Psychotic manifesto as a symbolic safe space

The clinical case reflects the manifestation of psychosis in a young boy who has always shown remarkable success in his studies and professional activities. The development of psychotic symptoms significantly reduced his overall activity and quality of life. Propensities: limited social and communicative skills, poor social experience, resistance to behavioral patterns, which in the patient were clinical manifestations of ASD and demanding mother. The growing social expectations, which in a certain period of life the patient was unable to respond, became provocative events that triggered the development of psychotic symptoms.


Introduction
22 years old patient, turned to a psychiatrist, accompanied by his parents , according to the mother, a week ago he began to behave strangely. He spoke inadequately, was restless, complained about hallucinations, constantly questioned how old he was, not sure of the recent date. He complained about headache and feeling of inner heat. The day before he turned off all his electronic gadgets (computer, mobile phone, TV) and was afraid to look into the mirror. He also said that his movements were managed by someone, so he could not walk and talk as usual, he did it awkwardly.

Anamnesis of life
Was born healthy, developed without delay, in 3 years knew all the letters of the alphabet, began to read. Adapted to the kindergarten hardly, could not sleep in the afternoon. Says that he changed the kindergarten because of the bad attitude of the educators towards him. At 5 years went to the second class as mastered the program of 1st class himself . Studied perfectly. At school was active, studied well, participated in social events, but from the words of the mother he always preferred to be alone, than in a company of peers. He has been communicating in Internet networks a lot. Later on he attended 2 Faculties of Philosophy and Law, which he graduated from. Recently had a difficult job interview which he attained a place at. However, as he has reported, he needed time to adjust to work, the company understood him and gave the opportunity to prepare and inform them when he will be ready. At home he was under the pressure of his parents which were forcing him to go to work as soon as possible. Soon, he contacted with the company, but the it had appointed a new interview. According to mother's words, these events were stressful for him, he became closed, silent, had a lowered mood. The patient explained this behaviour as a result of pressure from the family because of his work, and the because of the problems with establishing a close relationship with the girl he likes.
Relationships in the family over the past six months have become tense, was feeling pressure from his mother and grandfather, in connection with necessity to get a job. He reported that he was not against employment, on the contrary, he wanted to become independent, but could not get along with the forces, needed some more time. This explains with the influence of the mother, that she considers all his achievements her own merit and wants to continue to control him. He has a younger brother who often annoys him, he believes his parents badly educate his brother, so he tries to make a strong person himself out of him.

Anamnesis of the disease
A week ago during the whole day he had vivid visions, colours passed in front of his eyes, heard voices. He seemed to have lived during those 24 hours all years from the beginning of his life and he felt all the pain of mankind during this period. He also had the feeling that he is simultaneously in about different six time measurements, in each of them he has different ages. He had the impression that he could not escape the time loop. He felt severe burning in the middle of the body. Also had hyper-and hyposensitivity.
He told about the experiences that he had before, he believed in the underworld and had the feeling that he should die, because of it he was afraid to look in the mirror. Staged his own death, shut his eyes, took the knife in his hands, intended to strike him in the stomach, but approaching his hand with a knife to the abdomen he stopped. Feels that something keeps him alive.
He reported that he had similar experiences for the past 8 months (since last New Year Eve). Then, at that New Year night, he promised to himself to be more courageous, he wanted to establish a close relationship with a girl he likes, but during the year he failed to fulfil this promise, so he merged himself, was very dissatisfied. He reported that his mother probably had the opposite desire for the New Year to always be under her care. He felt that his thoughts could read the surroundings, especially the girl he liked, and he could read his mother's thoughts.

Psychiatry status
Behaviour is calm, the patient seems tense, anxious, alert, he listens to every sound .He asked to make sure nobody listens to the conversation, he was confident several times. The mood decreased, significant sense of sadness and pessimism, says that he has no hope for a good future. Emotionally labile, demonstrates affective outbreaks during conversation about the topic of experienced hallucinations, stories about his personalities and time measurements in which he experienced them. He was often repeating that he does not understand why he decided that he had lived for 24 hours in 2021, if now it is only 2017: «Where did I take 4 years?». The conversation is productive, answers in essence questions, openly, without hiding anything. Insignificant difficulties in the constructivism of clinical interviewing are observed with the complication of the conversation due to the disorganization of mental processes, namely, the slow pace of thinking, tangentiality, diversity, ambivalence, paralogism, which creates difficulties for a clear understanding of the patient's messages. Demonstrated a severe network of delusions and exhibited a severe level of disorganized thought. The hallucinatory behaviour was not shown during the survey. Socially excluded, apathetic, passively carries out the necessary actions. Verbal-cognitive processes during the interview are reduced, because of reduced working memory, concentration and attention, speed of information processing, violations of abstract and symbolic thinking processes. The patient shows a vague recognition of his illness, he has awareness of major symptoms that are present.

Psychodiagnostic examination MINI(international neuropsychiatric interview)
According to the MINI the patient meets criteria of the next scales: major depressive episode (major depressive episode, current); suicidality (high current suicide risk); social phobia (generalized social phobia (social anxiety disorder current); posttraumatic stress disorder in the past; psychotic disorders and mood disorder with psychotic features(current psychotic disorder) [1].

