Conduct a Comprehensive Psychiatric Evaluation

A 22-year-old young man is admitted to a psychiatric inpatient unit under involuntary admission. On admission, he is extremely agitated and hostile. He is very upset about having been admitted. He believes that he is of royal descent and is determined to punish those who are involved in ‘imprisoning’ him. It is reported by his family that he has no actual royal lineage, but that he sees himself as the person chosen to establish a new world government. He says he is on a mission. He has been angry and physically aggressive towards family members who contradict him. His grandmother banged the back of her head from when the man pushed her against a wall and has a bruised face. He refuses to allow a detailed mental status examination. He is pacing up and down the ward intimidating other patients. He is laughing out loud, talking to himself. He repeatedly makes threatening gestures at the ward staff. He lives with his grandmother. He has no contact with his father. His mother died of a drug overdose when he was 6 years old. He uses cannabis regularly spending £20 a week but does not abuse alcohol or any other drugs. He smokes 40 cigarettes a day. There is no significant previous medical or psychiatric history. He has been behaving strangely, according to his grandmother, for the past 2 weeks. She has observed him spending a lot of money and talking openly about his sexual exploits to her. He has hardly slept over the past week. Two days ago, he threatened her and pushed her when she tried to urge him to see the doctor. Since then, she has been feeling increasingly frightened of him. He was prescribed the antipsychotic medication olanzapine 5 mg nocte (at night), which he has taken a few nights. However, this morning, he hit her. She reported the matter to the police, which ultimately led to his admission. 

Mental state examination 

He appears dishevelled bearing 3-day-old stubble. He is pacing imperiously up and down the ward corridor, singing out loud. He also laughs and talks to himself. Any attempts to interview him result in him swearing, and when he does agree to temporarily come into the interview room he very quickly walks out slamming the door as he goes. He gives little eye contact and appears preoccupied with his own thoughts. It is not possible to discuss his thoughts or experiences with him. Physical examination He refuses a physical examination.