a case study of schizophrenia

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

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“One in a million”: A case of a very early onset schizophrenia

1 Assistant Professor of Psychiatry, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

2 PGY4-Child and Adolescent Psychiatry Fellow, Department of Psychiatry, Penn State Health Milton S. Hershey Medical Center, Hershey, Pennsylvania, USA

Address correspondence to:

Daisy Vyas Shirk

DO, 875 Stoverdale Road, Hummelstown, Pennsylvania 17036,

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Article ID: 100083Z06DS2020

doi: 10.5348/100083Z06DS2020CR

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Introduction: Very early onset schizophrenia (VEOS), psychosis prior to age 13, is rare with an incidence of less than 0.04%. Its clinical presentation, course, and outcome differ from early onset (ages 13–18) and adult onset (ages 18 and up) schizophrenia. It is associated with poor response to treatment, poorer prognosis, and multiple hospitalizations. Early identification and intervention has shown to improve overall functioning.

Case Report: We present a case of a 12-year-old female with significant family history of psychosis, admitted due to physical and verbal aggression, sexual inappropriateness, destruction of property, response to internal stimuli, decline in functioning, and 10 month history of social isolation. She responded to risperidone treatment. The patient was discharged to partial hospitalization program but could not tolerate the group setting resulting in discharge to outpatient services. Psychosocial supports were put in place to help with environmental and family dynamics to improve outcome.

Conclusion: As per a recent study, one-third of children and adolescents with psychosis initially present with negative symptoms. It has also been reported that 30% of those with negative symptoms develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of this case, it was imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis.

Keywords: Compliance, Intellectual disability, Psychotic disorders, Psychosocial support systems

INTRODUCTION

Very early onset schizophrenia (VEOS), defined as onset of psychosis prior to age 13, is considered to be very rare [1] . It has been shown to differ in its clinical presentation, course, and outcome compared to early onset (between ages 13 and 18) and adult onset (ages 18 and up) schizophrenia. It is associated with poorer prognosis, worse overall functioning, and multiple hospitalizations [2] . Early childhood adversity and borderline intellectual functioning have also been shown to contribute to development of psychosis [3] , [4] , [5] . Early identification and intervention have been shown to reduce the morbidity of the illness and improve overall functioning. Here we present the case of a young girl with very early onset schizophrenia.

CASE REPORT

This is a case of a 12-year-old female child who was admitted in the inpatient child psychiatry unit due to physical and verbal aggression toward peers and staff, sexually inappropriate touching, destruction of property, attempting to run out into traffic, and responding to internal stimuli.

The patient was reportedly doing well until 10 months prior to her hospitalization, after which she exhibited school refusal and declining grades. The only trigger reported was school bullying. She was noted to become more verbally and physically aggressive toward peers and school staff, with daily outbursts, eloping from school, poor sleep, and social isolation. At home, she was observed to sit in the halls in the middle of the night, conversing with herself. She changed from a child who “used to love talking, playing board games, and card game with her cousins” into someone who “now sits by herself and does not say anything to them or do anything with them.” She was also found one time sitting on her porch eating leaves.

She was referred and underwent partial hospitalization. During that treatment, she was observed to be impulsive, hyperactive, withdrawn, had difficulty with peer interactions, appeared internally preoccupied, laughed inappropriately, talked to herself, sing, or would dance alone without music. She struggled with boundaries and attempted few times to choke staffs with their lanyards or with her hands. She destroyed property, made verbal threats toward staff and peers, and made sexually inappropriate comments and gestures. She was given a trial of lithium and risperidone. She did not tolerate lithium but responded to risperidone 1 mg daily. Upon discharge, there was no follow-up and patient ran out of medication. This led to a deterioration of behaviors resulting in inpatient treatment.

Patient’s developmental history and medical histories are unremarkable. Her family history is significant for schizophrenia in her father who reportedly went from being a straight A student, attending college on a full scholarship to dropping out of school, having multiple incarcerations and now has been institutionalized in a long-term psychiatric facility for the past 10 years. The patient’s mother also received inpatient treatment after patient’s birth and there was a threat of all three children being removed by Children and Youth Services (CYS). At the time of hospitalization, she lived with her mother, 9-year-old sister, and 3-year-old brother. Child protection services were involved at the time of admission due to concerns of a possible sexual abuse based on patient’s sexualized behaviors.

Mental status examination at the time of admission

The patient had fair grooming but was agitated and uncooperative during the interview. Her eye contact varied from fair to intense staring. She did not display any motor abnormalities including tics or tremors. She spoke loudly and often repeated the phrase, “I don’t give a f***” to many questions. She refused to describe her mood and her affect was bizarre and labile; though content was characteristic of paranoia and perseverations. She refused to answer questions related to perceptual disturbances, suicidality, and homicidality. Her orientation, memory, and knowledge could not be fully assessed. Her attention, insight, and judgment were impaired.

Admission diagnosis

Unspecified psychosis was not revealed due to a substance or known physiological condition.

Course of inpatient treatment

The patient was diagnosed with unspecified psychosis on admission. Workup ( Table 1 , Table 2 , Table 3 , Table 4 , Table 5 , Table 6 ) was done and the patient was restarted on risperidone for her aggression and hallucinations. On her first three days of hospitalization, she displayed aggressive, impulsive, and disruptive behaviors toward peers and staffs. Her risperidone was titrated up to 1.75 mg/day. Her aggression subsided and she was able to attend groups. However, she had difficulty engaging with others, often preferring to sit by herself and away from the crowd. She initially endorsed auditory and visual hallucinations where she saw shadows or gravesite with numbers. She would occasionally have difficulty distinguishing reality from fiction, often asking staff if they were real or part of her imagination. Early on in her treatment, the patient had several days when she reported “itching” on her chest stating that she was being stabbed by someone. Once that was resolved, she became preoccupied by her fingertips and would often be seen picking at the tips of her fingers. She struggled with being able to process information and was often mute or would repeat things that had been said to her or perseverate on a specific sentence. She displayed paranoia on the unit, often worrying that someone would come in and hurt her and at times feared that the staff would hurt her. Initially, she had trouble sleeping at night and would often stand in her doorway staring at staff for the majority of the night. She was allowed to sleep on a mattress in her doorway which seemed to help at times but not consistently. Later, she denied having hallucinations although she appeared internally preoccupied throughout the stay.

Neuropsychological assessment was completed which revealed that the patient’s IQ was likely in the borderline range (70–79). She had limited verbal comprehension and expression, relative weakness in verbal knowledge, fluid reasoning, set-shifting, visual-motor integration, phonemic and semantic fluency, and rote verbal memory. She also had significant deficits in executive functioning and negative and positive symptoms of psychosis.

Medical issues

Started on Vitamin D3 to correct for low Vitamin D.

Interventions at discharge

Due to the many challenges this patient presented and concerns about compliance with aftercare recommendations, she was referred to as many outpatient services as possible to help improve her prognosis. These services included partial hospitalization, involvement of children and youth services, case management services, family support in the form of patient’s paternal grandmother, referral for electroencephalogram (EEG) and magnetic resonance imaging (MRI) of brain and school involvement.

Partial hospital treatment

Upon arrival to partial hospitalization, patient’s behaviors had deteriorated due to non-compliance with medications for a week as a result of problem with insurance. She reported sporadic hallucinations, giggled by herself, displayed thought blocking, disorganized behaviors, made random, unrelated, bizarre statements, sometimes loudly and perseverated on them and was paranoid.

During her partial hospitalization, she was disruptive, made sexually inappropriate comments and became verbally and physically aggressive toward staff. As a result of these behaviors and her inability to tolerate the group setting of partial hospitalization, she had to be discharged to outpatient services. As was the case during her discharge from inpatient treatment, patient’s mother did not show up for her discharge and CYS had to find her.

When found, her mother once again claimed she was unaware of the discharge.

Follow-up in outpatient treatment

In the outpatient clinic, risperidone was titrated up to 1 mg orally twice a day, with a good response. Patient’s mother reported that the patient was doing well in school and seemed to be at her baseline after dose increase. During outpatient visits, the patient denied hallucinations, thought blocking was noted to improve, and the patient was answering questions and smiling appropriately most of the times.

Response latency and processing time remained slow but showed improved from previous visits. Family based mental health (FBMHS) services were recommended and started with in-home therapy 2–3 times a week. A case manager through CYS was recommended to support family in managing follow-up appointments.

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Very early onset psychosis, defined as psychosis before the age of 13, is an extremely rare occurrence with an incidence of less than 0.04% [1] , [6] . One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those who present with negative symptoms at baseline go on to develop treatment failure with antipsychotics. Confounding these statistics is that VEOS is often difficult to diagnose, especially in this case due to lack of reliable collateral information from family. Our patient presented with several risk factors including father’s diagnosis of schizophrenia requiring institutionalization for the past 10 years. There was also a strong suspicion of mental illness in patient’s mother. Environmentally, our patient had a history of trauma in the form of bullying at school and she lacked social supports and lack of follow-up with treatment recommendations.

Additionally, our patient had several premorbid symptoms such as social withdrawal, poverty of speech, and steady decline in social and academic performance over the course of her educational history. Freeman et al. [4] have reported that there is a direct correlation between lower intellectual functioning and development of psychosis due to alteration in the way stimuli and events are interpreted. Another study demonstrated a significant association with psychosis and auditory hallucinations “that remained significant after controlling for age, gender, current social class and ethnicity” [5] . Childhood adversity, as experienced by this patient, also increases the risk of psychosis. A review by Varese et al. [3] showed that exposure to all types of adversity (except parental death) was related to an increased risk of psychosis. Furthermore, a recent study of adolescents experiencing psychosis suggested early intervention by a specialist team may improve treatment outcomes in both positive and negative symptoms [7] . This may also hold true for VEOS. At presentation, our patient displayed the following negative symptoms of schizophrenia: blunted affect, emotional withdrawal, poor rapport, social isolation, poverty of speech, mutism, and psychomotor retardation.

Comorbidities for this patient included oppositional defiant behaviors, borderline intellectual functioning and trauma in the form of physical and emotional abuse by peers, and suspicion of possible sexual abuse given her sexual acting out behaviors.

Our patient provided several treatment challenges due to her mother’s mental state and inability to provide reliable collateral information, non-compliance with follow-up with patient’s outpatient services, and non-compliance with following medication recommendations. Additionally, the lack of sufficient services for young children with psychosis made aftercare recommendations challenging for the treatment team.

Given the many complications this patient presented, the treatment team focused on utilizing the resources that were available such as patient’s paternal grandmother’s increased involvement in her care. There was also collaboration of care with outside agencies such as Children and Youth Services, Case Management, and her school. These services provided support to her mother and made her accountable for complying with aftercare plans and recommendations.

One-third of children and adolescents with psychosis initially present with negative symptoms and 30% of those with negative symptoms, develop treatment failure with antipsychotics. Given these statistics and the treatment challenges of treating children with psychosis, it is imperative to provide additional psychosocial supports to the patients and families, to improve overall functioning and long-term prognosis. This case presents an excellent example of many challenges that are faced in treating early onset psychosis.

SUPPORTING INFORMATION

Daisy Vyas Shirk - Conception of the work, Design of the work, Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Meenal Pathak - Acquisition of data, Analysis of data, Drafting the work, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Jasmin Gange Lagman - Acquisition of data, Analysis of data, Revising the work critically for important intellectual content, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Khurram S Janjua - Acquisition of data, Analysis of data, Drafting the work, Final approval of the version to be published, Agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

The corresponding author is the guarantor of submission.

Written informed consent was obtained from the patient for publication of this article.

All relevant data are within the paper and its Supporting Information files.

Authors declare no conflict of interest.

© 2020 Daisy Vyas Shirk et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.

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• Published: 03 January 2024

Challenges and opportunities in the diagnosis and treatment of early-onset psychosis: a case series from the youth affective disorders clinic in Stockholm, Sweden

• Mathias Lundberg 1 , 2 , 3 ,
• Peter Andersson 4 , 5 ,
• Johan Lundberg 1 , 5 &
• Adrian E. Desai Boström   ORCID: orcid.org/0000-0001-8604-9638 1 , 5 , 6  

Schizophrenia volume  10 , Article number:  5 ( 2024 ) Cite this article

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• Psychiatric disorders

Early-onset psychosis is linked to adverse long-term outcomes, recurrent disease course, and prolonged periods of untreated illness; thus highlighting the urgency of improving early identification and intervention. This paper discusses three cases where initial emphasis on psychosocial treatments led to diagnostic and therapeutic delays: (1) a 15-year-old misdiagnosed with emotionally unstable personality disorder and autism, who improved on bipolar medication and antipsychotics; (2) another 15-year-old misdiagnosed with autism, who stabilized on lithium and antipsychotics, subsequently allowing for gender dysphoria evaluation; (3) a 9-year-old autistic boy incorrectly treated for ADHD, who recovered with appropriate antipsychotic treatment. These cases illuminate the vital importance of adhering to a diagnostic hierarchy, prioritizing diagnostic utility, and conducting longitudinal evaluations to facilitate early targeted treatment of psychotic symptoms in early-onset psychosis. Adherence to such strategies can minimize delays in managing early-onset psychosis and improve long-term prognoses.

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Introduction.

Early-onset psychosis (EOP), a broad clinical concept referring to the onset of psychosis in conjunction with schizophrenia spectrum, affective and other non-affective psychotic disorders before the age of 18 1 impacts an estimated 11–18% of individuals diagnosed with schizophrenia spectrum disorders 2 . The age of onset is a significant predictor of long-term outcomes, with earlier onset associated with more frequent hospitalizations, relapses, and poorer occupational and social functioning 3 . Despite its significance, current EOP management strategies remain suboptimal, leading to unfavorable long-term outcomes in 50–60% of cases 4 . There is a clinical imperative to minimize the duration of untreated psychosis 5 , especially as EOP is associated with considerable delays in initiating antipsychotic treatment 6 . Furthermore, each recurrent episode of schizophrenia increases the risk of treatment resistance 7 .

The UN Committee on the Rights of the Child (CRC) recently advised Sweden to prioritize psychosocial interventions for child mental health, citing concerns about pharmaceutical overuse 8 . In a separate interview with Sweden’s newspaper of record, Dagens Nyheter, the chair of the CRC further clarified that medications should only be used for child and adolescent mental health when all other alternatives have been exhausted 9 . While well-intentioned, this policy recommendation may restrict treatment options for youth with EOP. Importantly, this advice appears to diverge from evidence indicating that timely administration of advanced medico-psychiatric treatments (e.g., Clozapine) can contribute to reducing suicide deaths in male adolescents 10 .

Diagnosis of EOP is already challenging due to the frequent occurrence of psychotic-like symptoms in other psychiatric disorders within this age group 11 . Further complexity arises from research showing that differing theoretical frameworks for understanding severe mental illness in youth can result in varied treatment approaches for the same symptomatology, demonstrated to profoundly impact patients’ chances of recovery 12 . Psychotic disorders/schizophrenia are further known to have overlapping symptoms, and increased frequency in comorbidity can be a diagnostic and therapeutic challenge in clinical practice. This may be of particular relevance to youth and EOP. There are marked regional variations in autism spectrum disorder (ASD) diagnoses among females aged 10-19—particularly with prevalence rates in Stockholm outpacing those in Gothenburg and Skåne by approximately threefold—raising questions about the overshadowing of undiagnosed severe mental disorders 13 . The clinical trajectory of youth initially diagnosed with ASD in Stockholm may serve as a critical case study with global implications. It highlights the risks of overshadowing other severe mental disorders when there’s an undue focus on ASD in youth psychiatric care 14 , especially in light of U.S. case reports that emphasize treatable yet often overlooked episodes of severe mental illness in autistic youth 15 .

This series features case studies from the Child and Adolescent Affective Disorders Clinic in Region Stockholm, established in September 2022. The clinic, staffed by two associate professors with extensive expertize in severe mental illness in youth, presents three cases where severe mental illnesses were initially overlooked in favor of psychosocial treatments. In light of the clinic’s patient profile—youth with severe symptoms and high suicide risk—the diagnostic approach prioritizes utility over validity 16 . For example, patients who display severe impairment and are deemed high-risk for underlying bipolar disorder may be diagnosed and treated accordingly, even when their symptoms have been previously interpreted otherwise. This approach allows for urgent and effective treatment interventions and is clearly communicated to, and consented by, patients and their legal guardians.

Patient 1. navigating complexities in treatment-resistant depression with psychotic features: a bipolar disorder perspective in an adolescent

Case presentation.

A 15-year-old Caucasian female patient comes from a well-functioning, upper-middle-class family with a history of schizophrenia in her grandmother. She also has a medical history of insulin-treated Type 1 Diabetes Mellitus (DM). She experienced her first depressive episode at the age of 13– which was conservatively treated with psychoeducation and supportive counseling. Prior to this, her childhood and schooling progressed without any psychopathological indications. Clinical interviews, anamnesis, and lab results showed no evidence of substance use or alcohol abuse. Furthermore, all drug screenings conducted upon admission to inpatient services have consistently been negative throughout her clinical course. During her adolescence, urine drug tests and blood tests of transaminases sensitive to alcohol consumption have repeatedly confirmed the absence of substance or alcohol abuse. However, her condition has deteriorated over the past two years: she has become socially isolated, engaged frequently in self-harm, consistently missed school, and made several severe suicide attempts that required intensive care.

Treatment onset and functional deterioration

The severity of the patient’s condition led her parents to set aside their professional commitments to focus solely on her care and well-being. Her treatment plan consisted of regular appointments with youth psychiatrists and sessions centered around Cognitive Behavioral Therapy (CBT). Following a suicide attempt shortly after initiating conservative treatment for MDD, she received a Children’s Global Assessment Scale (CGAS) score of 50. Initial pharmacological interventions included aripiprazole (with a maximum dose of 10 mg/day), and melatonin was administered for sleep issues before being replaced by propiomazine. Promethazine and sertraline (25 mg/day) were prescribed to address her affective symptoms. It’s worth noting that sertraline coincided with clinical observations of hyperactivity and intensified suicidal thoughts, leading to its discontinuation.

Reevaluation: unresponsive to SSRIs and indicators of autism

Subsequently, the patient’s lack of response to low-dose SSRIs and ongoing self-harm necessitated a clinical reevaluation. This reassessment was initiated by a clinician who first encountered her in the psychiatric emergency department following a suicide attempt. Despite her previously unremarkable functional history and current depressive symptoms, several potential signs of autism were observed, including rigidity, lack of facial expression, reticent speech, and low social functioning. The clinician speculated that camouflaging behaviors in her early life might have masked these autistic traits. Additionally, her suicidality was attributed to emotional dysregulation, which was thought to be secondary to a lack of adequate social adaptations at home and school for her suspected autism, thereby causing stress and dysregulation. Her self-harm was interpreted as an autistic ‘locking’ onto the concept, likely intensified by the inherent rigidity associated with autism. A subsequent neuropsychiatric assessment revealed a standard-range IQ but with specific deficits in visuospatial abilities. Autism Diagnostic Observation Schedule (ADOS) 17 testing led to a diagnosis of mild autism spectrum disorder, and she was also diagnosed with Reaction to Severe Stress, both according to ICD-10 criteria.

Ongoing suicidality and self-harm amidst autism interventions

However, despite undergoing autism-focused interventions—comprising psychoeducational therapy for both the patient and her parents, delivered by specialized neuropsychiatric habilitation services, as well as psychotherapy tailored to her autistic traits—her suicidality persisted. Frequent suicide attempts and escalating severity of self-harm episodes led to multiple short-term hospitalizations. During these stays, the emphasis was on stress reduction within a low-stimulus environment, accompanied by psychosocial preventive measures against self-destructive behavior. Although these interventions led to a decrease in both the frequency and intensity of self-harm and suicidal thoughts, frequent relapses were observed shortly after each discharge.

