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Letter to the Editor   |    
Reply to Freeman Letter
Daniel Antonius, Ph.D.
Am J Psychiatry 2010;167:997-998. doi:10.1176/appi.ajp.2010.10030394r
View Author and Article Information
New York

Accepted June , 2010.

Copyright © American Psychiatric Association

To the Editor: We appreciate Dr. Freeman's insightful comments on our case conference. Our assertion that this was an "obvious" case of an axis I disorder may not have been that obvious after all. The patient described in the case presented with a myriad of past diagnoses and had previously been prescribed a variety of antipsychotics and other medications. However, during the hospital course, many of the symptoms exhibited by the patient could potentially, as eloquently pointed out by Dr. Freeman, be attributed to a diagnosis of antisocial personality disorder. Somewhat unclear in this clinical picture are the effects of medications. It is possible that pharmacological treatment may have reduced the psychiatric symptoms, but not the antisocial behavior (1), which continued to be in full display on the unit. Additional information from records from other hospitals to thoroughly examine the patient's life course of psychiatric issues and antisocial behavior would have been beneficial for diagnostic clarification. What is important, however, with this case and others like it, is the violent and antisocial behaviors that must also be in the forefront of diagnostic considerations. This behavior needs to be addressed immediately and treatment tailored accordingly (which may include transfer to a secure psychiatric unit, a forensic institution, or even jail). Early implementation of interventions is critical to maintain a safe treatment environment for our residents, other staff, and the patients.

Swanson  JW;  Swartz  MA;  Van Dorn  RA;  Volavka  J;  Monahan  J;  Stroup  TS;  McEvoy  JP;  Wagner  HR;  Elbogen  EB;  Lieberman  JA; CATIE investigators:  Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia.  Br J Psychiatry 2008; 193:37—43
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Swanson  JW;  Swartz  MA;  Van Dorn  RA;  Volavka  J;  Monahan  J;  Stroup  TS;  McEvoy  JP;  Wagner  HR;  Elbogen  EB;  Lieberman  JA; CATIE investigators:  Comparison of antipsychotic medication effects on reducing violence in people with schizophrenia.  Br J Psychiatry 2008; 193:37—43
[CrossRef] | [PubMed]
 
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