Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.
Background
A 37-year-old man is brought into the emergency department (ED) after he was involved in a motor vehicle collision. He does not appear to have sustained any physical injuries. He exhibits extreme frustration with the emergency staff and police officers who are present, and he throws a cup of water at hospital personnel. His unusual agitation draws the attention of the clinical staff, who request a consultation from the hospital's psychiatry service.
The patient repeatedly yells to the evaluating physician that he is in the ED because "that woman cut me off on the highway!" To the confusion of the evaluating physician, it is discovered that the collision did not happen on the highway but instead occurred about 1 hour afterward. The patient states that he had followed the other motorist home, carefully considered a plan for revenge, and then intentionally rammed his vehicle into the woman's parked car. He says, "I wanted to show her what happens when she cuts people off." When the frightened woman came out of her home to see what had happened, the patient began to spit on her repeatedly. The woman then called the police.
During the evaluation, the patient continues to yell about how mean the other motorist had been to him and how she deserved to be spit on. He perseverates on the injustice of what happened and how angry he is about it. For the several hours that he remains in the ED, he is floridly agitated.
The patient is questioned about what had prompted him to run deliberately into the other motorist's vehicle. He states that he wanted her to drive more carefully and that after he had crashed into her car, she would know better than to do that to other people. When asked why he spit on her, he says, "I know I shouldn't hit people. I've gotten in trouble for that before." The physician asks whether he was hearing voices that were telling him what to do, and he replies, "There's always my voice in my head. It was angry!" When asked about paranoid thoughts, he responds, "What does that mean?" After a simplified explanation, he says, "Sometimes, I feel like people are trying to make fun of me. They always have." He does not perceive other voices, other than occasionally those of his parents, who tell him what to do. Overall, he demonstrates poor awareness of the intention of the physician's questions.
The patient's family arrives at the ED and provides collateral information. His parents explain that he has always lived with them. He has struggled with frustration tolerance for his entire life. The patient has not been able to hold down a regular job since he failed out of school in the 10th grade. He was previously fired from jobs where he delivered pizzas, lifted boxes in a warehouse, and pushed shopping carts back to a storefront. His employers consistently remarked that he required inordinate amounts of supervision, resulting in his termination.
His parents report that he has frequently punched walls or broken his phone when he does not get his way and that he has struggled with similar difficulties throughout his life. In addition, he has been briefly arrested for similar incidents in the past. He often engaged in fistfights, during which, he sustained punches to his head. His parents state that he does not have a history of significant substance use; however, they note that he has used cannabis daily since he was a teenager. They report that the patient had difficulty paying attention in classes in school. He often required separate classes because of his tendency to be disruptive to teachers or other students.
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Cite this: An Angry Cannabis User Who Rams Another Motorist's Car - Medscape - Jul 05, 2023.
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