This is a 28-year-old man who presented to the emergency department complaining of depressive symptoms and suicidal ideation, with a plan to overdose. His urine toxicology screen was positive for cocaine. His CT scan of the head showed a cleft by gray matter extending from the margin of the right posterior frontal lobe to the margin of the lateral ventricle, consistent with schizencephaly. Neurological exam was significant for left-sided hemiparesis, with decreased strength and sensation. He reported a childhood history of ADHD and reading disorder.
The patient admitted to chronic suicidal ideation and feelings of emptiness. He had taken several overdoses that led to psychiatric inpatient admissions. He reported severe mood swings that would last for a few hours, on average. He had started using marijuana at the age of 7 years and cocaine at the age of 15 years and had been in jail for 5 years after being charged with drug possession. He had been involved in multiple fights and had a big scar in his face after being stabbed by another man. The patient had multiple tattoos on his body with extreme statements such as “love” and “hate,” “life” and “death,” and derogatory comments against authorities. He had had several girlfriends, but acknowledged that he had not been able to establish intimacy with any. He reported hearing the voice of a man and a woman intermittently saying that he is not worth it. He showed frantic efforts to avoid abandonment; every time he was offered discharge, he stated that he was getting worse and stated on repeated occasions that he would commit suicide.