Date: 09.21.1994

Patient Name: Sebastian Warren

DOB: 03.12.1973

Height: 5’10”

Weight: 123 lb

History of Present Illness:

Patient is a 20 yo male, admitted to Dambel Psychiatric Hospital on 09.12.1994. The cause for his admittance is the lacerations in the shape of words on his back, chest, arms, and legs. Patient reports that they began to appear in May of 1992, in as many as 6 separate instances. He denies inflicting the wounds on himself, but does not provide any other explanation for how they might have come about.

Since the affliction has begun, the patient has consulted with several other physicians, including dermatologists, hematologists, psychiatrists and neurologists. The extensive medical history is attached, but in summary, an explanatory conclusion has yet to be drawn--at least none the patient has been pleased with.

Per chart review, the patient attempted suicide on 10.07.1992 and was subsequently admitted to St. Thomas Hospital for a 24 hour hold before being released.


Patient presented with numerous wounds on his chest, arranged to spell the words “GRIEF AND RELEASE ACROSS THE SEA”, perhaps in reference to his recent arrival in the United States. According to the patient the wounds are now two weeks old. Average length of each laceration is approximately 2 inches. Maximum depth is estimated to be about 1/4 inch. Though the healing process has already begun, the wounds are roughly consistent with what might be expected from a wound inflicted by a small blade, such as a kitchen knife or a razor blade. Scars from similar wounds are present on the patient’s thighs, arms and other areas of his torso. Patient is underweight and confesses to not having much of an appetite. Agrees to suggestions of being fatigued.

In our initial interview, patient appeared mostly lucid, if somewhat subdued. Patient was mostly cooperative, but answered only the bare minimum for interview questions. His affect was moderately blunted, showing little to no emotional response to even charged topics, including his withdrawal from university, his aunt and uncle’s departure, and his late parents. The sole exception was in response to the suggestion that his wounds had been self inflicted--which he passionately denied.

Initial Diagnosis: Schizoaffective disorder

Blunted emotional responses in combination with self harm and history of suicide suggestions this disorder, though it is difficult to tell whether the psychosis the patient experiences is a result of a mood disorder or in addition to it--his insistence that he did not inflict the wounds suggests the latter. The diagnosis should be updated if he experiences an episode during his stay at Dambel House. The apparent amnesia of the cause of the wounds may suggest dissociative identity disorder though there is not currently enough evidence for a positive diagnosis.


Patient has been prescribed a daily dosage of 100mg Chlorpromazine. Until the frequency and severity of the psychotic episodes can be better assessed a low dosage of antipsychotics is recommended. In addition, the patient has been scheduled for weekly group and individual therapy.


Patient has requested to be removed from antipsychotics. Request has been refused, though prescription has been lowered to 75mg.

Patient is integrating well with his fellows, and supports them enthusiastically in group therapy, making him a favorite of the nurses. Patient is still reticent to address his own issues, which is especially apparent in an individual setting. Not unexpected, while doctor-patient trust is still being established.


Patient experienced a psychotic episode and inflicted new lacerations on his right thigh. Claims again that they appeared on their own. Prescription has been re-upped back to 100mg. It is unclear how the patient managed to find a weapon, or where he had hidden it.

Progress is still slow in individual therapy.


Patient continues to request to be removed from antipsychotics, despite the return of the episodes. Antipsychotic treatment will continue, though perhaps the patient will have a better reaction to a different drug.

Prescription updated to 15mg Haldol.


Patient has again requested to be removed from antipsychotics. He now admits he has been lying about not inflicting the wounds himself, has been lucid when inflicting the wounds despite his earlier claims. When asked why he had lied earlier, admits he had been ashamed and scared. When asked why he chooses to self harm, the patient responded only that he wanted to and it made him feel better, and did not elaborate. When asked the meaning of the words he wrote, patient hesitated, said there was none.

In light of this new information, patient will be weaned off antipsychotics and switched to a course of antidepressants. Also to address his continuing ability to find instruments for self harm, patient will be moved without warning to a new ward. Interactions with nurses and other patients are to be kept to a minimum and carefully monitored.


Patient has again cut himself. This time the message indisputably implies the impending death of another inpatient. Patient insists it doesn’t mean anything, that he has no intent to harm his ward-mate. Patient has not shown previous disposition towards violence, though clearly has a propensity for dishonesty. Screening for antisocial personality disorder has occurred, though patient has answered the survey in such a way to meet little of the criteria.

For the safety of the patients and staff at Dambel House, as well as his own, patient is to be moved to a high security ward and allowed no time in common areas. Interaction with staff is to be kept to a minimum.


Patient has reneged on previous claim of inflicting the wounds himself, and now insists that he lied about deliberately harming himself in order to be removed from antipsychotics. He is again claiming the wounds appear on their own and he does not understand their meaning, that he means no harm.

It is unclear how to proceed from here. Therapy sessions have not been productive. There is no indication that medication is having any effect. Patient may be moved back to antipsychotics, but while he remains untruthful, an appropriate diagnosis and treatment will be impossible. One course is clear though: he must be kept away from any others.


The subject of the patient’s message was killed, but not by him. Another inpatient attacked her in the common room this morning. When interviewed, the attacker made no reference to the patient, nor did he appear to recognize him in any way. The patient was not present at the incident, still in solitary confinement in the opposite wing of the hospital. Staff reports little contact between attacker and patient.

We are considering securing funds and permissions to provide a way to not only monitor but also record the patient's activity. The expense is non-trivial, but in the face of conflicting information from the patient, there is little else we can do.


One of our nurses’ family perished in a car crash today. According to the staff, the patient had been advising said nurse to contact them in the proceeding weeks.


Patient inflicted wounds containing references to the evacuation last week due to the oncoming storm. Another message anticipated the escape of several inpatients, including their deaths due to exposure. Both messages were several months old.


Ward camera system has been successfully installed.


More marks on the patient’s back. Episode was caught on security footage.


And again.


Patient has been removed from antipsychotics. A mild sedative will be prescribed instead.

Patient is to be transferred to the Bethlehem ward. Regular updates are to be sent to the patient’s family.