Reply to Freeman Letter

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.