursue this avenue, at least for the time being. Too, I would look more closely at whether there could be some sort of neurological damage... extending sleep patterns could imply something going wrong with the sleep center of the brain (the reticular activation formation), and the more vivid dreams could also be the result of an insult. So, I would refer for a neurological exam to rule out a potential blow to the head, tumor, or degenerative disease.

THIRD SCENARIO: Now that our hero is beginning to tear away from reality (at least, the reality that is perceived by those around him) - I would be more convinced that we are either dealing with a neurological issue, some sort of psychotic disorder (again, very rare, but I would not, in good conscience, be able to professionally ignore the mounting data) - like schizophrenia (which would require a prodromal phase), a brief psychotic disorder (depending upon the time line), some type of extreme dissociative disorder (which would require abuse of emotional trauma), or maybe a personality disorder such as schizotypal personality disorder. Bipolarity would be out of the question, and by now he would have been drug tested at least twice, so substance abuse would have been ruled out. There is not really another choice that would cover all of the symptoms, so I would narrow my focus to the handful of diagnoses listed in this paragraph.

Hope this helps... let me know if there is anything else, or if you need clarification. I love this kind of stuff! If you are satisfied, please hit "Accept." That is the only way I can receive credit for my answer. Bonuses are also appreciated. Thanks-

Dr. Steve

Customer: replied 7 years ago.
Fantastic answer! Thanks!

A few follow-up questions for you:

In the case of the first scenario, what do you think a psychiatrist would be likely to do if they couldn't find any history that pointed to a bipolar episode, and couldn't find a history of trauma? If everything was ruled out except brief (very brief!) psychotic disorder, perhaps brought on by stress, do you happen to know what the response would be? Would a medication be prescribed? Or would it be considered as something which has passed and action taken to reduce stress?

Basically I really need to get the character into a more long term and caring therapy situation pretty quickly. I'm quite sure that after finishing with a psychiatrist, his mother would be inclined to send him to a psychologist for a longer period to make sure he's ok, whether it was advised or not.

It's also possible that there would be no criminal issues if the headteacher isn't hurt or doesn't press charges, so maybe I'll go that route and send him straight to a psychologist.

In scenario three you mention "some sort of psychotic disorder - like schizophrenia". Are there other psychotic disorders worth considering?

Finally, one thing about the character's history I didn't mention is that just before he was born, his father left them. I thought I'd mention this for the sake of genetic history. His father became an alcoholic after losing his job around the same time his wife got pregnant. It was too much for him and he ran away. Would that impact the thought process at all?

Beyond that I think my own further research can give me the details. I'll keep a link to your profile in my favourites though, so I can ask you directly if I have further questions when I come to write my first draft. Quite possible something else will come up later!

Thanks again for all your help. Although my funds are limited, some kind of bonus will certainly be forthcoming.

Okay, great are the answers to your questions:

(1) Most psychiatrists would not knee-jerk medication before s/he knows exactly what is going on, and a 15-minute evaluation would not get to the real problems, especially given the scenario as you have laid it out. However, in an effort to make it appear as though s/he was doing something, a mood stabilizer (like Depakote or Lamictal) may be prescribed, as might be an atypical anti-psychotic such as Seroquel or Risperdol. All of these meds have the essential effect of tossing a wet towel over the brain - they will knock you down a peg, and thus these are used at times to simply control behavior.

(2) Sorry I didn't flush out the psychotic disorders. Here are a few possibilities: (a) Brief psychotic disorder. Typically brought on by adverse reactions to medications, this disorder implies that the symptoms came on acutely, and have not persisted for more than a month. (b) Schizoaffective disorder - This one has mane of the improper cognitions (i.e., delusions or hallucinations), but are not nearly severe enough for full-blown schizophrenia, and are accompanied by a parallel mania or depression. (c) Delusional Disorder - This is the most likely early-stage diagnosis, as it implies a well-woven delusional structure but is at least somewhat grounded in reality - i.e., it is not totally bizarre like those in full-blown schizophrenia. Your guy on the bus scenario smacks of this one. (d) and then of course, there is the full-bore schizophrenia.

(3) I don't know that the father leaving would have a notable impact on the thought process in a flash point, acute incident such as the one you describe. I would be more inc lined to think that the father leaving would have more of a deleterious effect on the main character's self-esteem, self-worth, choices made toward either hyper-masculine or more feminine activities, etc. As for a quick hit like the one you described, I don't think there was much room for rational thought.

Let me know if there is anything else.

Dr. Steve

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