Diagnostic reassessment and treatment adaptions

During this period, Fluoxetine was introduced to manage anxiety. However, a rapid dose escalation was temporally correlated with worsening mood swings and a resurgence of persistent self-harm. As a result, her care was transitioned to a team specializing in Dialectical Behavior Therapy (DBT). She met five of the nine diagnostic criteria for Emotionally Unstable Personality Disorder (EUPD). The difficulties in ascertaining this condition in conjunction with the autistic traits were noted as a diagnostic challenge. Nevertheless, the EUPD diagnosis was selected to facilitate targeted DBT treatment for her self-harming behavior.

Despite attending 59 DBT sessions over an eight-month period—a regimen both she and the treating clinician described as beneficial—the frequency and severity of her suicidal behaviors escalated. This prompted a consultation with a clinic specializing in bipolar and psychotic disorders. The clinic referred the patient back for continued DBT treatment, citing an absence of manic episodes and suggesting a comorbid autism/EUPD diagnosis as more plausible. DBT sessions resumed for a brief period.

A particularly alarming incident involved a suicide attempt by insulin overdose. This led the treating clinician on the DBT team to diagnose the patient with Bipolar Disorder Type II. Treatment with Lamotrigine was initiated at 25 mg per day, with dose increases of 25 mg every two weeks, reaching a maintenance dose of 75 mg. Subsequently, the patient was referred to the Affective Disorders Clinic.

Diagnostic shift: considering bipolar II with psychotic features

The initial assessment of the patient revealed significant challenges, such as social withdrawal, self-injurious behavior, suicidal ideation, and familial discord. The patient’s limited social engagement and considerable functional decline were substantiated by a Children’s Global Assessment Scale (CGAS) score of 35. A reevaluation of an autism diagnosis was prompted by the absence of documented functional impairments before the age of 10. The psychiatric history review uncovered a pattern of emotional instability, particularly a rebound from a depressive state necessitating hospitalization. Following discharge, the patient displayed mood improvement, evidenced by meticulous diabetes management, enhanced social engagement, and the absence of depressive or anxiety symptoms. Yet, this period of amelioration was short-lived, as the patient soon relapsed into severe depression, necessitating further psychiatric care.

The patient’s non-response to Dialectical Behavior Therapy (DBT), symptom aggravation post-selective Serotonin Reuptake Inhibitor (SSRI) treatment, positive screenings on both the Mood Disorders Questionnaire (MDQ) 18 and the Child Mania Rating Scale-Parent Version (CMRS-P) 19 , along with mood-congruent auditory hallucinations promoting self-harm, all pointed towards Bipolar II Disorder with psychotic features as a differential diagnosis. This diagnosis was subsequently confirmed by the leading clinician using the Longitudinal, Expert, All Data (LEAD) standard (refer to Supplemental Table 1 for detailed diagnostic criteria). Noteworthy is the absence of any indicators of a thought disorder or disorganized behavior throughout the evaluations.

Symptom improvement post-lithium and psychotic feature revelation

Treatment with Lithium was promptly initiated, and weekly blood tests facilitated rapid titration to a predetermined blood concentration of 0.8 mmol/L, reflecting the severity of the patient’s psychiatric symptoms. In the first month following Lithium initiation, the patient showed marked improvement, becoming more communicative, presenting with reduced self-harm, and significantly diminishing the intensity of suicidal thoughts. As her depressive symptoms receded and communicability improved, the patient disclosed pre-existing psychotic symptoms, including tactile hallucinations of insects crawling under her skin and paranoid ideation. She indicated that these symptoms had been present at similar levels of intensity and frequency prior to starting Lithium therapy.

Pharmacotherapy optimization antipsychotic management

To further address these symptoms, Risperidone was initiated at 0.5 mg/day, with rapid increments of 0.5 mg every third day, targeting a dosage of 4 mg/day. Low-dose Olanzapine (5 mg) was also added, influenced by case studies suggesting that it can mitigate the common side effects of Risperidone and thereby enhance treatment tolerability 20 . During the titration phase for Risperidone, the patient experienced sedation and excessive daytime sleepiness, both of which fully resolved upon reaching the target dose. No other medication-related side effects were reported.

Clinical improvement and return to daily activities

The initiation of adjunctive antipsychotic treatment coincided with a dramatic clinical improvement. The patient became more proactive in her treatment, actively seeking help and communicating openly about her feelings and urges. Notably, her self-harming behavior ceased entirely, and she no longer displayed suicidal ideation. This significant treatment progress enabled her transition from daily psychiatric visits to spending time abroad on vacation with her family, and she has also recently returned to school.

Patient 2. unveiling the interplay of gender dysphoria, psychosis, and bipolar disorder: challenges and insights in adolescent care

A 15-year-old Caucasian, who was assigned female at birth and is reported to have been identifying as male for the past 3 years, has successfully undergone an official gender registration change. The patient demonstrated giftedness and artistic talent during childhood, and had no previous engagements with Child and Adolescent Mental Health Services. Onset of anxiety and depression emerged around the ages of 9-10 and progressively intensified. A reported traumatic episode involving peer-related sexual harassment was initially attributed to catalyzing these mental health issues. Prior to symptom onset, the patient maintained supportive relationships, was socially active in an age-appropriate manner, and showed no indications of substance abuse or inheritable severe mental disorders.

Initial treatment and neuropsychiatric assessment

Following the initial evaluation, trauma-focused CBT was implemented in tandem with adjunctive hydroxizine, melatonin, and sertraline (Sertrone 25–50 mg) to manage sleep disturbances and depressive manifestations. Worsening symptoms, marked by escalated anxiety, self-harm, and reported auditory hallucinations urging self-destruction, necessitated a referral to the psychosis and bipolar disorder clinic (i.e. the same clinic Patient 1 was referred to). However, the referral was declined in favor of a neuropsychiatric evaluation and low-dose aripiprazole (5 mg) administration. This intervention aimed to address auditory hallucinations, then believed to be stress-induced symptoms linked to potential undiagnosed autism. The subsequent neuropsychiatric evaluation resulted in a diagnosis of atypical autism, alongside suspected Emotionally Unstable Personality Disorder (EUPD) traits. Cognitive testing showed above-average abilities.

Escalating symptoms and treatment challenges

Six months post-initial psychiatry interaction, the patient made a suicide attempt by slashing their wrists in a bathtub after leaving a farewell note. This was followed by a second attempt via paracetamol overdose a month later. Outpatient assessment revealed an APSS score of 2.5, suggesting potential risk for a psychotic disorder. However, an alternative explanation was proposed that these symptoms could stem from dissociative causes, which guided initial interventions. Despite ongoing treatment, the patient remained largely unresponsive for the initial 18 months, with persistent CGAS scores below 50. Notably, to avoid potentially reinforcing EUPD-linked suicidal behaviors, inpatient services were frequently denied by emergency services after suicide attempts and severe self-harm events, and parents were instructed to not overly fixate on the patient’s self-destructive tendencies.

Reassessment at specialized clinic

A subsequent reevaluation at the clinic specializing in psychosis and bipolar disorders scrutinized the presence of auditory hallucinations and potential hypomanic indicators. It was inferred that the presented symptoms were more congruent with atypical autism and probable EUPD. Features considered dissociative included the patient’s perception that compulsive, self-harming thoughts were implanted in their mind, which apparently bolstered EUPD suspicions. A personality assessment focusing on EUPD and Dialectical Behavior Therapy (DBT) was recommended.

Navigating diagnostic and treatment complexities

During ongoing assessments conducted by the DBT team—prior to the initiation of any DBT treatment—the team identified a need for a more comprehensive assessment to either confirm the existence of EUPD traits or to determine if the symptoms could be more accurately described as a combination of autism, bipolar disorder, and post-traumatic stress disorder. Given the severity of the patient’s symptoms, treatment was initiated with low-dose sertraline (25–50 mg/day) to manage her depressive symptoms. Adjunctive lamotrigine treatment was also started at a dose of 25 mg/day, increasing by 25 mg every two weeks to a final dosage of 75 mg/day, with the aim of managing any potentially hypomanic manifestations. Despite these measures, the patient’s frequent self-injurious and parasuicidal behavior continued and remissions of psychiatric symptoms were inadequate. Concurrently, the patient was referred to the affective disorders clinic for an in-depth assessment.

Despite urgently needing it, the patient had been consistently denied a referral for a gender dysphoria assessment at a specialized clinic. The refusal was based on the argument that the severity of the patient’s symptoms made such an assessment inappropriate at the time.

Bipolar disorder consideration and treatment adjustment

During the initial evaluation at the Affective Disorders Clinic, the patient was administered the Mood Disorders Questionnaire (MDQ) 18 , the Adolescent Psychotic-Like Symptom Screener (APSS) 21 , and the Child Mania Rating Scale-Parent Version (CMRS-P) 19 , with scores of 13, 3, and 24, respectively. These scores indicated a positive screening for bipolar disorder with psychotic features. The findings were corroborated by the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). The patient also exhibited symptoms of atypical depression, including hypersomnia, a sensation of leaden paralysis, psychomotor retardation, and excessive guilt.

A review of the patient’s history revealed episodes of irritable mania, marked by heightened energy, increased activity, and risk-taking behaviors, with a notably more talkative demeanor and pressured speech. A comprehensive evaluation, integrating psychiatric assessment and detailed anamnesis from the patient and parents, led to the diagnosis of Bipolar Disorder Not Otherwise Specified (NOS) based on the LEAD procedure. Consequently, sertraline was discontinued. Refer to Supplemental Table 2 for a complete diagnostic assessment.

Rapid pharmacological impact and functional gains

Subsequent to this event, the patient engaged in self-harm with razors and sought emergency medical care. This prompted the need for enhanced clinical monitoring. A rapid titration regimen of Quetiapine XR was initiated: 100 mg on the first day, 200 mg on the second day, and 300 mg on the third day, supplemented with lithium. The intent was to transition solely to lithium therapy once a blood concentration of 0.8 mmol/l was reached. This dual pharmacological approach aimed to swiftly alleviate depressive symptoms while mitigating the risks of inducing hypomanic episodes and minimizing the potential for unwanted weight gain associated with long-term usage of Quetiapine XR. In the months that followed, there was a marked improvement in the patient’s affective stability, evidenced by the complete absence of any suicidal or self-harming behaviors requiring medical intervention. After transitioning to lithium monotherapy—titrated and confirmed to reach a concentration of 0.8 mmol/l within eight weeks—the patient’s CGAS scores consistently increased from a range of 42–48 to 55–65.

Psychosocial gains and high school transition

Auditory hallucinations persisted even after mood symptoms had stabilized—centered on egosyntonic voices inciting self-harm and suicide - prompting the introduction of risperidone at a starting dose of 0.5 mg. The dose was increased to 1.5 mg over the course of 4.5 months, beginning 5.5 months after the initiation of lithium therapy. This treatment regimen led to the cessation of hallucinations over approximately five months and was accompanied by a marked functional improvement. This improvement was reflected in the Children’s Global Assessment Scale (CGAS) scores, which consistently rose from 60 at the clinical visit where risperidone was prescribed to 75 after five months of treatment. By the end of this period, the patient had shown significant functional gains, was planning to start high school, had integrated well within their family, and was socially active. They even secured summer employment. Additionally, a previously deferred assessment for gender dysphoria was reinitiated and was reported to have significantly reduced distress for both the patient and their family.

Patient 3. reclaiming stability from disorganization: a medical journey to remission in a child with disorganized psychosis

The patient, a 9-year-old Caucasian boy, was brought to the clinic when his father reached out. There was a documented history with psychiatric services due to a diagnosis at age 4 of atypical autism, intellectual disability, and language disorder with delayed language development. This was based on observed challenges in verbal and social abilities. The patient hails from an upper-middle-class background, with both parents having postgraduate qualifications. Notably, there’s no history of substance abuse or traumatic events. Prior of to the current episode, with adequate support from the family, the patient had been able to achieve relatively good functioning, with no aggression, self-injurious behavior or affective lability. The family does have a history of dyslexia, and a third-degree relative on the father’s side has autism. Still, there is no known hereditary risk for severe psychiatric illness.

Patient 3 had been attending a specialized class designed for children with autism. Although he had to repeat a year of preschool due to learning difficulties, he adapted reasonably well until a year before this clinical encounter. At that point, his functional abilities notably deteriorated, marked by aggressive, restless, and self-harming behaviors. His school performance also declined, and contact with the Child and Adolescent Mental Health Services increased. An updated neuropsychiatric evaluation was conducted, resulting in a diagnosis of severe intellectual disability, high-impairment autism, ADHD, and a behavioral disorder. Consequently, treatment with central stimulants commenced about nine months prior to the patient’s presentation at the Affective Disorders Clinic.

Treatment initiatives and functional decline

The deterioration of the condition continued after initiation of central stimulant treatment, the patient’s condition deteriorated further with escalated outward aggression and reduced language skills. A subsequent introduction of a low dose of aripiprazole (5 mg/day) was followed by heightened motor activity, restlessness, and pronounced behavioral disturbances, including emotional agitation. The patient’s aggression, particularly towards his mother, escalated. Consequently, the father often had to relocate the patient to the family’s secondary apartment for play and respite. The situation worsened in the subsequent months, with increased violent behavior, self-harm, and significant school avoidance.

Suspicion of psychosis with disorganized symptoms

ML’s involvement as a senior consultant began about a year after the patient’s decline, initiated when the patient’s grandfather acutely visited the clinic and demanded an assessment. Previous attempts to assess the patient in emergency services had been rendered impossible due to the patient’s highly agitated behavior. The grandfather’s descriptions, which characterized the patient’s behavior as aimless, fearful, impulsive, and marked by a significant reduction in previous functional abilities, led to preliminary suspicions of disorganized psychosis. Given the urgent need to prevent harm and disability, it was decided to initiate treatment without a direct face-to-face assessment. Based on the information available in the patient’s medical records, low-dose risperidone started at 0.5 mg and later increased to 1 mg, with the condition of close follow-up. Central stimulants were discontinued promptly. The first in-person consultation with the patient took place a few weeks after the new treatment had been initiated. While improvements in self-harming tendencies and outward aggression were reported, the patient remained notably disorganized during the clinical visit and showed clear signs of paranoid thinking; for instance, the patient went to the window, observed cars, and pondered aloud whether they were police cars, even asking the clinician if he was a police officer. Self-rating was not possible due to the patient’s clinical condition.

Post-treatment behavioral and cognitive improvements

Four months post the antipsychotic treatment initiation, substantial improvements were observed. The patient’s language skills improved significantly, and disorganized behavior reduced considerably. By summer break, he resumed home-based school activities, with staff noting marked improvements compared to previous encounters. While the patient no longer exhibited overtly psychotic or intrusively disorganized behavior, some concentration challenges and subtle symptoms of thought disorders persisted.

Progress toward baseline functionality

At present, the patient is on a 2 mg dosage of risperidone, with gradual increments planned to achieve the optimal therapeutic dose. The parents report that the patient’s functional ability, relative to his age, seems to be reverting to its baseline state (refer to Supplemental Text 1 for a detailed rationale on the decision to continue treatment on the suspicion of disorganized psychosis).

Patient 1: the imperative of continuous diagnostic reassessment in adolescents

Firstly, while ‘camouflaging’ in autism is acknowledged, attributing rapid clinical decline solely to neuropsychiatric issues can miss urgent conditions. Prioritizing diagnostic validity over clinical utility—by strict adherence to NICE guidelines that require evidence of manic episodes—may withhold crucial treatments like lithium. A hierarchical diagnostic approach that prioritizes manifestations of severe mental illness appears more suitable for adolescents with severe psychiatric presentations 22 . This is further exemplified by the initial misinterpretations of imperative auditory hallucinations as symptomatic of conditions like autism or emotionally unstable personality disorder (EUPD). In contrast, a more hierarchical diagnostic approach would prioritize considering these hallucinations as potential indicators of psychosis, unless robust evidence suggests alternative explanations. This perspective underscores the critical need for nuanced diagnostic algorithms that recognize the high stakes of early intervention in achieving favorable long-term outcomes.

Secondly, it was the patient’s lack of response to a low dose of Sertraline (25 mg) for depression, rather than any adverse drug reaction, that prompted a reevaluation of the initial diagnosis from depression to autism. It’s crucial to note that in adult populations, Sertraline dosages below 50 mg/day have not shown a superior effect compared to placebo for treating MDD 23 . Although there is more limited data on adolescents, the non-response to this low dosage should not be the sole basis for a diagnostic shift, such as reclassifying the condition from depression to autism. Therefore, it’s important to exercise caution when interpreting the lack of response to low-dose SSRIs as diagnostic evidence.

Third, while self-harm may traditionally most be associated with EUPD and autism—this case demonstrates that untreated episodes of EOP may also introduce such behavior.

Therapeutic challenges

An eight-month period with 59 intense DBT sessions—reported by both patient and therapist as beneficial and crucial to prevent self-harm—coincided with increased suicidal behaviors; indicating that subjective reports of improvement may stem more from regular clinical interaction than effective symptom management. This has relevance to DBT-research practices, suggesting that subjective measures may not correlate with key outcomes, such as the frequency and intensity of suicidality in this case. It is worth noting that the ineffective application of DBT, could extend the duration of untreated illness. This is particularly concerning for severely mentally ill adolescents who require advanced psychiatric interventions.

Affective and psychotic symptom interplay

As mood symptoms receded, latent psychotic symptoms became evident. Addressing these was crucial for managing the patient’s suicidality, and clinicians may consider the possibility of latent psychotic symptoms in severe psychiatric presentations unresponsive to standard treatments.

This case accentuates the need for continual reassessment, especially when treatment resistance or new symptomology is observed. Given the stakes involved—sometimes life and death—meticulous attention to these factors is not just advisable but essential.

Patient 2: differential diagnosis in youth with complex neuropsychiatric presentations

The second case shows that treating bipolar disorder with psychotic features can make gender dysphoria assessments possible. Prior to treatment, the patient had been denied such assessments due to the severity of their symptoms. Up to 25% of individuals with schizophrenia may also experience gender dysphoria 24 , 25 . The case confirms both conditions can co-exist, and gender dysphoria may persist post-psychotic treatment. Effective treatment of psychotic symptoms thus serves dual purposes: improving mental health and facilitating gender reassignment assessments.

Furthermore, this case underscores the importance of adhering to a hierarchical approach in the diagnostic process. Similar to case 1, the auditory hallucinations were initially considered to be symptoms of less severe disorders rather than signs of an ongoing psychotic process. It was not until structured screening tools suggested the possibility of psychosis, which was initially thought to indicate dissociation associated with Emotionally Unstable Personality Disorder (EUPD), that a reevaluation occurred. As with case 1, a significant remission of symptoms was only achieved after these experiences were reclassified as psychotic symptoms and treated with targeted antipsychotic medication.

Patient 3: misdiagnosis and the primacy of severe mental disorders

This case emphasizes the need for thorough assessments in patients with rapidly worsening behavioral and cognitive symptoms. The symptom overlap between disorganized psychosis and comorbid ADHD/ASD further highlights the risks of not using a diagnostic hierarchy. Initial assessments focused on neuropsychiatric and behavioral comorbidities, potentially overlooking broader severe mental illnesses like psychosis. Such misdiagnoses can lead to ineffective treatments that exacerbate the condition; such as the prescription of central stimulants to a child with severe psychotic symptoms. In youth with acute episodes and significant functional impairments, clinicians may improve outcomes by focusing on possible severe mental illnesses rather than multiple, less severe conditions 22 . This approach requires deep understanding of neurobiology, cognitive processes, and symptom trajectory. Overall, the case stresses the importance of precise differentiation among these conditions, and suggests prioritizing treatment of severe mental disorders for better outcomes.

