Mr. O'Malley is a small, bent, disheveled 63-year-old man with a very faint Irish accent. He was referred for psychiatric evaluation when he attended the medical clinic where he was being followed for diabetes and maintenance of a colostomy that he had had for 5 years as a result of ulcerative colitis. He told his doctor that he was upset because he had been hearing voices, and was promptly sent to the psychiatry clinic for evaluation.

Mr. O'Malley is interviewed by a psychiatrist, and begins telling of his chief complaint, in traditional Irish fashion, with a story. A few weeks ago-he's not quite sure when-he took a fellow home from church, and feeling tired, lay down on the fellow's bed to take a nap. He awoke to find the fellow "on top of him" and raced out the door as fast as he could go. At this point, he's not sure whether it really happened or was a dream or a hallucination. In any case, it was followed some time later by an experience on the street in which a strange man called him "an Irish fag." This upset him a great deal, and he has been brooding about it ever since. He remembers that about a year ago, the owners of a new car wash in the neighborhood called him a "fag", and he wonders if these things are related. Two weeks ago he began to hear voices calling him a fag and saying other derogatory things about him, and his "whole system dropped down." He knows that he is not homosexual, and understands at some level that was is happening is "in my mind." Nevertheless, he feels that everyone in the neighborhood believes that he is a homosexual. He has been very nervous and shaky and has gone to his priest, who tells him that it is his imagination and he should ignore it. He is apparently still hearing the voices during the interview.

Mr. O'Malley describes his mood as "lousy" and "nervous and shaky." He doesn't volunteer feeling depressed, but says that he has not been interested in seeing friends or doing anything since this began. He also says that he has no appetite and has lost weight, but denies changes in his sleeping. Although he doesn't acknowledge feeling guilty about things he has done, he says he feels guilty about "the blasphemous words" the voices are saying. When asked specifically about suicide, he says that he's Catholic and he would not go to heaven if he committed suicide, so therefore he would not kill himself; however, he has though that he would be better off if something just happened to him to make his heart stop.

Mr. O'Malley had a similar experience 12 years ago when he heard blaspheming voices and became preoccupied with religious "scruples." He was treated as an outpatient for several months and took some kind of medication, the name of which he does not remember. He went back to work as a cab driver, and continued driving until his deteriorating physical condition caused him to go on disability 5 years ago. He lives with his wife and 25-year old son and spends a good deal of time in church-related activities, and playing the saxophone for various community affairs He has not had a drink for 30 years.

When questioned about memory problems, he describes making the wrong turn once on a highway and a few other instances of forgetting whether he had turned off the gas stove in his kitchen.

The following day, Mr. O'Malley's wife was interviewed by the psychiatrist on the ward to which he had been admitted. She reported that he had always tended to exaggerate slights and was quick to take offense and to read criticism into the remarks of others. She saw his distress of the past few weeks as simply an exaggeration of his nature. She noticed that he had been "listless" for a few days, and thought maybe he had a "virus." She described the episode 12 years earlier as similar to this one in that he had become increasingly nervous and suspicious and had begun hearing "voices."

If the diagnosis is schizoaffective disorder :

1. What symptoms did you use to meet diagnostic criteria for the diagnosis?

2. What other diagnoses should be or were considered for this patient? be sure to provide justification why you did not give this diagnosis

3. Describe at least TWO etiological considerations for this patient. You will need to use some of the theoretical models discussed in class for this answer (e.g., behavioral, biological, social, psychodynamic, interpersonal, etc...)

4.What treatments would you suggest for this patient? Please provide at least TWO treatment options with rationale for this treatment.