Case Study: Mario Mario walked into the public library. The 24-year-old was disheveled, looking as if he had not washed his hair nor shaved in some time. The most striking thing about his appearance, however, was that he was wearing a wetsuit for scuba diving. He sat in a public waiting area and proceeded to pour a bottle of water over his head. A staff member asked him what was wrong, and Mario replied, "I have a new row of teeth coming in." The police were called. When asked if he was all right, Mario responded, "There are sands and shade of bark, blue, and red, but up in the gummy bear you have to wait for ripe bicycles, and it was still wet." The police called an ambulance, and Mario was transported to the emergency room. The emergency room physician who evaluated Mario found that he did not smell of alcohol nor did he show any signs of drug use. He did not look as if he had hit his head. A stroke could cause the "word salad" that characterized his speech, but it would be unusual in someone so young. Despite his heart beating faster than normal, Mario did not seem to be confused or agitated, but clearly something was wrong. His speech was rambling, and he made several attempts to drink water from the sink in his room, to the point where a hospital staff member had to be stationed in his room to keep him from leaving or drinking any more water. His blood was drawn and analyzed; the results confirmed that there were no drugs or alcohol in Mario's system. However, the blood test also revealed that the amount of sodium in his body was unusually low. More tests were ordered. 1 While additional lab tests were pending, Mario's parents came to the emergency room. They were able to tell the doctor that Mario had been behaving erratically for several years. His parents said that they first noticed unusual behavior when he left for college. "His first two years were fine, but in his third year he started accusing his roommates of getting into his belongings," said his mother. The accusations progressed to Mario believing that his roommates were secretly telling his professors to fail him. When Mario began to believe his roommates were poisoning his food, he called his parents to come and get him. He moved back into his childhood room and seemed to do better back in familiar surroundings. He willingly worked in his father's auto repair shop but did not want to spend time with other people. Although his parents were concerned about his behavior, Mario's older sister had some roommate trouble in college, too. They thought that he needed to take some classes closer to home. Shortly after Mario returned home, however, it was clear that he was not the same person who had left the previous fall. Despite being a relatively well-adjusted teenager and well liked in high school, he wanted nothing to do with high school friends. Mario would not respond to phone calls or text messages. He left the house only when prodded to do so by his father and stopped using his cell phone all together. He had to be reminded to take a shower and brush his teeth. Eventually, he stopped going to work and preferred to stay in his room playing video games. His parents were concerned about his behavior but hoped it was just a phase he was going through. ( About six months after returning home, Mario asked his parents if they were hearing a voice that was telling them to do things. Concerned, his parents took him to the family doctor. During the exam, Mario admitted that he had been hearing voices that no one else could hear. He said that the voices came and went. Sometimes the voices would tell Mario that he was useless and no one liked him. Other times, the voices would tell him to "get ready." The family doctor prescribed antipsychotic medicine and said that Mario should be evaluated by a psychologist for psychosis. While Mario agreed to take the medicine, he refused further evaluation. As long as he was taking the medicine, he did relatively well, his parents said. When he was off the medication, however, Mario did not want to leave the house, refused to work, and often chose not to eat. He kept to himself. In the past month, Mario stopped taking his medication. A week prior, he had left the house and not returned. His parents found his room in disarray and a journal on his desk. Reading through the journal, it had become apparent that Mario had been getting more and more paranoid over the past month. He had written about how he had stopped making blog postings because he was worried that the CIA was able to use his computer to read his thoughts. Mario had written frequently in a blog but always with the setting on "private." His journal had several rambling entries about a hidden government conspiracy to steal water. Mario wrote that he knew that "precious water" was going to waste and that he had finally realized that the voice telling him to get ready" was to preserve as much water has possible. Mario had acquired a wet suit and had started to drink water compulsively. ' Mario was discharged from the hospital and outpatient psychotherapy was arranged. He had follow-up visits with a psychiatrist to monitor his medicine. A year later, Mario would be living on his own and working regularly in his father's shop. Schizophrenia and other Psychotic Disorders Driven by these delusional beliefs, Mario's behavior had landed him in the hospital. After finding no other cause for his low sodium, Mario's doctor diagnosed him with hyponatremia secondary to psychogenic polydipsia. Essentially, his body's sodium level became critically low due to Mario's excessive water intake. Treatment was started to help replenish sodium. Because his speech was barely understandable and he sometimes complained about the voices telling him he was not drinking enough water, Mario was restarted on antipsychotic medication. Over the course of a few days, his medical condition stabilized. His speech started to make more sense, and Mario stopped trying to drink water compulsively. His affect improved, and he became more interactive with his parents and his medical providers. He said that the voices in his head stopped. His facial expressions broadened from expressionless to sometimes smiling. He was less suspicious of the people caring for him. He admitted that in the past few weeks he had grown suspicious of his typical dose of antipsychotic medication. I was pretty sure I was being poisoned," he said. "The voices in my head were telling me not to take the medicine because it was toxic and would kill me." Mario was transferred to an inpatient psychiatric unit. He was evaluated both by a psychologist who administered tests to assess Mario's mental illness and by a psychiatrist who decided Mario needed to increase the dose of antipsychotic medication. The diagnosis of schizophrenia was confirmed. For more than a year, Mario had been showing waxing and waning psychotic symptoms. While there were times when he tended to do well, he was having episodes of delusions and hallucinations as well as disorganized speech. During these times, he had significant problems taking care of his daily needs, let alone functioning in school or at a job. 1