Strengths and limitations

The efficacy of advanced psychiatric interventions in treating complex cases supports the validity of the selected treatment strategies. However, not all patients may respond similarly, and these treatments are not devoid of side effects. For instance, antipsychotics are linked with increased neurological and metabolic adverse effects in young patients 26 , 27 , though strategies exist to lessen these effects 20 , 27 . Hyperprolactinemia is a clinically significant adverse effect of risperidone treatment in both adults 28 , 29 and, putatively, adolescents 30 . Clinical manifestations such as gynecomastia and galactorrhea represent potential concerns. In response, current evidence suggests that clinicians might consider adjunctive therapy with aripiprazole 31 or, when clinically indicated, transition to an alternative antipsychotic 32 as effective management strategies. In this clinic, continuous monitoring of this side effect is standard practice to ensure prompt and appropriate intervention. While lithium is proven safe and effective in the short term, the long-term effects and some observed adverse reactions necessitate ongoing clinical vigilance 33 , 34 . Registry studies suggest that lithium maintenance therapy correlates with reduced suicide rates and overall mortality in patients with high-risk bipolar disorder 35 , with additional evidence pointing to its neuroprotective properties 36 . It is crucial for clinicians to be skilled in conducting thorough risk-benefit analyses and in monitoring treatment responses vigilantly.

The precise prevalence of EOP in the general population has yet to be established. Nonetheless, its incidence is expected to be considerably greater in specialized clinical settings, especially among those severe cases that show resistance to conventional treatments. These instances are a recognized challenge within youth psychiatric services. Consequently, independent of the actual frequency of EOP, it is critical for youth psychiatric practices to possess the necessary expertize to identify and treat these patients effectively. This is akin to the responsibility of primary care professionals to adeptly detect and respond to less common presentations of chest pain, such as myocardial infarctions. For diagnostic clarification in complex clinical scenarios, hospitalization may be warranted to allow for rigorous observation by a multidisciplinary team. Such a team should follow a systematic and tiered approach to diagnosis to facilitate effective clinical management.

Clinical diagnosis is an evolving process, where initial hypotheses are honed based on the patient’s response to treatment. Such an iterative method is enlightening and often necessitates reevaluation of first impressions 37 . Integrating this dynamic approach into pediatric psychiatry practice has the potential to refine diagnostic pathways, accelerate the onset of effective treatments, and improve long-term patient outcomes.

The presented cases provide a window into the complex landscape of adolescent mental health care, where the medical and psychosocial models converge and diverge. In all cases, suspicions of severe psychopathology were raised early-on; yet failed initially to materialize into targeted treatment. Early clinical assessments in these cases initially leaned towards explanatory models that attributed these experiences to conditions considered less severe, yet also less amenable to advanced psychiatric interventions. This misdirection underscores the need for a shift in diagnostic focus. Prioritizing a hierarchical perspective, along with longitudinal course and clinical utility—a concept previously emphasized as important in nosological conceptualization 38 and diagnostic assessment 16 —over strict diagnostic validity, could be pivotal in the early recognition of severe illness states, such as EOP, in children and adolescents. For a summary of key clinical concepts illustrated by the cases and recommendations for diagnosis and treatment in pediatric psychiatry, please see Table 1 and Table 2 . Affective and psychotic symptoms pertaining to each case are described in Table 3 . For patient perspectives, please see Supplemental Text 2 .

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The work was conducted in accordance with the ethical standards of the Helsinki Declaration and in accordance with the Swedish laws on research ethics. No funding was received for this work.

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Lundberg, M., Andersson, P., Lundberg, J. et al. Challenges and opportunities in the diagnosis and treatment of early-onset psychosis: a case series from the youth affective disorders clinic in Stockholm, Sweden. Schizophr 10 , 5 (2024). https://doi.org/10.1038/s41537-023-00427-z

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• John P. John 2 &
• Binukumar Bhaskarapillai 3  

In Asian countries, about 70% of people with Schizophrenia live with their families or friends. Caregivers are the persons who have significant responsibility for the well-being of a person diagnosed with Schizophrenia. In developing countries, the joint family system and the sense of collectivism resist paid caregivers for a person with Schizophrenia. As a result, caregivers may experience psychological and emotional distress and have poor mental health. Aim of the Study: To assess the caregiver's burden, Quality of life and coping patterns of caregiver's of persons living with Schizophrenia. The researcher had used single case AB design pre- and postassessment methods. The researcher administered Pai and Kapoor's Family Burden Interview Schedule, Brief Cope by Carver et al., and WHO Quality of Life-BREF. The scaling technique was used to assess the change in the post-assessment. The therapist took 10 sessions, each lasting for 45–60 minutes. The therapist organized the sessions into initial sessions, which included 2 sessions for building rapport, providing psychoeducation, developing a case conceptualization, and discussing the techniques that would be used. Additionally, there were 6 middle sessions focused on implementing core therapeutic techniques. After conducting psychoeducation sessions, utilizing the miracle questions, discussing preferred future outcomes, exploring exception questions, and implementing coping techniques with the mother, behavior management was taught to address the client's demanding behavior and emotional outbursts. Two sessions were dedicated to gathering feedback on the therapy process, preparing the mother for potential setbacks, and developing relapse prevention strategies. At post-assessment, the caregiver reported amelioration in burden, coping pattern, and Quality of life. The mother learnt the management of the illness and was quite confident in handling the PLWS. The scaling question at the time of preassessment was 1, and at post-assessment was 7.

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Amit Kumar & Janaki Raman Kalyanasundaram

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Kumar, A., Kalyanasundaram, J.R., John, J.P. et al. Solution-Focused Brief Approach for Caregiver of a Person Living with Schizophrenia: A Case Study. J. Psychosoc. Rehabil. Ment. Health (2024). https://doi.org/10.1007/s40737-024-00434-y

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Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy

Purpose: The purpose of this case report is to demonstrate the importance of a thorough patient interview. The case involves a man referred for physical therapy for a musculoskeletal dysfunction; during the patient interview, a psychiatric disorder was recognized that was later identified as schizophrenia. A secondary purpose is to educate physical therapists on the recognizable signs and symptoms of schizophrenia.

Client description: A 19-year-old male patient with chronic shoulder, elbow, and wrist pain was referred for physical therapy. During the interview, the patient reported that he was receiving signals from an electronic device implanted in his body.

Measures and outcome: The physical therapist's initial assessment identified a disorder requiring medical referral. Further management of the patient's musculoskeletal dysfunction was not appropriate at this time.

Intervention: The patient was referred for further medical investigation, as he was demonstrating signs suggestive of a psychiatric disorder. The patient was diagnosed with schizophrenia by a psychiatrist and was prescribed Risperdal.

Implications: This case study reinforces the importance of a thorough patient interview by physical therapists to rule out non-musculoskeletal disorders. Patients seeking neuromusculoskeletal assessment and treatment may have undiagnosed primary or secondary psychiatric disorders that require recognition by physical therapists and possible medical referral.

RÉSUMÉ

Objectif : L'objectif de cette étude de cas consiste à démontrer l'importance de réaliser des entrevues en profondeur avec les patients. Le cas étudié concerne un homme dirigé vers la physiothérapie en raison d'une dysfonction musculosquelettique. Au cours de l'entrevue avec ce patient, un problème psychiatrique a été décelé; par la suite, de la schizophrénie a été diagnostiquée. Le deuxième objectif de cette étude de cas est d'éduquer et de sensibiliser les physiothérapeutes aux signes et aux symptômes aisément reconnaissables de la schizophrénie.

Description du client : Le patient est un jeune homme de 19 ans qui souffre de douleurs chroniques à l'épaule, au coude et au poignet et qui avait été dirigé en physiothérapie. Au cours de l'entrevue, le patient a déclaré qu'il recevait des signaux provenant d'un appareil électronique implanté dans son corps.

Mesures et résultats : L'évaluation préliminaire du physiothérapeute a permis d'identifier un problème qui nécessitait que le patient soit redirigé vers un médecin. Une gestion plus poussée de la dysfonction musculosquelettique de ce patient a été jugée inappropriée à cette étape.

Intervention : Le patient a été dirigé vers une investigation médicale plus approfondie, puisqu'il manifestait des signes de possibles problèmes psychiatriques. Le patient a par la suite été diagnostiqué comme schizophrène et on lui a prescrit du Risperdal.

Implication : Cette étude de cas vient réaffirmer l'importance, pour le physiothérapeute, de procéder à des entrevues approfondies avec les patients pour s'assurer qu'il n'y a pas d'autres problèmes que les seules dysfonctions musculosquelettiques. Les patients qui souhaitent obtenir une évaluation et un traitement musculosquelettique peuvent souffrir aussi d'un problème psychiatrique primaire ou secondaire non diagnostiqué qui exige d'être reconnu par le physiothérapeute et qui nécessitera vraisemblablement une attention médicale ultérieure.

INTRODUCTION

A recent US study demonstrated that less than one-third of diagnoses provided to physical therapists by primary-care physicians are specific. 1 The same study illustrated that physical therapists must assume a greater diagnostic role and must routinely provide medical screening and differential diagnosis of pathology during the examination. 1 Similarly, studies conducted in Australia and Canada have concluded that the majority of referrals for physical therapy are not provided with a specific diagnosis. 2 , 3 Medical screening is important, since physical therapists are increasingly functioning as the primary contact for patients with neuromusculoskeletal dysfunctions, 4 , 5 which means a greater likelihood of encountering patients with non-musculoskeletal disorders, including psychiatric disorders.

As demonstrated by the World Health Organization's International Classification of Functioning, Disability and Health, it is imperative to take an individual's psychological state into account, since disorders in this area can lead to disability. 6 Many psychiatric conditions are commonly encountered in physical therapy practice; for example, depression, anxiety, and fear-avoidance have all been associated with low back, neck, and widespread musculoskeletal pain. 7 – 9 These psychiatric disorders have been identified both as risk factors for musculoskeletal dysfunction and as an important secondary psychosocial aspect of disablement. 7 – 10 It is therefore important for physical therapists to consider the primary and secondary roles of psychopathology in disability.

Although various models of primary-care physical therapy have demonstrated physical therapists' expertise in the realm of neuromusculoskeletal dysfunctions, there is a need for increased competencies in academic, clinical, and affective domains. 5 Few et al. propose a hypothesis-oriented algorithm for symptom-based diagnosis through which physical therapists can arrive at a diagnostic impression. 11 This algorithm takes into account the various causes of pathology, including psychogenic disorders. 11 Although additional research is necessary to validate Few et al.'s algorithm, it provides one model that considers underlying pathologies in determining the appropriateness of physical therapy intervention. 11 The present case report further illustrates the importance of considering the patient's affective and psychological state in order to more effectively screen for and identify psychiatric disorders that require medical referral.

The purpose of this case report is to demonstrate the importance of a thorough patient interview. We present the case of a man, referred for physical therapy for a musculoskeletal dysfunction, who was determined during the patient interview to have an undiagnosed psychiatric disorder, later identified as schizophrenia. In addition, this report is intended to educate physical therapists about the recognizable signs and symptoms of schizophrenia.

CASE DESCRIPTION

The patient was a 19-year-old male university student. His recreational activities included skateboarding, snowboarding, break dancing, and weight training. The patient first sought medical attention from a sport medicine physician in January 2006, when he reported right lateral wrist pain since falling and hitting the ulnar aspect of his wrist while skateboarding in October 2005. Plain film radiographs taken after the injury were negative, and the patient did not receive any treatment. The physician found no wrist swelling, minimal tenderness over the ulnar aspect of the right wrist, full functional strength, and minimally restricted range of motion (ROM). The patient was given ROM exercises and was diagnosed with a right wrist contusion.

Over the next 22 months, the patient returned to the same sport medicine clinic 10 times, reporting pain in his wrist, shoulder, elbow, knee, ankle, and neck. He stated that the elbow, wrist, and shoulder injuries were due to falls while skateboarding and snowboarding or to overuse during weight training; some injuries had no apparent cause. Over the course of his medical care, the patient followed up with three different physicians at the same clinic. He was diagnosed by these physicians, in order of occurrence, with (1) right wrist contusion and sprain; (2) right wrist impingement and left wrist strain; (3) right shoulder supraspinatus tendinopathy; (4) right peroneal overuse injury and strain; (5) disuse adhesions of the right peroneals and right hip adhesions; (6) right ankle neuropathic pain secondary to nerve injury and sprain and right-knee patellofemoral pain syndrome (PFPS); (7) neuropathic pain of the right peroneal nerve; (8) trauma-induced left-knee PFPS; (9) ongoing post-traumatic left-knee PFPS; and (10) right levator scapula strain, chronic right infraspinatus strain, right elbow ulnar ridge contusion, and right wrist chronic distal ulnar impingement secondary to malaligned triangular fibrocartilage complex (TFCC).

After his tenth visit to a physician, the patient was referred for physical therapy for chronic right levator scapula strain and right supraspinatus strain. During the interview, the patient stated that he had right shoulder pain because of a snowboarding injury sustained 1 year earlier and because of a fall onto the lateral right shoulder 2 years ago. Aggravating activities to the shoulder included pull-ups, rowing, and free weights. No position or movement alleviated his pain, and the pain did not fluctuate over the course of the day. His sleep was disturbed only when lying on the right shoulder. The patient was in generally good health, but he said that his right wrist and left knee occasionally felt cold for no apparent reason. He denied experiencing any loss of sensation, decreased blood flow, or numbness or tingling in the knee and wrist. The patient said he believed that his knee and wrist became cold as a result of electromagnetic impulses sent to the joint via an electrical implant in his body and that this device was the cause of his ongoing shoulder pain.

According to the patient, this device had been implanted into his body 2 years earlier by a government organization (the Central Intelligence Agency, the US government, or the US Army) to control his actions. Electromagnetic impulses generated by the implant had caused his falls and injuries; they also caused his joints to become cold or painful when he was doing something “they” did not want him to do, such as break dancing, snowboarding, skateboarding, or exercising. The patient also believed that many other people unknowingly had implants; he claimed that friends, neighbours, professors, and strangers were “working with them” and that they “emotionally abuse[d]” him by giving signs such as kicking a leg back to let him know he was being watched. Furthermore, he indicated that he often received commands telling him to harm his friends or family and that these orders came either from the electrical implant or from the people he claimed were emotionally abusing him. He therefore distanced himself from some friends because he did not want to follow through with these commands. I asked the patient if he felt he would harm himself or others because of his psychotic-like symptoms. He denied any desire to inflict harm on himself or others. Had he posed a threat to himself or others, he would have been “formed” (i.e., committed to a psychiatric facility by the appropriate medical professional).

The patient's past medical and family history were unremarkable. He did not use any prescription or over-the-counter medications, but he felt his thoughts about electrical implants were decreased by the use of marijuana, which he used socially. He was a non-smoker and a social consumer of alcohol. He had a normal gait and appeared comfortable in an unsupported seated position. He denied any weight changes, bowel or bladder problems, night pain, or difficulty breathing.

PHYSICAL EXAMINATION

The patient reported a maximum verbal numeric pain rating scale (NPRS) score of 8/10 and a minimum score of 0/10, with pain usually present in the shoulder. In a double-blind, placebo-controlled, multi-centre chronic pain study, when the baseline NPRS raw score fluctuated by 0 points, the sensitivity and specificity were 95.32% and 31.80% respectively; 12 , 13 when there was a 4-point raw score change, the sensitivity and specificity were 35.92% and 96.92% respectively. 12 The patient stated that when he experienced shoulder pain, it was located on the anterior, posterior, and lateral aspects of his shoulder and radiated down to his elbow and wrist. He reported 0/10 shoulder pain while seated.

Standing posture was assessed in the frontal and sagittal planes. 14 The patient had a mild forward head posture and internally rotated glenohumeral joints in the sagittal plane. The frontal-plane analysis revealed a slight elevation of the right shoulder and level iliac crests. Such visual assessment of cervical and lumbar lordosis has an intrarater reliability of k =0.50 but an interrater reliability of k =0.16. 15

In the frontal plane, the right scapula was abducted four finger-widths from the mid-thoracic spine, and the left scapula was abducted three finger-widths. The scapulas were superiorly rotated bilaterally. Surface palpation of the acromial angle, inferior angle, and spine of the scapula differed less than 0.98 cm, 0.46 cm, and 0.67 cm, respectively, from the actual bony location, with a 95% confidence interval. 16 There was visible hypertrophy of the pectoralis major muscle bilaterally. Active and passive ROM were tested for the shoulders as recommended by Magee. 14 The patient had full bilateral active ROM, with minimal pain at end-range flexion and abduction that was not increased with overpressure in accordance with Magee. 14 He had full passive ROM with no pain reported.

Manual muscle testing based on Hislop and Montgomery revealed 4/5 strength of external rotation at 0° and 45° of abduction, with pain reported along the anterolateral shoulder. 17 Testing also showed 3/5 strength and no pain with resisted abduction with the arm at the side at approximately 30° of abduction. 18 Manual muscle testing is a useful clinical assessment tool, although a recent literature review suggested that further testing is required for scientific validation. 18 Palpation of the shoulder, as described by Hoppenfeld, revealed slight tenderness over the greater tubercle, as well as along the length of the levator scapula muscle. 19

Special tests were negative for the sulcus sign, Speed's test, the drop arm test, and the empty can test, as described by Magee. 14 Research shows that Speed's test has a sensitivity and specificity of 32% and 61% for biceps and labral pathology respectively; 20 the drop arm test has a sensitivity of 27% and a specificity of 88% as a specific test for rotator cuff tears, and the empty can test has a sensitivity of 44% and a specificity of 90% in diagnosing complete or partial rotator cuff tears. 20 , 21 The Neer and Hawkins-Kennedy impingement tests were both negative. 14 According to a meta-analysis by Hegedus et al., the Neer test is 79% sensitive and 53% specific, while the Hawkins-Kennedy test is 79% sensitive and 59% specific, for impingement. 21

I (NS) diagnosed the patient with mild supraspinatus tendinosis, with no evidence of tearing of the rotator cuff muscles, based on the following findings drawn from the patient interview: shoulder pain aggravated by pull-ups, rowing, and free weights; increased pain when lying on the affected shoulder. Additional significant findings from the physical examination included full shoulder active ROM with minimal pain at end-range flexion and abduction; pain along the anterior lateral shoulder with resisted testing of external rotation at 0° and 45° of abduction; negative drop arm and empty can tests; and tenderness over the greater tubercle of the humerus. The musculoskeletal dysfunction did not explain the level of pain reported by the patient (maximum NPRS 8/10), nor was the physical examination able to reproduce the exact location of the reported shoulder pain or the elbow, wrist, and knee pain described by the patient.

I was concerned about a serious pathology or a psychological disorder, given that this 19-year-old had made 10 medical appointments over 22 months for 6 different regions of the body; in my experience of examining and treating patients between the ages of 18 and 25, the frequency of the appointments and the variation in afflicted body parts are not typical of a young patient. The patient's description of his shoulder pain, in terms of location and severity, was not reproducible by physical examination. Throughout our interview, the patient did not maintain good eye contact, spoke in a monotone voice, and had an overall flat affect. Even when he described his beliefs about implants and government control, his voice and demeanour remained expressionless. The patient described persecutory delusions, command hallucinations, and social isolation from friends and family, all of which are signs of psychosis according to the Diagnostic and Statistical Manual of Mental Health . 22

Based on the findings from the patient interview and the physical examination, the patient did have symptoms consistent with a known musculoskeletal dysfunction; however, the undiagnosed and uncontrolled psychiatric symptoms made it more appropriate to refer him back to the physician for evaluation and treatment of his psychosis than to provide physical therapy intervention for his shoulder dysfunction. Furthermore, because research shows that the rate of suicide among patients with schizophrenia can range from 2% or 4% to as high as 15% 23 , 24 and that the rate of suicide is highest among patients close to the date of diagnosis, early recognition is crucial. 23

INTERVENTION

Based on the findings from the patient interview and the signs and symptoms of psychiatric disorders, I explained to the patient that there was a need for further medical investigation. Although the patient did not agree with this initial assessment, he did consent to a follow-up with the referring physician.

I spoke to the referring physician in person and explained to him my findings from the patient interview, specifically the patient's belief that he had electrical implants in his body. I also pointed out the patient's affect and the limited physical findings during the physical examination. I provided the physician with some direct quotes from the patient to demonstrate the level of psychosis he was presenting with. I stated my conclusion that the patient was suffering from some form of psychosis that precluded physical therapy treatment for his shoulder at that time. The referring physician was quite concerned about the patient and called him during our meeting to arrange a follow-up medical appointment.