A psychodiagnostic personality survey was conducted (FPI -Freiburg Personality Questionnaire)
The high mark on the "neurotic" scale characterizes the high level of personality neuroticism that corresponds to the expressed neurotic syndrome of asthenic type with psychosomatic symptoms in the form of frequent headaches, rapid fatigability and exhaustion. Reduction of excitability thresholds, increased sensitivity, as a result of which small and indifferent stimuli can easily cause irritation and excite flares that quickly fade.
High scores on the scale of "spontaneous aggression" indicate a lack of social conformality, moderate self-control and impulsiveness, a strong expressive attraction to acute affective experiences. Strives to satisfy his desires immediately in personal behaviour, without seriously thinking about the consequences of their actions, acting impulsively and ill-advised.
The high point on the scale of "depression" makes it possible to diagnose signs characteristic of psychopathological depressive syndrome. Immerse himself in his own experiences. In a close circle of close friends, he is able to get rid of his slack and fence, comes to life, become fun, talkative, even a joker. Any activity for him is heavy, unpleasant, proceeds with a feeling of excessive mental stress, quickly tired, causing a feeling of complete impotence and exhaustion. Particularly painfully experiencing real troubles, cannot throw them out of the head, prone to self-excuse. The events of the past and present life, regardless of their actual content, cause reproaches of conscience, a depressing premonition of misfortune.
High marks on the irritability scale indicate that he is acutely unsuccessful in self-indicating reactions. Conflict behavior, as a rule, is the most commonly used form of protection from emotions that affect his personality.
High marks on the scale of "Reactive aggression" characterize him as a person indifferent to praise and punishment, often neglects moral and ethical standards. Aspires to an immediate satisfaction of his desires, regardless of the circumstances and desires of others. Feels hostile feelings in relation to those individuals who atleast in some way try to control his behavior, actions, forcing them to stay in a socially acceptable framework.
Results on the scale of "shyness" reflect the presence of anxiety, stiffness, uncertainty, resulting in difficulties in social contacts. Not able to make decisions without hesitation and uncertainty, needs advice and support from the family side [2].

Thematic apperception test
Traced violations of dynamic and associative processes of thinking indicate the presence of severe mental illness, psychotic nature. The urgency is the poverty of expressive characteristics (emotional exhaustion). Anxiety and fear as an affective saturation of psychopathological ideas and a sense of confusion. Disharmonious violation of verbal-cognitive characteristics. Active social avoidance. Current topics, needs and goals, obstacles, attitudes and self-esteem are not those that reflect the basic structure of the individual, but are, in the majority, a consequence of active psychopathology. However, they contain a part of the characterological signs of the client and the client's mental movements are not in a state of acute violation [3].

SCI-PANSS (Positive and negative syndrome scale)
During the interview we got the next results [4]: P1. Severe delusions: presence of stable set of delusions that are crystallized, systematized, clearly interfere with his thinking; P2.Moderate Severe conceptual disorganization: generally has difficulty organizing his thoughts as evidenced by frequent irrelevancies and disconnectedness; P3.Severe hallucinatory behaviour: hallucinations are present almost continuously causing major thinking and behaviour disruption; N4.Moderate severe passive\apathetic social withdrawal: passively participates in few activities and shows virtually no interest or initiative; G2.Moderate severe anxiety: reports serious anxiety problems that have significant physical and behavioural consequences such as marked tension, poor concentration; G6.Moderate Severe depression : his mood is distinctly depressed and associated with obvious sadness, pessimism, loss of social interest, psychomotor retardation; G9.Severe unusual thought content: the patient expresses many illogical and abused ideas; G15.Severe Preoccupation: the patient displays marked preoccupation with autistic experiences that seriously delimits his concentration ,ability to converse and orientation to the surroundings.

ADI-R (Autism Diagnostic interview)
Conclusion: The criteria for autism spectrum disorder are fulfilled [5].

Stereotyped behaviors and restricted interests-2;
The criteria for autism spectrum disorder are fulfilled [6].

Diagnosis and it's justification
At the same time, the patient fulfills the criteria for several psychiatric disorders: a major depressive episode, social and generalized anxiety disorder, posttraumatic stress disorder, suicidal thoughts, intentions, attempts in the past, indicating high current suicidality, current psychotic disorder. The criteria for autism spectrum disorder are fulfilled. Considering that at the time of the appeal for help the main and most expressive symptoms were symptoms of psychotic disorder, which manifested in the form of auditory and visual hallucinations, conceptual disorganization, delusions, active suicidal thoughts, was established the next diagnosis: Acute polymorphic psychotic disorder with symptoms of schizophrenia and active suicidal ideations. Mixed anxiety and depressive disorder. Highly functional autism with a deficit of socio-emotional interaction, limited and repetitive patterns of behavior.

Treatment
Quetixol 150 mg per night, arilental 10 mg per day (in the morning) during 10 days, and then increase the dose to 15 mg per day. A week later, the patients parents reported a significant improvement in their son's condition. On the recommendation of the attending physician, he turned for a consultation to the prof. Haustova O.O., who confirmed the diagnosis and made corrections in the treatment: canceled quetixol and prescribed 10 mg olanzapine per day. A month later, on the background of a successful treatment, the patient began attending sessions at a psychotherapist with a client focused psychotherapy direction.

Conclusions
The clinical case reflects the manifestation of psychosis in a young boy who has always shown remarkable success in his studies and professional activities. The development of psychotic symptoms significantly reduced his overall activity and quality of life. Propensities: limited social and communicative skills, poor social experience, resistance to behavioral patterns, which in the patient were clinical manifestations of ASD and demanding mother. The growing social expectations, which in a certain period of life the patient was unable to respond, became provocative events that triggered the development of psychotic symptoms.