The physician examined the patient, made similar observations, concurred with my assessment, and concluded that the patient was experiencing some form of psychosis. The plan of care involved referral to a psychiatrist, follow-up with the physician, and explaining to the patient that physical therapy would not be appropriate at this time because of the presence of a serious psychiatric disorder. The patient did not believe that he had a psychiatric disorder, but he was willing to follow up with a psychiatrist. The physician noted that the patient was not a threat to himself or others and that he did not report having homicidal or suicidal thoughts.

The patient followed up with the psychiatrist 11 days after his appointment with the physician. He was diagnosed with schizophrenia and started on a daily dose of risperidone (Risperdal). The patient was also instructed to follow up with the psychiatrist every second week to ensure compliance with the medication and to discuss progress. Further details of the psychiatric assessment and treatment were not available for this case report. Outcomes are also unavailable for this case report, since follow-up by the physical therapist was not possible.

Case Summary

This case report describes a 19-year-old man referred to physical therapy with shoulder, wrist, and knee pain who was later diagnosed with a psychiatric disorder. After completing a thorough patient interview and physical examination, I concluded that the patient was suffering from an undiagnosed psychiatric disorder that required medical referral. The interview revealed that the patient had delusions about electrical devices' being implanted in his body and was experiencing various forms of hallucination. The patient was promptly referred for medical consult and was diagnosed with schizophrenia by a psychiatrist.

Patient Symptoms and Schizophrenia

Schizophrenia is a psychiatric disorder affecting between 0.5% and 1.5% of adults worldwide, with a slightly greater prevalence in men. 22 The age of onset may be from 5 to 60 years; however, more than 50% of first episodes occur between the ages of 15 and 24. 22 , 25 , 26 An earlier onset is more common among men, while later onset is more common among women. 25 Schizophrenia shows a higher incidence in individuals born in urban areas than in those born in rural areas. 22 , 25 Because the patient in the present case fell into several of these categories (male, born in an urban area, experienced onset of symptoms around age 17) and presented with clear symptoms of a psychiatric disorder (delusions, hallucinations), schizophrenia seemed the most likely diagnosis.

The signs and symptoms of schizophrenia are classified as either positive or negative. 22 Positive symptoms are an excess of normal function and include delusions, hallucinations, and disorganized speech; 22 , 27 negative symptoms are a deficiency of normal function and include limited goal-directed behaviour (avolition), limited fluency and productivity of speech and thought, and a flat affect. 22 , 27 The diagnosis of schizophrenia requires the presence of at least two of these positive or negative symptoms lasting at least 6 months. 22 , 27 In this case, the patient presented with delusions (e.g., electrical implants trying to control his and others' actions), including persecutory delusions (e.g., “they are emotionally abusing me”), hallucinations (e.g., hearing voices, seeing signs), and a flat affect. Since the patient was enrolled in university at the time of diagnosis, his cognitive function is assumed to be well preserved. The patient reported no change in symptoms for 2 years.

Schizophrenia is subdivided into five types: paranoid, disorganized, catatonic, undifferentiated, and residual (see Table ​ Table1 1 ). 22 , 28 Based on these observations and on the literature, the patient's symptoms were suggestive of paranoid schizophrenia, 22 which is the most prevalent form of schizophrenia in most parts of the world. 22

Schizophrenia Subtypes 6

The aetiology of schizophrenia remains unknown. 29 , 30 There is a strong genetic predisposition. 29 , 30 Patients who experience the onset of schizophrenia before age 22 are 10 times more likely to have a history of a complicated caesarean birth than patients with a later onset of schizophrenia, which suggests a possible neurodevelopmental factor in early-onset schizophrenia. 31 Mild childhood head injuries may play a role in the expression of schizophrenia in families with a strong genetic predisposition to this disorder. 32 Psychological stress has also been implicated in the onset of schizophrenia, since it often precipitates the first psychotic episode or increases the likelihood of a relapse. 33 , 34 In this case, the patient described a family “break-up” which may have precipitated the onset of psychosis. Details about his childhood head injuries and the circumstances of his birth were not obtained. After being diagnosed with schizophrenia, the patient revealed to the referring physician that his father had experienced something similar when he was younger, which may point to a genetic predisposition.

There are no conclusive diagnostic tests for schizophrenia. 22 However, imaging studies have suggested neurophysiologic changes as an associated finding. Volumetric magnetic resonance imaging (MRI) studies of patients with schizophrenia have demonstrated an overall reduction in grey matter; an increase in white matter; decreased size of the amygdala, hippocampus, and parahippocampus; an overall reduction in brain volume; and larger lateral ventricles relative to a control group. 35 – 37

Psychiatric Disorders as They Relate to Musculoskeletal Dysfunction

As primary-care practitioners, physical therapists may encounter patients with possible psychiatric disorders such as schizophrenia. However, the physical therapy literature on psychiatric disorders as they relate to musculoskeletal disorders focuses mainly on low back pain (LBP). 7 , 8 In an examination of a large number of physical and psychological factors, one prospective case-control study points to the importance of psychological variables as a risk factor for chronic LBP and widespread musculoskeletal pain. 8 Previous research has also concurred with this study in implicating psychological variables as risk factors for LBP and neck pain. 9 , 10 These articles provide a link between psychological disorders and patients seeking physical therapy for musculoskeletal dysfunctions.

In this case report, the physical examination was suggestive of a mild supraspinatus tendinosis, but this did not explain the severity of pain reported by the patient or the referral of pain to the elbow, wrist, and knee. One of the limitations of the physical examination was that there was not sufficient time to perform physical examination of the elbow, wrist, and knee. The patient's undiagnosed and uncontrolled psychiatric symptoms took priority over the musculoskeletal dysfunction and required immediate medical referral without physical therapy intervention. Because of the inconsistencies between interview and physical examination, as well as the patient's perception that an electrical implant was causing his musculoskeletal pain, there is a possibility that at least some of his musculoskeletal symptoms may have been manifestations of his psychiatric disorder.

Effective Patient Interviews

The medical literature indicates that 50% of all mental illness is recognized during the interview process as part of medical assessment by the primary-care physician. 38 As physical therapists embrace their role as providers of primary care, 4 , 5 they must rely on their skills in patient interviewing and physical examination to rule out medical pathology. Improved assessment skills by the physical therapist may help to identify primary or secondary medical pathologies that have not previously been diagnosed. Within the peer-reviewed literature, a number of case studies demonstrate identification of non-musculoskeletal or visceral pathology that can manifest as musculoskeletal disorders; 39 – 41 these case studies are examples of how physical therapists can perform an initial assessment, identify a medical pathology that precludes treatment, and make an appropriate referral. During a patient interview, physical therapists must be well aware of the psychological and psychosocial aspects of the examination to identify relevant aspects of the patient's demeanour (e.g., appropriate self-care) and emotional state (e.g., inappropriate affect). The patient interview should consist of non-leading, open-ended questions about how pain in multiple areas is related and how it is caused. Furthermore, physical therapists should avoid rationalizing the patient's symptoms during the interview process. At a minimum, patients should be permitted to speak about and describe their symptoms in a way that is meaningful to them.

Schizophrenia and Primary Care

Schizophrenia is most often initially recognized by the primary-care physician. 42 Psychiatrists, psychologists, and even the lay community have also been noted in the literature as making the initial identification. 43 – 45 Although conspicuously absent from the literature on the initial identification of schizophrenia, physical therapists are in a position to be important first-contact care providers who can make the initial identification of schizophrenia, and other psychiatric disorders, through effective patient interviews. Although labelling patients as having a psychiatric disorder is outside physical therapists' scope of practice, the diagnostic process is not exclusive to any one profession. In this case, the process of diagnosis, which involves assessing the patient, grouping findings, interpreting the data, and identifying the patient's problems, led me to conclude that the primary dysfunction was psychiatric in nature. 46 This process, which Few et al. call “diagnostic reasoning,” is well within physical therapists' scope of practice and is something we constantly engage in during our daily clinical practice. 11 Diagnostic reasoning involves taking into account all of the possible pathological structures and determining the most likely cause of the patient's symptoms. In practice, expert clinicians do not follow standardized protocols; 46 rather, they pay attention to cues provided by the patient, recognize patterns, and test hypotheses to arrive at a probable cause for the patient's symptoms. 11

IMPLICATIONS AND FUTURE DIRECTIONs

The medical literature has identified gaps in the knowledge of primary-care physicians, specifically a lack of awareness of the symptoms and epidemiology of schizophrenia. 28 To facilitate early recognition, referral, and diagnosis of schizophrenia, the medical literature has suggested increased collaboration among family physicians and mental-health professionals, as well as ongoing mental-health training for family physicians. 47 , 48 Physical therapists should also heed these suggestions. A study in the physical therapy literature recommends mental-health training for recognizing the symptoms of depression in a population with LBP; 7 the same study, conducted in Australia, concluded that physical therapists' ability to recognize depressive symptoms in an outpatient setting was poor. 7

An initial step to address these gaps could be a position paper that draws on the medical literature to inform physical therapists about the presence, prevalence, signs, and symptoms of common psychiatric disorders. As well, future research needs to focus on the incidence of musculoskeletal signs and symptoms in patients with common psychiatric disorders.

KEY MESSAGES

What is already known on this topic.

To the authors' knowledge, there are no known studies in the literature describing a case of a patient referred to physical therapy for musculoskeletal dysfunction who was later diagnosed with schizophrenia.

What This Study Adds

This case report contributes to the existing literature on physical therapists functioning as competent providers of primary care who have the knowledge and skills needed to rule out non-musculoskeletal pathology. It also educates physical therapists about the signs and symptoms of schizophrenia.

Shah N, Nakamura Y. Case report: schizophrenia discovered during the patient interview in a man with shoulder pain referred for physical therapy. Physiother Can. 2010;62:308–315

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Recognition of schizophrenia and quality of treatment during the COVID-19 pandemic: A Danish nationwide study

Affiliations.

• 1 Department Bispebjerg-Gentofte, Mental Health Center Copenhagen, Mental Health Services of the Capital Region in Denmark, Copenhagen University Hospital, Esther Ammundsens vej 36, 2400 Copenhagen, Denmark. Electronic address: [email protected].
• 2 The Danish Clinical Quality Program - National Clinical Registries (RKKP), Hedeager 3, 8200 Aarhus, Denmark.
• 3 Department Bispebjerg-Gentofte, Mental Health Center Copenhagen, Mental Health Services of the Capital Region in Denmark, Copenhagen University Hospital, Esther Ammundsens vej 36, 2400 Copenhagen, Denmark.
• PMID: 39277925
• DOI: 10.1016/j.schres.2024.09.001

Background: The COVID-19 pandemic may have exacerbated the state of ill-health among patients with schizophrenia. We examined the number of patients diagnosed with schizophrenia, the number of hospital admissions and outpatient contacts and the quality of treatment during the pandemic in comparison with the previous years.

Methods: We identified patients ≥18 years old registered in the Danish Schizophrenia Registry from 2016 to 2022. Using a generalized linear model, we estimated prevalence ratios (PR) and 95 % confidence intervals (CI) for each variable of interest.

Results: A minor reduction in the number of new cases, admissions and outpatient contacts was seen during the first lockdown; however, there was no overall change across the pandemic period compared with the pre-pandemic period. We found no change in the proportion of patients who were interviewed using a diagnostic tool (37.0 % during pandemic vs 37.9 % pre-pandemic; PR = 0.87; 95 % CI 0.68-1.12) or received family intervention (57.7 % vs 57.1 %; PR = 0.97; 95 % CI 0.81-1.15), and no decrease was observed in the proportion of patients assessed for social support. Furthermore, no change in the proportion of patients re-admitted within 30 days (35.9 % vs 35.0 %; PR = 0.96; 95 % CI 0.88-1.07) or screened for suicide risk in relation to discharge (55.2 % vs 56.8 %; PR = 0.96; 95 % CI 0.97-1.09) was observed.

Conclusions: Recognition and treatment of schizophrenia was minimally affected during the first lockdown, but across the pandemic period no overall change was observed. The quality of treatment of schizophrenia was unchanged.

Keywords: COVID-19; Epidemiology; Quality of treatment; SARS-CoV-2; Schizophrenia.

Copyright © 2024 Elsevier B.V. All rights reserved.

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Declaration of competing interest The authors report no conflict of interest.

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Case Study Illustrates How Schizophrenia Can Often Be Overdiagnosed

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Study author Russell Margolis, director of the Johns Hopkins Schizophrenia Center, answers questions on misdiagnosis of the condition and reiterates the importance of thorough examination.

It’s not uncommon for an adolescent or young adult who reports hearing voices or seeing things to be diagnosed with schizophrenia, but using these reports alone can contribute to the disease being overdiagnosed, says  Russell Margolis , clinical director of the Johns Hopkins Schizophrenia Center. 

Many clinicians consider hallucinations as the sine qua non, or essential condition, of schizophrenia, he says. But even a true hallucination might be part of any number of disorders — or even within the range of normal. To diagnose a patient properly, he says, “There’s no substitute for taking time with patients and others who know them well. Trying to [diagnose] this in a compressed, shortcut kind of way leads to error.”

A case study he shared recently in the  Journal of Psychiatric Practice  illustrates the problem. Margolis, along with colleagues Krista Baker, schizophrenia supervisor at Johns Hopkins Bayview Medical Center, visiting resident Bianca Camerini, and Brazilian psychiatrist Ary Gadelha, described a 16-year-old girl who was referred to the Early Psychosis Intervention Clinic at Johns Hopkins Bayview for a second opinion concerning the diagnosis and treatment of suspected schizophrenia.

The patient made friends easily but had some academic difficulties. Returning to school in eighth grade after a period of home schooling, she was bullied, sexually groped and received texted death threats. She then began to complain of visions of a boy who harassed her, as well as three tall demons. The visions waxed and waned in relation to stress at school. The Johns Hopkins consultants determined that this girl did not have schizophrenia (or any other psychotic disorder), but that she had anxiety. They recommended psychotherapy and viewing herself as a healthy, competent person, instead of a sick one. A year later, the girl reported doing well: She was off medications and no longer complained of these visions.

Margolis answers  Hopkins Brain Wise ’s questions.

Q: How are anxiety disorders mistaken for schizophrenia?

A:  Patients often say they have hallucinations, but that doesn’t always mean they’re experiencing a true hallucination. What they may mean is that they have very vivid, distressing thoughts — in part because hallucinations have become a common way of talking about distress, and partly because they may have no other vocabulary with which to describe their experience. 

Then, even if it  is  a true hallucination, there are features of the way psychiatry has come to be practiced that cause difficulties. Electronic medical records are often designed with questionnaires that have yes or no answers. Sometimes, whether the patient has hallucinations is murky, or  possible —  not yes or no. Also, one can’t make a diagnosis based just on a hallucination; the diagnosis of disorders like schizophrenia is based on a constellation of symptoms. 

Q: How often are patients in this age range misdiagnosed?

A:  There’s no true way to know the numbers. Among a very select group of people in our consultation clinic where questions have been raised, about half who were referred to us and said to have schizophrenia or a related disorder did not. That is not generalizable.

Q:   Why does that happen?

A:  There is a lack of attention to the context of symptoms and other details, and there’s also a tendency to take patients literally. If a patient complains about x, there’s sometimes a pressure to directly address x. In fact, that’s not appropriate medicine. It is very important to pay attention to a patient’s stated concerns, but to place these concerns in the bigger picture. Clinicians can go too far in accepting at face value something that needs more exploration. 

Q: What lessons do you hope to impart by publishing this case?

A:  I want it to be understood that the diagnosis of schizophrenia has to be made with care. Clinicians need to take the necessary time and obtain the necessary information so that they’re not led astray. Eventually, we would like to have more objective measures for defining our disorders so that we do not need to rely totally on a clinical evaluation. 

Learn more about Russell Margolis’ research regarding the challenges of diagnosing schizophrenia .

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Very Early-Onset Schizophrenia in a Six-Year-Old Boy

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• Open access
• Published: 27 June 2023

Recovery journey of people with a lived experience of schizophrenia: a qualitative study of experiences

• Zhidao Shi 2 ,
• Yanhong Chen 3 &
• Xiquan Ma 4  

BMC Psychiatry volume  23 , Article number:  468 ( 2023 ) Cite this article

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Mental health recovery involves an integration of clinical and psychosocial frameworks. The recovery journey of individuals diagnosed with schizophrenia and the factors that influence it have been extensively studied. Because the recovery journey is culturally influenced, we examined the recovery process expriences of individuals diagnosed with schizophrenia in China, focusing on the influence of a Confucian-dominated collectivist and family-centred culture.

An Interpretive Phenomenological Analysis (IPA) study was conducted; data were gathered through in-depth interviews with 11 individuals with lived experience of schizophrenia.

Four themes were identified in this study: traumatic illness experiences, influence of the family, motives for recovery, and posttraumatic growth, comprising ten subthemes. “For the family” and “relying on oneself” are the main drivers of recovery for individuals with a Chinese cultural background. Some people believe that taking care of themselves is an important way to ease the burden on their families and treat them well. There is a link between ‘for the family’ and ‘relying on oneself.

Conclusions

Individuals living with schizophrenia in China have undergone significant traumatic experiences and have profound interactions with their families. Post-traumatic growth reflects an increase in the individual’s connection to others and individual agency. It also suggests that the individual is not receiving enough support outside of the family. The impact of individual agency and family relationships should be considered in services that promote recovery, and clinic staff should enhance support outside the home to the individuals.

Peer Review reports

Schizophrenia is a severe psychiatric disease, and it usually causes social dysfunction in individuals [ 1 ]. In 2017, 19.78 million individuals were diagnosed with schizophrenia worldwide, a 62.74% increase from 1990 [ 2 ]. In a 2022 report prompted, although the crude incidence of schizophrenia has decreased in China, the age-standardized incidence rate (ASIR), ,crude disability-adjusted life year (DALY) rate and age-standardized DALYs rate (ASDR)all showed a generally increasing trend over the last three decades [ 3 ]. In China, schizophrenia has become an important public health problem [ 4 ].

With the rise of the recovery movement, individuals are increasingly writing about their treatment experiences and journey to recovery, raising awareness that recovery from schizophrenia is possible [ 5 , 6 , 7 , 8 ]. The results reported in these studies indicate that approxmately half of the participants recover or significantly improve over the long term, suggesting that remission or recovery is much more common than previously thought [ 9 , 10 ]. On the other hand, by studying the stories of those who have recovered, it is possible to tease out what recovery means to them, what factors affected and helped their recovery and what they think is critical to the recovery process [ 11 ].

Spaniol and his colleagues pointed out that the four broad stages of mental illness recovery are being overwhelmed by the illness, fighting with the illness, coexisting with the illness, and surpassing the illness. The three main steps related to the recovery process are (1) an interpretive framework for understanding the experience of severe mental problems (2) gradually controlling mental illness and (3) obtaining a meaningful, productive, and valuable status in society. For individuals, understanding the experience of serious mental problems is their first step towards recovery [ 12 ].

Brammer believes that recovery is neither a matter of biomedical/clinical nor psychosocial recovery; it is an integration of clinical and psychosocial frameworks [ 13 ].

Sambeek and colleagues point out that researchers often ignore the sociocultural context of the narrative [ 14 ] or focus only on its personal or social dimensions [ 15 ].

Some cross-cultural studies suggest that cultural differences can lead to differences in individuals’ stigmatizing attitudes towards mental illness [ 16 , 17 ] and can also influence the psychological experience of family members in caring for individuals and how they care for them [ 18 , 19 ].

Chinese culture is dominated by collectivism under Confucianism. In Chinese culture, family and individual bonds are solid and interdependent [ 20 ]. In this context, does the recovery process differ from that in the West?

Some researchers have explored the field, and Yen-Ching Chang has highlighted the influence of Chinese culture on recovery-oriented services. He identified the search for cooperation from family members and the elimination of stigmatizing influences as the main challenges faced by professionals in a non-Western context [ 21 ].

Eva Yin-han Chung’s review of several papers argues that the concepts and philosophies of Western community-based rehabilitation cannot be directly applied to the Chinese context. Chinese cultural values have influenced CBR practice in Chinese communities [ 22 ]. Traditional peasant culture, traditional Chinese philosophy, and socialist ideology primarily influence current rehabilitation and CBR practices in China. Traditional cultural beliefs influence community members’ views of health, disability, autonomy, and family relationships [ 23 ]. For this reason, many argue that introducing externally planned CBR programs is counterproductive because they need to consider local needs and existing local practices. Therefore Eva Yin-han Chung claims an appropriate model or framework is needed to adapt to the unique Chinese cultural context and to guide practice in the Chinese community [ 22 ].

The above research suggests that the theory of recovery in China needs to consider Chinese culture. Researching Chinese people with lived experiences of schizophrenia recovery can help us understand the recovery process of individuals and consider the similarities and differences in the recovery journey of people with lived experiences of schizophrenia acoss cultures.

Participants and methods

Participants.

Participants were recruited through clinical staff at the Wuhan Mental Health Centre from November 2017 - March 2018. Participation was voluntary and was possible only with informed consent. The Inclusion criteria were (1) being diagnosed with schizophrenia according to the International Statistical Classification of Diseases and Related Health Problems “Diagnostic criteria for schizophrenia in the 10th edition; (2) having experienced at least two relapses or having residual symptoms but a current BPRS score of less than 35 on the 18-item BPRS as scored by the psychiatrist responsible for recruitment. [ 12 ](The verbal expression of individual with the severe condition are impacted. Therefore we used the BPRS as a screening tool. We wanted the participants to be able to express themselves well enough to articulate the themes we wanted to explore. ); (3) recieving a participant information sheets from staff, from which potential participants could ask questions of the staff; and (4) being wlling to participate in the qualitative research interview and signing an informed consent form after reading the informed consent form. The exclusion criteria were (1) having an intellectual disability; (2) having severe physical or cerebral organic diseases; (3) abusing or being dependent on psychoactive substance. Eleven individuals were finally enrolled.

The study’s sample selection mainly used the purposive sampling method and followed the principle of saturation. The interviews are conducted face-to-face; each lastiong from 1 to 1.5 h. The interview location was in the psychotherapy room of the hospital. After obtaining the individual’s consent, signed the informed consent form, the interview was performed and recorded. The research team consisted of three psychiatrists and a graduate student in psychology. The interviewer was a graduate student in psychology. All of the researchers were trained in and had previously conducted qualitative research. Some individuals underwent supplementary interviews according to the needs of the investigator. We used a code assigned to each participant to ensure anonymity.

We adopt the interpretative phenomenological analysis (IPA) method in this study. IPA was developed by Jonathan A. As a qualitative research method in the fields of health psychology and social science, IPA focuses on how people perceive experience, that is, it studies their experience living in the world [ 24 , 25 ]. The hypothesis of IPA is that the content of the participant’s psychological world that the analyst pays attention to may be manifested in the form of belief and structured by the participant’s words, or the participant’s story itself represents the identity of the participant [ 25 , 26 ]. IPA researchers want to analyse in detail how participants perceive and attach meaning to events that happen to them, so they need a flexible means of data collection. IPA mainly uses semistructured interviews to collect data [ 26 , 27 ].

This study aimed at exploring the illness-related experiences and recovery processes of people who have experienced schizophrenia. The interviews mainly focused on how they get sick, how they think about the illness and the impact of the illness on themselves. How do they cope with these effects? How is recovery perceived, what is good for recovery, and what is bad for recovery. We also asked individuals to report their current living conditions. (An outline of the interview is available within the Supplementary Material) The interview was semistructured and interactive. The researcher asked open questions and clarified the answers encouraged the individual to express themselves as completely as possible until they felt there was nothing more to say.

The interviews and our analysis were conducted in Chinese. The initial writing was also done in Chinese, and then, a final translation into English was conducted, using direct translations where possible but using paraphrases for difficult parts. This section resulted in a loss of information, and to minimize this, the research team discussed the translation content and made it acceptable to each researcher.

The interviewers converted the recordings into verbatim transcripts after each interview, and IPA was conducted following Smith and colleagues’ (2009) guidelines [ 28 ]: (1) reading and rereading; (2) initial noting; (3) developing emergent themes; (4) searching for connections across emergent themes; (5) moving to the next case, (6) looking for patterns across cases.

Each interview was first analysed individually by MM and CYH. After several readings of the transcripts for familiarity, the first emergent themes, which included descriptive, verbal, and conceptual comments, were identified through an initial coding process. These emergent themes were then grouped into higher-order categories, creating a list of superordinate themes for each interview. The research team then reviewed these themes until a consensus was reached and looked for links between the superordinate themes throughout the interviews. The research team then moved on to the next case and finally looked for patterns across cases.

The Ethics Committee of the Wuhan Mental Health Centre approved the study. All potential participants were informed of the purpose of the study and their right to refuse participation without any adverse effect on their support or relationship with the organization and measures to ensure confidentiality. Following this explanation, all individuals agreed to participate in the study and provided written consent to participate.

Participant characteristics

The participants were aged between 22 and 55 years, with an average age of 38.5 years; five men and six women took part; the participants were mostly single or never married (63.6%)and lived with their families (63.6%).

The participant’s general information is shown in Table  1 .

Four themes were identified in this study: traumatic illness experiences, influence of the family, motives for recovery, and posttraumatic growth, comprising ten subthemes. (Table  2 ), each supported by quotes from participants’ records.

Traumatic illness experiences

Each participant referred to the traumatic experience of having schizophrenia, which included symptom-induced distress, stigma, and feelings of powerlessness.

Symptom-induced distress.

These included both bodily and psychological distress. Even after the individual’s symptoms were under controll, the pain remained fresh in the individual’s mind. The distressed experience might be why the individual continues in treatment or wants to seek help from a doctor.

“It is so unbearable, worse than death, and people who have never had the illness cannot feel the pain. The onset of the illness is too painful, too torturous. It’s all about the physical discomfort and the pain. The pain in my body is so bad that I can get sick at any time, my chest and back feel like a nail is stuck there; my hands and feet are numb, and it is particularly uncomfortable. “(G) . “It (referring to the symptoms) is not cyclical. It suddenly comes and goes, but wait a bit. The key is not to be anxious; once it happens, your thoughts will not work if you are anxious. You don’t think about anything. I don’t want to think about anything. “(F) . “It’s just hard, hard. I can’t stop thinking about problems. I can’t control them. I don’t want to think about problems. My mind will still think about them. I want to clear my mind, but there are voices in my head that keep talking. It’s hard. I can’t help it. I can’t think about extreme problems, but my head gets dizzy when I think about unnecessary problems.“ (C) . “Couldn’t sleep the next day. My mental state was terrible, and my condition was worse. “(B) .

Stigma and self-stigma

Some participants reported being talked about, shunned, isolated, and devalued. They felt lonely, devalued, restricted, and angry. One participant complained that her child was also being bullied. Some participants said they felt low self-esteem because of mental illness, felt pessimistic about the future, avoided contact with the outside world, or feared that others would know about their illness.

“I walk out. People point at me and murmur: she is the wife of whoever, she is the daughter of whoever. And she has a mental illness. It’s like I’m boxed inside that dungeon.“ “I found that everyone ignored me when I returned from the hospital. They don’t care about me. They teach the children to ignore me. En, I’m so lonely and isolated there. No one wants to care about me.“ “Even my child was bullied. The other kid was bigger and hit my kid on the leg with a big stone. I went to argue, and he ignored me.“ (A) . “The psychological impact of the illness, maybe, is inferiority and a little pessimistic about the future. The inferiority complex means that people with the mental disorders are often looked down upon by others. A person is often looked down upon by others. His life is over. Pessimism means that you feel very pessimistic about your future.“ (B) . “We, as patients, are also stigmatized in society. I was afraid to tell anyone about my illness. But it affected me all my life. Right? I can’t even talk about it. Maybe someday I’ll meet someone I love. I can’t even talk about it. Friends, I lost a lot of friends that I used to have. I initiated contact with them, and they didn’t talk to me. “(J) .

Loss of hope, feeling of powerlessness

Most participants described a loss of hope and powerlessness, while others felt scared. Some participants had this feeling for a while after the illness, and some had in this feeling all the time. This feeling was related to being diagnosed with schizophrenia, being on medication for a long time, or having recurrent illness episodes.

“After I found out my diagnosis was schizophrenia, I felt like I just lost hope in life, I didn’t want to care about anything, I didn’t want to do anything” (F) . “It felt scary, saying something about (the diagnosis of) schizophrenia; it just felt quite scary and could scare people to death. …… When does the second life start? The first life was given to me by my mother; I feel like there is no second life, and I feel like a wasted person when I keep taking medication and eating.“ (L) . “When I got out of the hospital, my ability to survival was poor. I was weak. When I heard the doorbell, I was scared.“ (J) . “It just wasn’t good; I didn’t feel so lucky. Quite a lot of my classmates that I hang out with don’t have it, and I’m the only one who has it.“ (C) . “A bit pessimistic about the future, I guess …… pessimistic means feeling very pessimistic and disappointed about the future.“ “My parents are old, 50 or 60 years old. If they die, how do I do.“ “Schizophrenia, well, can’t be cured completely, mentally very tortured.“ (B) .

Influence of the family

Most of the participants lived with their families. Among the three participants (D, E, and I) who did not live with their families, 2 (E and I) also had close contact with their families. Only participant D stated that he rarely communicated with his family. All participants had a permanent home and no experience of homelessness. Most participants stayed at home for some time after being diagnosed with schizophrenia or discharged from the hospital. They reduced their contact with the outside world. As individuals stayed at home, family members interacted intensely with them.

Interactions with family members significantly impacted the participants’ moods and behaviours. Family members’ attitudes and behavior towards the participants’ medication also significantly impacted the participants’ treatment and mood.

Staying at home

The participants found coping with the stress of relationships and work challenging, so they returned to their homes and had less contact with the outside world. Some participants felt relaxed staying at home, but others experienced diminished capacity and were concerned about their diminished capacity.

“I do not have a good relationship with strangers and would rather be alone at home with a book and TV. At least I feel more relaxed.“ (K) . “I want to go out to work like everyone else. I cannot do anything if I have this symptom all the time. It’s better not to have those kinds of grumpy people in my cirle. I work in that circle, and if I have that kind of people messing around every, I get a bit unhappy when I face them. I don’t want to see him. He’ll affect my mood.“(C) . “After a while, I was in a bad mood, and my ability to work was weak. Unlike before, I did not want to work for quite a long time. I always stay home, lie in bed, watch TV, and do not want to go out. Then, I returned to the old state of poor performance, that feeling.“(J) .

Impact on mood

The attitude of family members towards the individual has a great impact on the individual’s mood. Criticism and blame from family members can cause anger or depression, and worries from family members can increase an individual’s apprehension and depression. When family members are encouraging, understanding, and affirming, the individual will increase communication with family members and will be able to maintain positive behavious.

Discrimination, blame from family members

The participants experienced impatience, unconcern, and blame from family members, for which the participants felt angry and depressed.

“My husband, if people ask him who she (meaning A) is. His attitude then becomes like this, too, just saying to ignore her and not to talk to her. I once tried cross-stitching, which requires a lot of patience. When I was halfway through the embroidery, my husband said, ‘What are you embroidering? You can’t even do your housework properly and still embroider this’. He denied me. What housework did I fail to do? Did I not cook, did I not take care of my children, did I not take care of my mother-in-law? “(In an outraged tone) (A) . “The children don’t come to see me either, and I’m particularly depressed and bitter emotionally” (D) . “My parents pick on my sore spot and talk nonsense. En, all this talk is making me feel bad.“(E) .

Family worries

The participants experienced a variety of worries from family members, such as family members worrying about their condition, the side effects of medication, the relationships, and the future. Family members’ worries about the individual could add to the individual’s fears.

“As long as I have this symptom, I can’t do anything. My parents are worried and afraid that my interpersonal relationship outside are shallow. If I want to do something, I need a person to lead me to do it. My parents don’t have anyone right now.“ (C) . “ My mother was disappointed in me. She said I would become a farmer like them if I were still so negative. I was a little worried about myself. En, I swallowed the whole bottle of pills. A bottle of clozapine.“ (K) .

Family communication, encouragement

The participants experienced that their family members wanted to listen to what was bothering them, cared about them, or were encouraging them and affirming the positive changes they were making. Listening, caring, and support from family members made the participants want to talk and care more about their family members.

“My parents also say that I’m a different person. They all think I’m good. I’m good to them. (J) “I talk to her (referring to the daughter) a little bit, a little bit (about the condition), sometimes she opens up and tells me to, um, learn to control myself, and she also, she asks me to, but I can’t do it, I told her that too, I said I can’t do it.“ (D) . “My daughter lives where she works, and she’s very concerned about me and often calls me. After all, I was worried about her being a girl, but I have since discovered that she is capable, so I am relieved now.“ (I) .

Role in medication compliance

Family members had an important influence on the participants’ medication use. Family members reminded the participants to take their medication. Some family members accompanied the participants to hospital appointments and help with prescriptions, and the participants felt supported. However, some family members made taking medication an essential thing for the participant, constantly reminding the participant and equating failure to take the medication with the onset of the participant’s illness. Other family members force-fed medicines to the participant, and these coercive methods made the participant unhappy and resentful. Some family members were also concerned about the side effects of the medication and asked the participants to stop taking it.

“I was then always very positive and cooperative in my treatment. At first, it was my 70-year-old father who brought me to the doctor, and then later, I slowly came to the doctor on my own.“ (J) . “My family always asked me if I had eaten or taken my medication. I had to remember to take my medicine and not forget to do so. These were just a few words. I felt like I had accomplished a considerable task.“ (A) . “My mother was afraid I would get sick from my medicine, so she told me not to take it.“ (B) . “Whenever I get angry and don’t take my medicine, my parents think I will be sick.“ (L) . “They (referring to parents) would take a scoop, open my mouth with the scoop, and ask me to take my medicine, and I also felt disgusted.” (E) .

Motives for recovery

Individuals wanted to get better, but taking the initiative to take steps to start getting better, rather than avoiding people and situations that made it difficult for them, required a driving force. The individual’s narrative revealed that being for the family and relying on oneself were the motivating factors to increase individual initiative.

For the family

Individuals took responsibility for their families and wanted to be able to take care of them, such as their elderly parents, younger siblings, and children, to “take on the burden of the family” and to provide financial and emotional care for them. The participants interpreted the improvement of their situation as a way of not “causing trouble” for their families. “easing the burden” on them, and taking responsibility for them.

“My father is dead too, …. My mother is old, and I have two younger sisters, so I have to bear the burden of my family.“ “If I lose touch with society and drag my family down with me, at the end of the day, it’s all; it’s all hurting myself, it’s all hurting my family.“ (F). “My mum and dad are very old and emaciated…. I want to lighten the burden on my family” “My mum and dad are physically ill. I think this burden I have to pick up. Then I went out to work again, and I forced myself when I was working. Slowly I was able to do the job.“ “Now I can take part of the responsibility of the family, and I also care for my sister, my brother-in-law, my niece, my dad, and my mum.“ (J). “I hope not to give my daughter any trouble. When she needs money, I can help her. The first is not to be hospitalized. I want my life to be about taking medicine, eating, closing my eyes, and not being hospitalized again. When I was in the hospital, those who cared about me, including my parents and my daughter, were affected. I was also sick and had much pain.“(I) .

Relying on oneself

Four participants referred to ‘relying on oneself’, which included relying on oneself to manage life’s chores, regulate one’s emotions, take care of oneself, and encourage oneself. Relying on oneself is also an expression of taking responsibility for one’s life and supporting oneself.

“The reality is that you still have to rely on yourself, you have to do a lot of tedious things in real life by yourself, you can’t be a little bit lazy, it’s like taking care of yourself, if you are a little bit lazy, you will end up not wanting to do it more and more.“ “If you don’t make any progress at all, if you’re not willing to go in a good direction and improve yourself, then the doctor can’t do anything with you, and the medicine can’t do anything with you.“ (I) . “You have to unlock the locks yourself, but if your heart is locked, you can’t open it,“ “You have to rely on yourself, you have to rely on yourself.“ (F) . “We ordinary people, we have to rely on ourselves, …… can’t give up on ourselves.“ (G) . “Now it’s about being strong on your own. Keep yourself in an optimistic frame of mind and look down on some things a little bit.“ (H) .

Posttraumatic growth

Some participants reported positive changes associated with their experiences. Posttraumatic growth is the recovery and improvement of physical and mental health from adversity and regaining control over one’s life; posttraumatic growth took time and did not develop linearly. Post-traumatic growth included the subthemes of increased connection with others and individual agency.

Connections with others

The emotional connection to relationships with others had two components: on the one hand, the individual trusted others, communicated more with them, and felt more supported by them; on the other hand, the individual felt more supported by others.

Feeling supported by others

Developing trust in others and increased interaction leads to a feeling of support from others. These others were often family members or health professionals, and one participant also talked about relationships with friends.

“I see how a doctor treats another patient with warmth, the little gestures, the little things taken into consideration, and it touches my heart, and I feel trustworthy. “ (G) . “(I’m) annoyed or unhappy, I feel uncomfortable, but then, well, I talk to the girl.” (E) . “I now talk to my sister when I’m upset about something.” (I) . “I have a friend who knows about my illness and recovery. She’s always been there for me, and she’s very open about it. I cherish this friend.” (J) .

Support for others

The participants were more likely to help, had more tolerance for others, and could work with others and share benefits.

“I am not as aggressive as I used to be, and I can get along well with other people.“, " Because of this illness, no matter how strong people are, there is still a day when they fall. Many things are unexpected. One has to be open-minded, healthy is a must, and living is a victory.“ “In the company, I feel that a team is more powerful than a single person, and I have learned to share now. What I used to have, commission or not, performance or not, I have to take it all into my arms. Now I take some of it out and share it with others.“, “My parents also say I’m better than I used to be. I’m more caring; I used to be very selfish. I used to spend all my money on myself. Now I can take responsibility for my family…Mum and Dad can rely on me. I’m proud of myself now.“ (J) .

Individual agency

Individual agency is reflected in how individuals adopt methods to improve their emotions, cope with symptoms, try new behaviours and ultimately empower themselves.

Emotional self-regulation

The participants used methods to reduce their discomfort and improve their mood when experiencing painful feelings or mental symptoms; they used self-encouragement when it was challenging to continue to persevere in their actions.

“When I’m upset or unhappy, I feel uncomfortable, but I tell my daughter that I’m not uncomfortable, and sometimes I just go and play with my jumper by myself. It calms me down, so I like to do it” (E) . “If I feel uncomfortable, I’ll walk with my head down for a few minutes or go to bed.“ (C) . “When I’m not happy, I think of something happy, or I go and play cards with my friends.“ “It’s still hard to take the trouble to do something for yourself every day and take care of things at home, but it’s better to cheer yourself up and be strong with this. I reassure myself, ‘If I fail, I’ll try again’.“ (F) .

Proactive behaviour

The participants took action to try, learn and accomplish things, such as household chores, financial management, and work. Gradual improvement in the ability to do things in action was followed by self-affirmation and increased autonomy. Completing tasks often required constant experimentation and could fluctuate and be repetitive.

“Sometimes there was supposed to be a price to keep track of when selling things, and (I) didn’t do much of that. Now it’s different, I write down the price sometimes, and I can sell it.“ “Now I do more housework; sometimes I clean the house. I wipe the sofa and mop the floor.“ (C) . “Since I have this illness, I can’t say I’ll never do anything for the rest of my life; what if I get old? Then I can only do some simple things and slowly recover that ability. I then went to work overseas for two years.“ (F) . “At home, I bought groceries, started keeping accounts, and basically wrote down everything I bought. I hope not to give my daughter trouble. She needs help when she needs enough money because I used to spend so much money on my daughter. If there is a need for financial help, who can she call? I have to go to help her. I do not need to eat or drink very well in my own life, as I am also gaining weight and cannot eat too well now. That is mainly for my daughter. I do not want to give her trouble.“ (I) . “Once I started working, my ability came back quite OK. I started working and took a few orders, and my boss impressed me. However, after a while, my mood and my ability to work were weaker. Unlike before, I didn’t want to work for quite a long time. I always stayed at home, lying in bed, watching TV, not wanting to go out. I don’t have any orders, and then I’m back to my old, kind of poor state, that kind of feeling. Later, I thought that this would not work, as my mother and father were both ill, and I felt that I had to take up this burden. Then I went back to work, and when I worked, I forced myself to work. Slowly, I was able to do the job. I went from feeling quite overwhelmed at the beginning to getting used to it, and then eventually, I could do it.“ (J) .

It is evident from the accounts of the individual in this study that the illness causes great suffering to individuals and that after developing schizophrenia, individuals experience or have experienced a lack of hope, a lack of strength, and a lack of ability to face life again in the future.

Previous studies have suggested that developing schizophrenia is a traumatic experience for individuals [ 29 , 30 , 31 ]. Some studies have linked traumatic experiences to psychotic symptoms and treatment experiences [ 32 ], while others have linked traumatic experiences to shame [ 33 , 34 ].

People with severe mental illness (SMI) often encounter stigmatizing perceptions of mental illness [ 35 ]. These perceptions can lead to social exclusion, discrimination, and microaggressions against people with serious mental illnesses [ 36 , 37 , 38 ]. The effects of stigma include self-stigma, where a person internalizes socially stigmatizing messages about mental illness. Self-stigma can lead to depression, low morale, lower self-esteem, poor disease management, social avoidance, and impediments to pursuing and achieving recovery goals [ 39 , 40 , 41 , 42 ].

Isabella Berardelli suggested that demoralization is a syndrome of existential distress. This symptom may occur in people with chronic mental illness that threatens the integrity of existence or the meaning of people as participants in the world [ 43 ]. Frank identified low morale as helplessness, incompetence, declining self-esteem, despair, being stuck in a rut, loneliness, and meaninglessness, possibly followed by a wish to die [ 44 ]. Onken argued that the low morale can be a significant obstacle in the recovery process [ 45 ]. Ritsher argued that three sub-themes of self-change, pessimism about the future, and feelings of control construct the individual’s sense of powerlessness [ 46 ]. A study by Liu Liang and colleagues. on Chinese individuals who had a lived experienced schizophrenia found that individuals lacked clear judgments about their personal experiences in many areas, including physical experiences, mental states, and related factors. The participants often felt nervous, sensitive, and vulnerable in their daily lives and were unsure whether their feelings or judgements were ‘normal’. They lose confidence and become powerless in their lives [ 47 ].

However, this suffering comes not only from a sense of stigma and powerlessness but also from the symptoms themselves. The painful experience of symptoms is why individuals seek treatment, and some use hospitalization as the ultimate solution to cope with the pain of their symptoms. Some individuals are opposed to treatment and feel that hospitalization is forced upon them and that prolonged medication increases their sense of powerlessness.

After a traumatic illness experience, individuals often choose to stay at home to reduce the stress on them in terms of relationships and work. As staying in the home becomes more interactive with the family the influence of the family on the individual becomes more apparent.

Many researchers have reported on the effects of family on people with schizophrenia. Individuals who a lived experience of schizophrenia who came from families with high emotional expression (expressing high levels of criticism, hostility, or excessive involvement) have higher relapse rates than those with schizophrenia from families without similar problems [ 48 , 49 , 50 ].

Family warmth and positive remarks have been found to have a protective effect and reduce the likelihood of relapse [ 51 ].

Johannes Jungbauer and colleagues, in a study of German people diagnosed with schizophrenia, found that at the time of the interview, 41% of the people were still living with their parents or had moved back to their homes [ 52 ].

90% of people diagnosed with schizophrenia in China live with their families, compared to 60% in the UK and 40% in the US [ 53 ]. Such a high proportion of individuals live with their families and interact more with them, and the influence of family members on individuals is more evident.

This study suggests that an individual’s interaction with family members significantly affects the individual’s mood and behaviour. With family discrimination and blaming, the individual develops negative emotions and impulsive behaviours; he or she may also develop depressive and withdrawal behaviours. Family members’ worries may also increase individuals’ worries about the future and the outside world. At the same time, family members’ willingness to communicate with individuals may also improve their communication with family members strengethening the connection between individuals and their families.

A study by Johannes Jungbauer and colleagues found that re-enforcement of the parent-child relationship may lead to decreased social contact outside the individual’s family [ 52 ]. Whereas all of the participants in this study, except D, maintained close relationships with their families. Some participants also had much social contact outside the home. Therefore, the differences between individuals with much social interaction and those with little social contact should be further studied. One possible reason for little social contact outside the home is that family members feel uneasy about the outside world, thus discouraging individuals from social contact with the outside world, For example, in the case of C. A qualitative study by Zhang Yanqing and colleagues in Taiwan also found that when families were not actively involved or supportive of their relatives’ recovery journeys or could not work with their relatives, individuals’ recovery was negatively affected. This study also suggested that families’ overprotection or fear of making changes for their relatives with mental illness prevented people with mental illness from participate in independent learning and decision-making [ 54 ].

Because of the prominent influence of family members on individuals, Chinese individuals who experience schizophrenia need to improve their family-individual interactions and change the overprotective response of family members. Family influence was found in this study to manifest in individuals’ motivation to recover.

With medication, the influence of family members is also evident, as individuals are more likely to accept medication if their family members are gently supportive. In contrast, family members ordering or even forcing medication can cause anger in the individual and lead to tension between the family and the individual.

Joanna referred to the primary motivation for recovery as the ‘drive to move forwards’, which is the foundation or starting point for recovery. This forwards momentum includes hope, optimism, determination, belief in a higher power, and an awakening of motivation. In his study, some participants spoke of recovery as a spiritual journey and a connection to a higher power. Finding meaning and purpose is a key part of recovery, and some people seek and find this meaning in their religious beliefs [ 55 ].

Janne claimed that religion and spirituality hold a great deal of power in the search for meaning in the lives of people with mental illness [ 56 ].

In contrast, the participants in this study did not mention religious beliefs. What, then, constitutes meaning in their lives? According to some participants, “for family” has become the meaning of life. Several participants in this study described that taking responsibility for one’s family was often the turning point in their decision to work towards recovery. Their description suggests that for Chinese participants, family not only has an important influence on them but is also a source of motivation for recovery.

This phenomenon is related to the psychological characteristics of the Chinese people. Yang Guoshu suggests that familism is a major indigenous set of Chinese psychological and behavioural principles and a complex indigenous cultural phenomenon in Chinese society. Familism is the Chinese idea and practice of putting the family first in all matters. Familism aims to maintain the strength and harmony of the family, for which the children must pass on the family line and support and obey their parents. The basis of its ideology is filial piety. The responsibility a child to provide for one’s parents is an important part of familism, and it forms an important part of Chinese life [ 57 ]. Eva Yin-han Chung also argued that for Chinese people, identification and connection to family give meaning to life; responsibility and commitment are important factors that motivate people and empower them to live meaningful lives [ 58 ].

Abdullah argued that in Asian populations, individuals’ inability to care for their parents when they are old and sick can create a sense of stigma for the individual diagnosed with schizophrenia [ 16 ]. In a study by Yin-Ling Irene Wong and colleagues on Chinese individuals diagnosed with schizophrenia and their families, participants with schizophrenia expressed a sense of shame and low self-esteem, and talked about being a burden to their families [ 53 ].

This study shows that individuals’ renewed responsibility for parental support, assisting a younger sibling, and raising and helping children is an essential expression of their life’s meaning and catalyses the their recovery. Individuals feel proud if they can achieve these goals. Therefore in the eyes of Chinese individuals, being able to achieve the task of caring for their families gives them a sense of pride, while not being able to do so increases their sense of stigma.

On the other hand, the particpants also express that they are “relying on oneself”, dealing with life’s chores, regulating their emotions, taking responsibility for their lives, and supporting themselves.

Nonetheless, the participants also stated that they wanted to be “relying on oneself” a concept that requires self-support and motivates individuals to take action to deal with life’s chores, regulate their emotions, and take responsibility for their own lives to achieve self-support.

The factors suggestive of traumatic growth in this study are the connection with others and the individual’s agency. The other connections mentioned more often by individuals were relationships with family members.

“For the family” and “relying on oneself” are cognitive demands, while individual agency is a behavioural response. Guided by the concepts of “for the family” and “relying on oneself " individuals adopt proactive behaviours directed towards helping the family, thus strengthening the individual’s bond with the family.

Several researchers have described recovery as a transformative process of self-discovery and self-renewal, which involves adjusting one’s attitudes, feelings, perceptions, beliefs, roles, and life goals [ 12 , 58 , 59 ]. Yulia and colleagues’ study considered the individual’s sustained efforts towards positive transformation and improvement as the basis of the recovery process. The opposite of this is abandonment, i.e., the acceptance of the individual’s negative identity as an individual with a chronic illness and the lack of intrinsic motivation to want to get better [ 60 ]. Larry Davidson claimed that rebuilding an “enhanced sense of self” protects people from being struck down by illness and provides a solid foundation for their recovery [ 49 ]. Onken argued that rejuvenation is often rooted in agency and self-activity [ 45 ]. A study by Deegan and colleagues identified the right to individual choice and empowerment as important elements of recovery [ 61 ]. Markowitz suggested that for individuals to recover from the trauma of schizophrenia, the healing process involves not only a new lifestyle and control of symptoms but also increasing proficiency in overcoming stigma and discriminatory experiences in the social sphere [ 62 ].

It is an important direction of recovery to promote the development of self-discovery and the self-ability of the individual.

It is worth noting that some participants in this study took good care of themselves as an important way to relieve their families’ burden and treat them well. They reported if they are not well, their families will suffer; if they are well, they can ease the burden on their families. Thus, “relying on oneself” is associated with “for one’s family”.

It is clear from this study that both the self and the family are emphasized in the individual’s experience of recovery. The individual is an individual in the family. The honour and shame of the individual are closely linked to the honour and shame of the family. Therefore, the individual’s efforts can improve the family’s situation. So the individual’s efforts are as much for himself as for his family.

Limitations

The study may be limited for several reasons. The participants had certain geographical limitations. The study was carried out in only one large city in China. Our sampling method may have resulted in selection and response bias. The participants were recruited through clinical staff. In addition to recommending individuals who fit the study’s inclusion criteria, clinical staff tended to refer people with good relationships.

People with schizophrenia living in China have undergone significant traumatic experiences and have profound interactions with their families. Posttraumatic growth enables an increase in the individual’s connection to others and autonomy. The study also found that individuals did not receive adequate support outside their families. These findings suggest that the impact of individual autonomy and family relationships should be considered in services that promote recovery and that support outside the home should be enhanced.

Careful consideration of the impact of Chinese culture on individuals and the establishment of recovery in a Chinese cultural context is an important issue in Chinese psychiatric recovery services.

Data availability

The datasets generated and analysed during the current study are not publicly available due [ this is a Qualitative Study ] but are available from the corresponding author on reasonable request.

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Acknowledgements

We would like to thank Dr. Dehui Zhou and Chunyan Wu for their help in writing and Chunyan Wu for her work in the translation of the thesis.

The program was funded by the Wuhan Municipal Health and Wellness Commission (WX17B14).

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Clinical Research Center for Mental Disorders, Shanghai Pudong New Area Mental Health Center, School of Medicine, Tongji University, Shanghai, China

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Yanhong Chen

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MM and SZD wrote the main manuscript text, CH was the interviewer, and MXQ prepared the timetable. All authors participated in the interpretive phenomenological analysis of the data. Zhidao Shi is co-first author. All authors read and approved the final manuscript.

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Correspondence to Xiquan Ma .

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Supplementary Material 1 Timetable

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Ma, M., Shi, Z., Chen, Y. et al. Recovery journey of people with a lived experience of schizophrenia: a qualitative study of experiences. BMC Psychiatry 23 , 468 (2023). https://doi.org/10.1186/s12888-023-04862-1

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DOI : https://doi.org/10.1186/s12888-023-04862-1

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Case study: treatment-resistant schizophrenia

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Learning objectives

After reading this article, individuals should be able to:

• Describe the management of schizophrenia;
• Understand pharmaceutical issues that occur during treatment with antipsychotics, especially clozapine ;
• Explain how the Mental Health Act 1983 impacts on care;
• Understand the importance of multidisciplinary and patient-centred care in managing psychosis.

Around 0.5–0.7% of the UK population is living with schizophrenia. Of these individuals, up to one-third are classified as treatment-resistant. This is defined as schizophrenia that has not responded to two different antipsychotics ​[1,2]​ .

Clozapine is the most effective treatment for such patients ​[3]​ . It is recommended by the National Institute for Health and Care Excellence (NICE)[4], and is the only licensed medicine for this patient group ​[4,5]​ . For treatment-responsive patients, there should be a collaborative approach when choosing a treatment ​[4]​ . More information on the recognition and management of schizophrenia can be found in a previous article here , and in accompanying case studies  here . 

This case study aims to explore a patient’s journey in mental health services during a relapse of schizophrenia. It also aims to highlight good practice for communicating with patients with severe mental illness in all settings, and in explaining the role of clozapine. 

Case presentation

Mr AT is a male, aged 26 years, who has been diagnosed with paranoid schizophrenia. He moved to the UK with his family from overseas five years ago. He lives with his parents in a small flat in London. His mother calls the police after he goes missing, finding his past two months’ medication untouched. 

He is found at an airport, attempting to go through security without a ticket. He is confused and paranoid about the police asking him to come with them. 

He is taken to A&E and is medically cleared (see Box 1) ​[6]​ . 

Box 1: Common differentials for psychotic symptoms

Medical conditions can present as psychosis. These include:

• Intoxication/effects of drugs (cannabis, stimulants, opioids, corticosteroids);
• Cerebrovascular disease;
• Temporal lobe epilepsy.

Mr AT’s history is taken by a psychiatrist, and his crisis plan sought (as per NICE recommendations) but he does not have one ​[7]​ .

He has been under the care of mental health services for two years and disputes his diagnosis of paranoid schizophrenia. He was admitted to a psychiatric hospital 18 months ago where he was prescribed the antipsychotic amisulpride at 600mg daily. 

He is teetotal, smokes ten cigarettes a day and smokes cannabis every day. His BMI is 26 and he has hypercholesterolaemia (total cholesterol = 6.1mmol/L, reference range <5mmol/L) but all other tests are normal. 

He has no allergies. His only medication is amisulpride 600mg each morning, which he does not take. 

Medicines reconciliation

Mr AT is transferred to a psychiatric ward and placed under Section 2 of the Mental Health Act , allowing detention for up to 28 days for assessment and treatment (see Box 2).

Box 2: The Mental Health Act 1983

This legislation allows for the detention and treatment of patients with serious mental illness, where urgent care is required. This is often referred to as “sectioning”.

It includes regulations about treatment against a patient’s consent to safeguard patients’ liberty, which become more stringent with longer detentions.

Patients may only be given medication to treat their mental illness without their consent and may refuse physical health treatment. 

He denies any mental illness and tells the team they are conspiring with MI6. He is visibly experiencing auditory hallucinations: seen by him talking to himself and looking to empty corners of the room. Amisulpride is re-prescribed at 300mg, which he declines to take. 

A pharmacy technician completes a medicines reconciliation and contacts the care coordinator. The technician provides information about Mr AT’s treatment and feels he is still unwell as he has continued to express paranoid beliefs about his neighbours and MI6.

The ward pharmacist speaks to the patient. As per NICE guidance on medicines adherence , they adopt a non-judgemental attitude ​[8]​ . Mr AT is provided with information on the benefits and side effects of the medication and is asked open questions regarding his reluctance to take it. For more information on non-adherence to medicines and mental illness, see Box 3 ​[9]​ .

Box 3: Medicines adherence and mental health

Adherence to medication is similar for both physical and mental health medicines: only about 50% of patients are adherent. 

Side effects and lack of involvement in decision making often lead to poor adherence. 

In mental illness, other factors are: 

• Denial of illness (poor ‘insight’); 
• Lack of contact by services;
• Cultural factors, such as family, religious or personal beliefs around mental illness or medication.

Mr AT reports gynaecomastia and impotence, and says that he will not take any antipsychotics as they are “poison designed by MI6”, although is unable to concentrate on the discussion owing to hearing voices. 

He is prescribed clonazepam 1mg twice daily owing to his distress, which is to be reduced as treatment controls his psychosis. He is offered nicotine replacement therapy but decides to use an e-cigarette on the ward. 

He is unable to weigh up information to make decisions owing to his chaotic thinking and is felt to not have capacity to make decisions on his treatment. The team debates what treatment to offer.

Patient preference

Mr AT refuses all options presented to him. A decision is made to administer against his will and aripiprazole is chosen as it is less likely to cause hyperprolactinaemia and sexual dysfunction. He then agrees to take tablets “if it will get me out of hospital”. 

After eight weeks of treatment with orodispersible aripiprazole 15mg, Mr AT is able have a more coherent conversation, but is hallucinating and distressed. He is clearly under treated. The pharmacist attempts to complete a side-effect rating scale ( Glasgow Antipsychotic Side-effect Scale [GASS] ) but he declines. He is pacing around the ward in circles: it is felt he may be experiencing akathisia (restlessness) — a common side effect of antipsychotics (see  Table 1 ). 

Treatment review

The team feels clozapine is the best option owing to the treatment failure of two antipsychotics.  

The team suggests this to Mr AT. He refuses, stating the ward is experimenting on him with new medication and he refuses to take another antipsychotics. 

The pharmacist meets the patient with an occupational therapist to discuss what his goals are. Mr AT states he wants to go to college to become a carpenter. They discuss routes to achieve this, which all involve the first step of leaving hospital and the conclusion that clozapine is the best way to achieve this. The pharmacist clarifies the patient’s aripiprazole will not continue once clozapine is established. They leave information about clozapine with the patient and offer to return to discuss it further. 

Mr AT agrees to take clozapine a week later (see Box 4) ​[10–14]​ . Aripiprazole is tapered and stopped.

Box 4: Clozapine characteristics

Clozapine significantly prolongs life and improves quality of life ​[10]​ . Delaying clozapine is associated with poorer outcomes for patients ​[11]​ . 

Clozapine is under-prescribed owing to healthcare professionals’ anxiety and unfamiliarity around its use ​[12–14]​ .

It causes neutropenia in up to 3% of patients so regular monitoring is required . Twice-weekly monitoring is needed if neutrophils are <2 x10 9 /L. Most patients should stop clozapine if neutrophils are <1.5×10 9 /L. These ranges can differ from some laboratory definitions of neutropenia. 

Other side effects include sedation, hypersalivation and weight gain. See  Table 2  for red flags for serious side effects. 

Clozapine is titrated up slowly to avoid cardiovascular complications. A treatment break of >48 hours warrants specialist advice for a retitration plan. 

The pharmacist meets with Mr AT to discuss clozapine. He is told that this is likely to be a long-term treatment. The pharmacist acknowledges that the patient disagrees with his diagnosis, but this treatment is likely to prevent him from returning to hospital. 

He is started on clozapine at 12.5mg at night, which is slowly increased. Pre- and post-dose monitoring of his vital signs is completed. 

On day nine of the titration, his pulse is 115bpm. He otherwise feels well and blood tests show no signs of myocarditis (see   Table 2), so the titration is continued but slowed.

After 3 weeks he is taking 150mg twice daily of clozapine and his symptoms have significantly improved: he is regularly bathing, not visibly hallucinating and engaging with staff.

The pharmacy technician completes a GASS form. Mr AT reports constipation, hypersalivation and sedation. 

A pharmacist meets the patient to reiterate important counselling points, and discuss questions he may have about his treatment and how to manage side effects. Medication changes are made with the patients’ input: 

• His constipation is monitored with a stool chart and he is started on senna 15mg at night;
• He is started on hyoscine hydrobromide 300 micrograms at night for salivation;
• He is switched to clozapine 300mg once daily at night to simplify his regime and reduce daytime sedation. His clonazepam is reduced and stopped.

Smoking is discussed owing to tobacco’s role as an enzyme inducer (more information on tobacco smoking and its potential drug interactions can be found in a previous article here ). Mr AT states he will continue to use an e-cigarette for now. He is informed that if he starts smoking again, his clozapine may become less effective and he should immediately inform his team. 

He is discharged a few weeks later via a home treatment team and attends a clinic once weekly. On each attendance, he has a full blood count taken and analysed on site. He is assessed by a pharmacy technician and nurse for side effects and adherence to treatment, and his smoking status is clarified. 

The technician asks what he thinks the clozapine has done for him. Mr AT states he is still unsure about having a mental illness, but recognises that clozapine has helped him out of hospital and intends to continue taking it. 

Good practice in the pharmaceutical care of psychosis involves:

• Active patient involvement in discussions on treatment decisions;
• Regular review of treatment: discussing efficacy, side effects and the patient’s view and understanding of treatment; 
• Multidisciplinary approaches to helping patients choose treatment;
• For patients who dispute their diagnosis and the need for treatment, open dialogue is important. Such discussions should involve the patient’s goals, which are likely to be shared by the team (rapid discharge, preventing admissions, reducing distress); 
• Information about treatment should be provided regularly in both written and verbal form;
• Where appropriate, involve carers/next of kin in decision making and information sharing. 

Important points

• Schizophrenia affects 1 in 200 people, meaning such patients will present regularly in all settings;
• Patients with acute psychosis, who are in recovery, may be managed by specialist teams, who are the best source of information for a patient’s care;
• Collaborating with the patient on a viable long-term treatment plan improves adherence;
• Clozapine is recommended where two antipsychotics have failed;
• Clozapine is a high-risk medicine, but the risks are manageable;
• Hydrocarbons produced by smoking (but not nicotine replacement therapy, e-cigarettes or chewing tobacco) induce the enzyme CYP1A2, which reduces clozapine levels markedly (up to 20–60%). Starting or stopping smoking could precipitate relapse or induce toxicity, respectively.
• 1 Conley RR, Kelly DL. Management of treatment resistance in schizophrenia. Biological Psychiatry. 2001; 50 :898–911. doi: 10.1016/s0006-3223(01)01271-9
• 2 Gillespie AL, Samanaite R, Mill J, et al. Is treatment-resistant schizophrenia categorically distinct from treatment-responsive schizophrenia? a systematic review. BMC Psychiatry. 2017; 17 . doi: 10.1186/s12888-016-1177-y
• 3 Taylor DM. Clozapine for Treatment-Resistant Schizophrenia: Still the Gold Standard? CNS Drugs. 2017; 31 :177–80. doi: 10.1007/s40263-017-0411-6
• 4 Psychosis and schizophrenia in adults: prevention and management. NICE. 2014. https://www.nice.org.uk/guidance/cg178/ (accessed Jan 2022).
• 5 Clozaril 25 mg tablets. Electronic medicines compendium. 2020. https://www.medicines.org.uk/emc/product/4411/smpc (accessed Jan 2022).
• 6 Psychosis and schizophrenia: what else might it be? NICE. 2020. https://cks.nice.org.uk/topics/psychosis-schizophrenia/diagnosis/differential-diagnosis/ (accessed Jan 2022).
• 7 Service user experience in adult mental health: improving the experience of care for people using adult NHS mental health services. NICE. 2011. https://www.nice.org.uk/guidance/cg136/ (accessed Jan 2022).
• 8 Medicines adherence: involving patients in decisions about prescribed medicines and supporting adherence . NICE. 2009. https://www.nice.org.uk/guidance/cg76/ (accessed Jan 2022).
• 9 Taylor D, Barnes T, Young A. The Maudsley Prescribing Guidelines in Psychiatry . 13th ed. Hoboken, New Jersey: : Wiley 2018.
• 10 Meltzer HY, Burnett S, Bastani B, et al. Effects of Six Months of Clozapine Treatment on the Quality of Life of Chronic Schizophrenic Patients. PS. 1990; 41 :892–7. doi: 10.1176/ps.41.8.892
• 11 Üçok A, Çikrikçili U, Karabulut S, et al. Delayed initiation of clozapine may be related to poor response in treatment-resistant schizophrenia. International Clinical Psychopharmacology. 2015; 30 :290–5. doi: 10.1097/yic.0000000000000086
• 12 Whiskey E, Barnard A, Oloyede E, et al. An Evaluation of the Variation and Underuse of Clozapine in the United Kingdom. SSRN Journal. 2020. doi: 10.2139/ssrn.3716864
• 13 Nielsen J, Dahm M, Lublin H, et al. Psychiatrists’ attitude towards and knowledge of clozapine treatment. J Psychopharmacol. 2009; 24 :965–71. doi: 10.1177/0269881108100320
• 14 Verdoux H, Quiles C, Bachmann CJ, et al. Prescriber and institutional barriers and facilitators of clozapine use: A systematic review. Schizophrenia Research. 2018; 201 :10–9. doi: 10.1016/j.schres.2018.05.046
• This article was corrected on 31 January 2022 to clarify that tobacco is an enzyme inducer, not an enzyme inhibitor

Useful structured introduction to the subject for clinical purposes

Thank you Amrit for your feedback, we are pleased that you found this article useful.

Michael Dowdall, Executive Editor, Research & Learning

Please note that smoking causes enzyme INDUCTION not INHIBITION as stated. (Via aromatic polyhydrocarbons, not nicotine)

Hi James. Thank you for bringing this to our attention. This has now been corrected. Hannah Krol, Deputy Chief Subeditor

Only with Herbal formula I was able to cure my schizophrenia Illness with the product I purchase from Dr Sims Gomez Herbs A Clinic in South Africa

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Case Study: Schizophrenia and Work: Martin’s Story

Martin had been out of work for several years following a prolonged psychotic episode which began when he was studying at university. He desperately wanted to get into work but found that employers treated his prolonged absence “on the sick” with suspicion. He thought that if he could do a period of work experience that would show prospective employers that he was capable of working again but he was afraid that if he did it might affect his benefits.

So Martin made an appointment to see the Disability Employment Advisor at the Jobcentre to discuss his plans. She was understanding and helpful and explained that a work placement would not affect his benefits as long as it was done as part of the Jobcentre’s own scheme. She also told him that the scheme would pay his travel-to work expenses while he was on the placement.

Job-searching

Next Martin researched local employers using the internet and the local press, looking for companies that might have vacancies in the sort of clerical and administrative work he thought he could do. Then he called the companies by ‘phone and speaking to the person on the switchboard checked that he had the correct postal address for them and asked the name of the person in charge of recruiting. It is vital to be able to write to a named person rather than just the Human Resources Manager.

Martin had already spent a lot of time on his CV so now he compiled a covering letter to go with it. It took him about a month to work up his CV and covering letter using books that he got from the local library. He also managed to get advice from a local back-to-work scheme recommended by the Disability Employment Advisor at the Jobcentre. Martin knew that it was essential that his letter and CV had the maximum impact.

Martin sent his CV and letter off to six employers and then waited about a week before calling them up on the ‘phone. He asked to speak to the person he had written to but if the person on the switchboard asked the reason for his call he simply said that he was calling to follow up a letter he had written.

After approaching about 20 employers in this way he finally found one who said there could be an opening for work experience in a couple of months time. So over the next three months Martin kept in touch with the company by ‘phone once a month just to let them know that he was still keen on coming to work for them.

The interview

Finally the company asked him in for an interview. Before going to the interview Martin prepared really well in advance by researching the company well and trying to anticipate the sorts of questions he would be asked. He also went to the local library and took out some books on interview techniques and managed to get on a one day course on interview skills that the Jobcentre had told him about. This included a mock interview which he found particularly useful.

The day of the interview arrived and Martin was very nervous but he was up early and washed and dressed. To be sure of being on time he left an hour early and checked out the location of the office. Then he went to Starbucks for a coffee while he waited. This gave him an opportunity to flick through his notes and prepare on some of the answers he had been working on. He made sure that he was punctual and well groomed and did his best to present himself well at the interview.

Despite being really well prepared walking through the front door of the office was one of the hardest things that he had done for years. But the receptionist was polite and could not have been more helpful. She made him feel welcome and even offered him a coffee (which he declined).

The Human Resources Manager who interviewed Martin was very professional but quickly put him at his ease. He asked questions about his education at school, his hobbies and pastimes and his qualifications and then came the bit that Martin had been dreading when the HR Manager asked him why he had dropped out of college. Martin explained that he had had a breakdown caused by too much stress while he was at college. He went on to explain that although it was a bad breakdown it was behind him now and that with the help of his family and friends and his doctor he had been able to make a really strong recovery. He also explained that in some ways the experience had made him a stronger person and that he had matured as a result of it.

As the end of the interview approached Martin was sure that he had flunked it but the interviewer told him that he had been successful and asked him to start on Monday. Martin was delighted to be offered a period of three months unpaid work experience during which he would work for two days a week at their local office doing clerical and administrative work.

Martin was walking on air when he left the office. All his hard work had been worth it.

The next day Martin called the Disability Employment Advisor at the local Jobcentre to tell them about the offer and see how his benefits would be affected. She confirmed that his benefits wouldn’t be affected as long as he only worked for 16 hours a week.

The placement

For the next three months Martin worked hard at his placement. He made sure that he got all the basics right: being punctual and well groomed every day. At work he was helpful and got on well with the other workers. Although he was very shy at first he soon learned the importance of making small talk with his colleagues and building good working relationships.

As the end of his placement approached Martin wondered if he would be offered a permanent position. He asked the HR Manager about this but sadly he was told that there were no permanent vacancies at that time so when the end of his placement came Martin had mixed feelings. On the one hand he was disappointed that the work experience had not turned into a permanent job but on the other hand he had had three months experience in the workplace and had something to put on his CV to demonstrate to other employers that he could work. And most importantly he had that all important reference from a well respected local employer.

But that isn’t quite the end of the story. Martin continued searching for a job without success for another six months but continued to keep in touch with the HR Manager he had worked for during his work experience. One day he saw in the local press that they were advertising for a clerical assistant so he called them and explained that he was still jobsearching and would be available for this position. The HR Manager was very pleased to hear from him and said that he would call him back. The next day Martin got a call asking him to go in for an interview straight away and was offered the job.

Martin called the Jobcentre Plus helpline and found out what benefits he would be entitled to while he was working and was pleased to find out that he would be better off in work.

Martin has now been employed in his new job for two years and is delighted to be living an independent lifestyle free of the benefits culture he was in before. It has had its difficulties though. For instance Martin found that his illness had left him emotionally very sensitive and that he found it difficult to cope if his work was criticised. But he knew that this was something he had to learn to live with and gradually he managed to learn new social skills that helped him to cope better and at the same time helped him in other areas of his life.

Martin has enjoyed the structure that the new job has brought to his life. He enjoys the work and the social contact that the job entails. He has made new friends and above all his self-esteem has grown vastly. Now when people ask him what he does for a living he no longer has to say that he is unemployed.

Some Key Points from Martin’s Story:

• Research the local job market really well
• Before writing to a firm call to check the postal address.
• Find out the name of the person in charge of recruitment. Writing to a named person makes sure your letter gets read.
• You can’t spend enough time preparing your CV and cover letter. Get as much help as you can from books, the library etc.
• When making follow up calls avoid Mondays and Fridays as these are busy days for people in business. Similarly don’t call too early in the morning or after 3.30 pm and don’t call around lunchtime.
• When making follow up calls be prepared for few false starts but use these to develop your technique. Treat the first half a dozen calls as practice calls.
• Don’t pester firms with too frequent follow up calls. Once every three weeks is about right.
• Be prepared for disappointment and don’t feel let down by it.
• Before going for an interview research the firm really well. Google and Google News and the local press are useful sources.
• It is perfectly normal to be nervous at an interview. Try to minimise the nerves by making sure you have planned and prepared well and getting a good night’s sleep beforehand.
• At the interview you may be asked about your illness. Be honest but there is no need to disclose your diagnosis at this stage unless you are asked directly: a broad brush explanation such as “a breakdown” is sufficient.

LWS Speaking Out

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• > Journals
• > Behavioural and Cognitive Psychotherapy
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• > A Behavioural Family Intervention with a Schizophrenic...

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A behavioural family intervention with a schizophrenic patient: a case study.

Published online by Cambridge University Press:  16 June 2009

A schizophrenic patient and his family were provided with a nine month multi-component behavioural intervention programme as part of a controlled study. The patient was at high risk of relapse according to the High EE status of his parents. Multiple outcome measures were used to assess the efficacy of the programme. The components of the intervention are described in detail, and the specificity of component effects in this case are examined. Given the methodological limitations of this type of study, it is not possible to demonstrate conclusively intervention effects in the case reported. However, following the intervention the relapse rate of the patient was reduced, his social functioning improved and the EE status of his parents changed from High to Low.

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• Volume 15, Issue 3
• Christine Barrowclough (a1) and Nicholas Tarrier (a1)
• DOI: https://doi.org/10.1017/S0141347300012337

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Case Study of a Young Patient with Paranoid Schizophrenia

• January 2015
• International Journal of Psychology and Psychiatry 3(2):139

• Vallabh Government College, Mandi (Himachal Pradesh)

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INTRODUCTION

Clinical pearl i – pharmacokinetics, clinical pearl ii – clozapine and agranulocytosis, clinical pearl iii – hyperprolactinemia and associated complications, case based clinical pearls: a schizophrenic case study.

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O. Greg Deardorff , Stephanie A. Burton; Case Based Clinical Pearls: A schizophrenic case study. Mental Health Clinician 1 February 2012; 1 (8): 191–195. doi: https://doi.org/10.9740/mhc.n95632

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Clinical pearls based on the treatment of a patient with schizophrenia who had stabbed a taxi cab driver are discussed in this case study. Areas explored include the pharmacokinetics of fluphenazine decanoate, strategies to manage clozapine-associated agranulocytosis, and approaches to addressing hyperprolactinemia.

Forensic psychiatry is a subspecialty in the field of psychiatry in which medicine and law collide. Practiced in many facilities such as hospitals, correctional institutions, private offices and courts, forensic psychiatry requires the cooperation of health care and legal professionals with the common goal of helping patients become competent of their legal charges and returning to a productive life in the community. In contrast to general psychiatric patients, the clients in this field have been referred through court systems instead of general practitioners and are evaluated not only for their symptoms but also their level of responsibility for their actions.

These patients can be some of the most challenging to treat because of factors such as non-compliance, an extensive history of failed medication trials, and the severity of their mental illness. Some of the most severe mentally ill patients reside in forensic psychiatric hospitals and have spent much of their lives institutionalized. Treatment refractory schizophrenia, defined as persistent psychotic symptoms after failing two adequate trials of antipsychotics, is a common occurrence in forensic psychiatric hospitals and often requires extensive manipulation of medication regimens to obtain a desired therapeutic response. Like other patients, these patients may present with barriers to using the most effective treatment such as agranulocytosis, inability to obtain and maintain therapeutic drug levels due to fast metabolism, or bothersome adverse effects such as hyperprolactinemia. In treatment resistant patients, it may still be necessary to use these medications even when barriers are present due to a lack of alternative therapeutic options not previously exhausted. In addition to complex regimens, treatment plans for these patients often require trials of multiple medication combinations or unique exploitation of interactions and biological phenomena.

We report a forensic case study that exemplifies multiple clinical pearls that may be useful in patients with treatment refractory schizophrenia. A 31-year-old African American female presented to the emergency room escorted by law enforcement after stabbing a cab driver with a pencil. The patient stated she was raped by the cab driver and while in the emergency room stated that “dirty cops brought me here.” She was admitted to the inpatient psychiatric unit to determine competency to stand trial for the assault of the cab driver. She had been in many previous correctional institutions with a known history of schizophrenia and additional diagnoses of amenorrhea, hyperprolactinemia, and obesity.

The patient's history was significant for auditory hallucinations and paranoid delusions beginning by age fourteen with a diagnosis of major depression with psychotic features. By age eighteen, she was diagnosed with schizophrenia, paranoid type. She had multiple previous hospitalizations and a history of poor compliance as an outpatient. There was no known history of tobacco, alcohol, or illicit drug use. Her family history was significant for schizophrenia, diabetes mellitus, and drug use. The patient reported abusive behavior by her grandmother, who was her primary caretaker as a child.

During hospitalization, the patient continued to report sexual assaults, accusing both patients and staff of rape, and declined to participate in groups. She denied any visual or auditory hallucinations but continued to exhibit paranoid delusions. The patient was later found to be permanently incompetent to stand trial and was committed to the state's department of mental health for long term treatment of her psychiatric illness.

The patient was previously treated with fluphenazine decanoate intermittently for two years with difficulty obtaining the desired therapeutic response. After approximately two months of therapy, the patient presumably at steady state (~14 day half-life) still failed to demonstrate any clinical response. There is no conclusive evidence that fluphenazine levels correlate with clinical outcomes, however the psychiatrist had worked with this patient in the past and felt the lack of response in this situation justified a fluphenazine level. 1 The fluphenazine level was shown to be 2.2ng/ml (therapeutic range 0.5–3 ng/ml) while taking fluphenazine decanoate 50mg intramuscularly (IM) every two weeks. Increasing the target drug level to the upper edge of the normal range was warranted in this patient due to the persistent positive symptoms and a desire to continue using a long-acting injectable agent, which can ensure the delivery of medication in uncooperative and noncompliant patients. Fluphenazine is a high potency first generation antipsychotic that can improve positive symptoms of schizophrenia; however it is not effective in treating the negative symptoms. It was decided that the addition of a CYP2D6 inhibitor such as fluoxetine would not only provide increased levels of fluphenazine, but would also improve the patient's negative symptoms such as flat affect, anhedonia, social isolation and amotivation. 2 Thus, fluoxetine was given as 20 mg orally (PO) daily resulting in an increase of the fluphenazine level by 0.9 ng/ml (40%) after twenty two days of therapy to 3.1 ng/ml. One month later the fluphenazine decanoate dose was increased to 125 mg IM every two weeks (max 100mg/dose), with continued fluoxetine treatment, resulting in a supratherapeutic level of 3.6 ng/ml. Positive and negative symptoms only showed minor improvement. A 6-week study by Goff, et al. demonstrated an increase of up to 65% in fluphenazine serum concentrations in patients administered concomitant fluoxetine 20 mg/day. 2 In this case, the addition of fluoxetine safely and effectively elevated fluphenazine blood levels. Addition of an inhibitor may be beneficial in patients who are CYP2D6 ultra-rapid metabolizers, as was suspected in this patient.

Many complications, including prolonged jail time, can arise from forensic clients being non-compliant with their medications, which is the reason long acting injectables are often warranted. Our patient had a history of non-compliance and continued to experience positive symptoms despite treatment with fluphenazine. Therefore, the decision was made to try another long-acting antipsychotic injection. After reviewing the patient's chart, it was noted that a previous trial of oral haloperidol 30mg/day showed moderate improvement. Thus, after tolerability and efficacy was determined with oral haloperidol the patient was converted to haloperidol decanoate 300 mg (10–15 x oral daily dose of haloperidol) administered every three weeks beginning two weeks after discontinuation of fluphenazine decanoate 125 mg IM every two weeks. Fluphenazine levels approximately six weeks after its discontinuation (and two weeks after the discontinuation of fluoxetine 20 mg PO daily) were still supratherapeutic. Given that this patient had a fluphenazine level of 3.6 ng/ml near the time of haloperidol decanoate administration, it would be questionable whether another high potency antipsychotic would be of any additional benefit in comparison to the increased risk of extrapyramidal side effects (EPS). Data provided in one study showed fluphenazine decanoate as being detectable for up to 48 weeks after discontinuation. 3 Because fluphenazine decanoate can be detected for such an extended period of time, it leaves the patient at a continued risk for extrapyramidal side effects, especially if another antipsychotic is added shortly thereafter. In the forensic population, many patients have treatment refractory schizophrenia and the use of antipsychotics will need to be life-long. It is often common for these patients to be on multiple concurrent agents, increasing the risk for developing long-term extrapyramidal side effects. Therefore, it is important to minimize the risk of these symptoms whenever possible.

Despite supratherapeutic levels of fluphenazine, the psychiatrist felt it would be beneficial to continue haloperidol decanoate 300 mg every three weeks with increased monitoring for signs and symptoms of EPS.

During the current admission the patient continued to exhibit paranoid behavior and lack of insight, expressed anger, and disliked attending or participating in groups. Her medication history included haloperidol, fluphenazine, quetiapine, aripiprazole, asenapine, olanzapine, paliperidone, and sixteen days of clozapine therapy before leukopenia warranted discontinuation. Due to her extensive history of failed antipsychotics and the known superior effectiveness of clozapine, this patient was an ideal candidate for clozapine therapy. Additionally, because of the poor quality of life a declaration of incompetency would lead to, using the most effective possible agent is an important priority in forensic patients. Clozapine is the most effective antipsychotic based on the U.S. Clinical Antipsychotic Trials of Intervention Effectiveness (CATIE) and the UK Cost Utility of the Latest Antipsychotic Drugs in Schizophrenia Study (CUtLASS). 4 , 5 In regards to the significant blood draws and monitoring that is continuously required, clozapine can be a challenging medication to use in treatment refractory patients.

One strategy we are currently working on in our hospital to help increase the number of patients on clozapine is using a point of care (POC) lab device which will allow a complete blood count (CBC) plus 5-part differential to be completed by finger stick, instead of weekly blood draws that our nurses, physicians and, especially, patients dislike. The cost of the POC lab device is approximately $20,000, although upon completion of a cost analysis it was found that five CBCs per day would pay for the cost of the machine after one year. Many times, these patients can become irritated and violent when having their blood drawn, especially, if on a consistent basis. Repetitive blood draws was noted by our physicians to be the largest obstacle in using clozapine in our treatment refractory patients.

Our primary challenge in using clozapine for this patient was finding a way to maintain the absolute neutrophil count (ANC) within acceptable limits (≥1500mm 3 ), which is not uncommon for many patients. The Clozaril Patient Monitoring Services revealed 0.4% of patients had pre-treatment white blood cell counts (WBC) too low to allow initiation of clozapine. Of these patients, 75% were of African or African-Caribbean descent, likely due to the increased leukocyte marginalization that has been shown to be more prominent in these populations. 6 Of all neutrophils in the body, 90% reside in the bone marrow and the remainder circulates freely in the blood or deposit next to vessel walls (margination). The addition of lithium has been shown to increase neutrophil counts by 2000/mm 3 through demarginalization of leukocytes. 7 This increase is not dose –related but may require a minimum lithium level of 0.4 mmol/L. 8 , 9 Lithium therapy used to increase neutrophil counts may be especially effective in patients of African or African-Caribbean descent due to demarginalization of leukocytes. In this patient case, lithium 300 mg by mouth three times daily was initiated for fifteen days to increase the absolute neutrophil count from 1200/mm 3 to ≥ 1500/mm 3 for continuation of clozapine while the white blood cells continued to stay within appropriate limits of ≥3000/mm 3 . It was soon realized that lithium was being cheeked, so liquid form was given, but discontinued after the patient continued to spit the medication out. Unfortunately, clozapine was discontinued thereafter as a result of noncompliance with the lithium causing failure to maintain appropriate white blood cell counts.

Another possible strategy for obtaining appropriate WBC and ANC levels that would enable clozapine continuation is to obtain blood samples later in the day. A study recently published compared the same set of patients having early morning blood draws to blood draws taken later in the day (mean sampling time - pre/post was 5 hours 24 minutes). 10 They showed a difference in the pre/post time change in WBC values being marginally significant (mean increase=667/mm 3 , p=.07), with a significant difference (mean increase=1,130/mm 3 , p=.003) between the pre/post time change in ANC values. ANC values were impacted to a greater extent by the time change than WBC values in this sample. Changing the time at which blood draws are taken during the day may allow for clozapine continuation by limiting the risk of pseudoneutropenia, however it remains the clinician's responsibility to discern between benign or malignant neutropenia. 10 It is recommended, for patients with WBC values trending down or below the predefined criteria, to have labs redrawn several hours after the morning lab before clozapine therapy is discontinued. 10 In this case study, obtaining the sample later in the day may have allowed our patient to continue clozapine therapy.

The patient in this case had additional diagnoses of amenorrhea and hyperprolactinemia. The diagnosis of amenorrhea prompted clinicians to obtain labs showing a prolactin level of 168.8 ng/ml (normal ranges: 3–20ng/ml for men; 4–25ng/ml for non-pregnant women; 30–400ng/ml for pregnant women). Lab monitoring of prolactin levels is not necessary if the patient is not exhibiting symptoms such as disturbances in the menstrual cycle, galactorrhea, gynecomastia, retrograde ejaculation, impotence, oligospermia, short luteal phase syndrome, diminished libido or hirsutism. Monitoring guidelines published in 2004 by APA recommend screening for symptoms of hyperprolactinemia at each visit for the first year and then yearly thereafter. Mt. Sinai Conference Physical Health Monitoring Guidelines for Antipsychotics published in 2004 recommended monitoring at every visit for the first twelve weeks and then yearly.

Occasionally, practitioners are confronted with the dilemma of whether treatment of hyperprolactinemia is warranted in asymptomatic patients. In answering that question, a few things should be considered, such as the patient's risk for osteoporosis and/or cardiovascular disorders. If there are no physical issues of concern, then psychological issues should be addressed. Estrogen deficiency, which may occur with increased prolactin, mediates mood, cognition and psychopathology. 11 Results of several studies conducted in women with hyperprolactinemia have demonstrated increased depression, anxiety, decreased libido and increased hostility. Men shared similar problems but did not exhibit an increase in hostility. 12 The authors hypothesized that women demonstrated increased hostility as a protective mechanism for their offspring.

Antipsychotic medications have differing potencies in regards to hyperprolactinemia, which may help guide product selection. The most potent inducer is risperidone, followed by haloperidol, olanzapine, and ziprasidone. 13 Clozapine and quetiapine are truly sparing, and aripiprazole has even been shown to reduce prolactin levels. 14 Aripiprazole may be a viable treatment option in some patients with hyperprolactinemia. In one study, females with risperidone induced hyperprolactinemia taking therapeutic doses of risperidone 2 to 15 mg/day showed significantly lower prolactin levels from weeks 8 to 16 compared to baseline when administered aripiprazole (3, 6, 9, or 12 mg daily). 15 The mean percent reductions in prolactin concentration at 3, 6, 9, and 12 mg daily were approximately 35%, 54%, 57%, and 63%; however, there was little variability in prolactin levels above 6 mg daily of aripiprazole. Therefore, unless giving liquid form, aripiprazole 5mg daily should be an optimal dose in lowering prolactin levels. In this case, the patient exhibited the clinical symptom of amenorrhea, which correlated with an elevated prolactin level. The addition of aripiprazole 10 mg by mouth once daily decreased this patient's prolactin level by 51 ng/mL (30.3%) after twelve days of treatment.

If an elevated prolactin level is incidentally found, the patient should be monitored for symptoms and labs may be repeated. In patients exhibiting symptoms of hyperprolactinemia with a serum level <200 ng/mL, the antipsychotic dose should be reduced or the agent changed to a more prolactin-sparing drug. 13 If switching the agent is not reasonable, the addition of a dopamine agonist such as bromocriptine or cabergoline may be beneficial, as well as the antiviral agent amantadine. 16 In patients with levels >200 ng/mL, or with persistently elevated levels despite changing to a more prolactin-sparing agent, an MRI of the sella turcica should be obtained to rule out a pituitary adenoma or parasellar tumor. 13 Practitioners should be aware that prolactin levels may remain elevated for significant periods of time following discontinuation of a long acting causative agent due to continued D 2 receptor antagonism. 1 One study found elevated prolactin levels in patients who discontinued fluphenazine decanoate as much as six months after the last injection. 1 , 3  

In summary, we have discussed a few clinical pearls to be considered when working with treatment refractory patients with schizophrenia and outlined some unique aspects of treatment in forensic clients. First, we reviewed potential complications and concerns with using fluphenazine decanoate. In addition, we discussed that ultra-rapid CYP2D6 metabolizers may need an increase in dose when appropriate and/or an addition of an inhibitor. Secondly, patients with agranulocytosis that may benefit from clozapine may find improvement in WBC and ANC values with the administration of lithium and/or changing the time of day in which labs are drawn.

Lastly, hyperprolactinemia may result in not only physical symptoms but psychological symptoms as well. Also, health care providers should not only be cognizant regarding how and when to monitor for hyperprolactinemia, but also the various treatment options available, such as changing to less offensive agents, dopamine agonists, or adding low dose aripiprazole. This patient case exemplified multiple strategies that can be considered when managing treatment refractory patients in which alternative options for therapy are not readily available.

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Paranoid Schizophrenia: a Case Study Analysis

How it works

• 1 Introduction
• 2 John Doe’s Diagnosis and Early Symptoms of Paranoid Schizophrenia
• 3 Medications and Therapy for Schizophrenia
• 4 The Social and Personal Impact of Paranoid Schizophrenia on Daily Life
• 5 Conclusion

Introduction

Paranoid schizophrenia is a really tricky and complex mental disorder. It messes with how a person thinks, feels, and behaves. Out of all the types of schizophrenia, paranoid schizophrenia stands out because of its strong delusions and hearing things that aren’t there, usually about being persecuted or having grand ideas. This essay is gonna dive into the details of paranoid schizophrenia using a real-life case study. We’ll look at the symptoms, how it’s diagnosed, the treatments, and how it affects someone’s life.

By looking closely at one person’s experience, we’ll get a better idea of the challenges and details of dealing with this disorder. This will help us understand both the medical side and the personal side of paranoid schizophrenia, which can improve how we treat it and how society views it.

John Doe’s Diagnosis and Early Symptoms of Paranoid Schizophrenia

Let’s talk about John Doe, a 35-year-old guy diagnosed with paranoid schizophrenia. John started showing symptoms in his early twenties. At first, he began to withdraw from social situations, acted kinda strange, and had trouble keeping up with school and work. Over time, things got worse. He started having delusions, thinking government agencies were following him, and heard voices saying mean things about him. These symptoms made it hard for him to live a normal life, leading to several hospital stays and needing lots of support from his family. According to the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), you need to have at least two main symptoms like delusions, hallucinations, messed-up speech, or weird behavior to diagnose schizophrenia. John’s constant delusions and hearing things, along with his struggles at work and socially, confirmed he had paranoid schizophrenia.

Medications and Therapy for Schizophrenia

Treating John’s condition has been a mixed bag, using both meds and therapy. He takes antipsychotic drugs, mainly second-generation ones like risperidone and olanzapine, to help manage his symptoms. These drugs work by affecting brain chemicals, especially dopamine, to reduce hallucinations and delusions. But, John’s response to these meds has been hit-or-miss. Sometimes he feels better, but then he’ll relapse, needing changes in his meds or dosage. Besides meds, John has tried cognitive-behavioral therapy (CBT) to help him rethink his delusions and cope with stress and bad feelings. His family also gets involved through family therapy, which teaches them how to better support John at home. Still, John faces big challenges, showing he needs ongoing, complete care and support.

The Social and Personal Impact of Paranoid Schizophrenia on Daily Life

The effect of paranoid schizophrenia on John’s life goes beyond just his symptoms. It hits his social life, work opportunities, and overall well-being. Social isolation is common with schizophrenia, and John is no different. His delusions and paranoia have strained his relationships with friends and coworkers, making him feel more alone. Work-wise, John struggles to keep a steady job, which leads to money problems and relying on disability benefits. On top of that, the stigma around mental illness makes it harder for him to fit in and get help. Despite all this, John has shown a lot of strength. Thanks to his treatment team and family, he’s joined vocational rehab programs to boost his skills and job chances. Plus, peer support groups have given him a sense of community, letting him share experiences and tips for managing his condition.

John Doe’s story shows just how complex paranoid schizophrenia is and why a well-rounded treatment plan is so important. This case study gives us a look into the deep impact of the disorder, covering not just the medical symptoms but also the bigger social and everyday life issues. To manage paranoid schizophrenia well, you need a mix of meds and therapy, tailored to each person. Plus, fighting the stigma around mental illness and creating supportive environments are key to improving life for those affected. As we keep learning more about schizophrenia, it’s crucial to take a compassionate and thorough approach, recognizing the courage and humanity of people like John who bravely face this disorder.

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KarXT: PDUFA Date Approaches for Potential Treatment for Schizophrenia

The PDUFA date for KarXT for schizophrenia is September 26, 2024. Here’s what one expert thinks of this potential treatment.

CLINICAL CONVERSATIONS

The US Food and Drug Administration will issue a response by September 26, 2024, to the New Drug Application for Bristol Myers Squibb and Karuna Therapeutic’s highly-anticipated schizophrenia drug, KarXT. In advance of this decision, Psychiatric Times sat down with experts like Gil Lichtshein, MD, to learn more about how mental health clinicians feel about this possible treatment.

Psychiatric Times : There has been much excitement about the potential approval of KarXT for the treatment of schizophrenia. Why should clinicians care about this agent? What are you most excited about regarding this agent?

Gil Lichtshein, MD: This could be a very important development. First, it is essential to note that postmortem studies show lower levels of M1 and M4 receptor expression in brain regions implicated in schizophrenia. 1 Additionally, 25% of patients with schizophrenia have greater than 75% fewer M1 receptors than healthy patients. 2 M1/M4 receptor knockout models replicate the phenotype of schizophrenia in mice, and muscarinic agonists, especially for M4, improve positive and negative symptoms of schizophrenia in mice and humans. 3

This is where xanomeline-trospium (KarXT) comes in. Xanomeline is a muscarinic M1/M4 agonist that improved Brief Psychiatric Rating Scale (BPRS) and Positive and Negative Syndrome (PANSS) scores in patients with schizophrenia. While gastrointestinal adverse effects limited further clinical development, ultimately, the addition of trospium made xanomeline-trospium viable. Trospium is a muscarinic receptor antagonist that has minimal, if any, penetration of the blood brain barrier, blocking unwanted peripheral cholinergic adverse effects of xanomeline.

PT : How does the unique mechanism of action of KarXT, targeting muscarinic receptors, impact the positive and negative symptoms of schizophrenia?

Lichtshein: In terms of efficacy advantages, the effect sizes of xanomeline-trospium for symptom reduction are as high or higher than agents approved for schizophrenia in the past 25 years, and have been replicated in 3 clinical trials.

In terms of tolerability, there are no metabolic, endocrine, or motor adverse effects. Xanomeline-trospium does require titration in the first week to mitigate its pro-cholinergic adverse effects. As to practical issues, concurrent use of centrally acting anticholinergics (eg, benztropine) and possibly strongly anticholinergic antipsychotics (eg, olanzapine) can interfere with the mechanism of action for muscarinic agonists or positive allosteric modulators. Since KarXT has much less motor adverse effects, the need for use of centrally acting anticholinergics would be less likely.

PT : How might the approval of KarXT influence the current guidelines for schizophrenia treatment, and where do you see it fitting in the treatment algorithm?

Lichtshein: Muscarinic agents may be considered first-line treatments along with standard serotonin/dopamine antagonists. They certainly will be options in patients who have not responded to 1 or 2 serotonin/dopamine antagonists and could undoubtedly improve patients who have not done well on current atypical antipsychotics.

PT : If approved, what practical advice would you give to clinicians who are considering including KarXT in their treatment plans for patients with schizophrenia?

Lichtshein: This is what I do with new medications: I try to learn as much as I can about any new medicines by attending conferences or doing CME articles and understanding the positives and negatives of any new medication, what it is indicated for, and how it could be best utilized in treating patients. In this case, treating patients with schizophrenia, I may consider M1 M4 muscarinic agents as first-line treatments. I might use them initially in new patients with schizophrenia given their more benign adverse effect profile as the potential development of metabolic syndrome is a significant concern and patients with schizophrenia are already at an increased risk of developing metabolic syndrome.

PT : If approved, what types of patients do you think will benefit the most from this agent?

Lichtshein: Once approved, I believe that these types of medications will potentially benefit patients who have not responded to standard, atypical antipsychotics and ones who are being considered for clozapine as a potential option before choosing the route of clozapine.

PT : You recently attended a conference where this agent was being discussed. What was the sense from your colleagues about it? What did you take away from that discussion?

Lichtshein: I attended a conference on psychopharmacology at the University of Cincinnati about 1 year ago, and they were very excited about discussing muscarinic agents and the treatment of schizophrenia, which provides some shift in the treatment focusing away from dopaminergic agents to cholinergic agents.

PT : Is there anything else you want to share with your colleagues?

Lichtshein: This is exciting because it provides another treatment option for patients who are not responding to atypical antipsychotics, and many atypical psychotics cause weight gain and increase the risk for metabolic syndrome and KarXT as reduced risk for weight gain and subsequent development of metabolic syndrome.

The main feature of the M1 M4 muscarinic agents is that they modulate dopaminergic activity without causing motor or metabolic adverse effects.

PT : Thank you!

Dr Lichtshein is a board-certified psychiatrist in Boca Raton, Florida.

1. Scarr E, Hopper S, Vos V, et al. Low levels of muscarinic M1 receptor–positive neurons in cortical layers III and V in Brodmann areas 9 and 17 from individuals with schizophrenia. J Psychiatry Neurosci . 2018;43(5):338-346.

2. Money TT, Scarr E, Udawela M, et al. Treating schizophrenia: novel targets for the cholinergic system. CNS Neurol Disord Drug Targets . 2010;9(2)241-256.

3. Foster DJ, Bryant ZK, Conn PJ. Targeting muscarinic receptors to treat schizophrenia. Behav Brain Res . 2021;405:113201.

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Understanding Schizophrenia: A Case Study

Schizophrenia is characterized mainly, by the gross distortion of reality, withdrawal from social interaction, disorganization and fragmentation of perception, thoughts and emotions. Insight is an important concept in clinical psychiatry, a lack of insight is particularly common in schizophrenia patient. Previous studies reported that between 50-80% of patients with schizophrenia do not believe, they have a disorder. By the help of psychological assessment, we can come to know an individual's problems especially in cases, where patient is hesitant or has less insight into illness. Assessment is also important for the psychological management of the illness. Knowing the strengths and weaknesses of that particular individual with psychological analysis tools can help to make better plan for the treatment. The present study was designed to assess the cognitive functioning, to elicit severity of psychopathology, understanding diagnostic indicators, personality traits that make the individual vulnerable to the disorder and interpersonal relationship in order to plan effective management. Schizophrenia is a chronic disorder, characterized mainly by the gross distortion of reality, withdrawal from social interaction, and disorganization and fragmentation of perception, thought and emotion. Approximately, 1% world population suffering with the problem of Schizophrenia. Both male and female are almost equally affected with slight male predominance. Schizophrenia is socioeconomic burden with suicidal rate of 10% and expense of 0.02-1.65% of GDP spent on treatment. Other co-morbid factors associated with Schizophrenia are diabetes, Obesity, HIV infection many metabolic disorders etc. Clinically, schizophrenia is a syndrome of variables symptoms, but profoundly disruptive, psychopathology that involves cognition, emotion, perception, and other aspects of behavior. The expression of these manifestations varies across patients and over the time, but the effect of the illness is always severe and is usually long-lasting. Patients with schizophrenia usually get relapse after treatment. The most common cause for the relapse is non-adherent with the medication. The relapse rate of schizophrenia increases later time on from 53.7% at 2 years to

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