Understanding and Caring for People with Schizophrenia

Fifteen Clinical Cases

Ragy R. Girgis, Gary Brucato, Jeffrey A. Lieberman

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000209914
• Edition: 1
• Topic: Psicologia
• Subtopic: Neuropsicologia

This book challenges professional and public misconceptions of schizophrenia as an illness with intractable symptoms and inexorable mental deterioration, educating clinicians and researchers on the effectiveness of treatment to change the course of or prevent the onset of illness.

The authors illustrate such effectiveness through fifteen case studies examining psychosis in diverse clients. These case studies are divided into the three phases of the illness—prodromal/clinical high risk, first-episode, chronic, and treatment-refractory—with accompanying analyses of the causes, symptoms, interventions and treatments. By depicting patients at different clinical stages of the illness, with accompanying explanations of how they got to that point, what might have been done to avoid – or has been done to achieve – this outcome, the reader will gain an appreciation of the nature of the illness and for the therapeutic potential of currently available treatments.

Readers will learn about the various clinical aspects of schizophrenia and treatment including diagnosis, prognosis, clinical presentation, suicide risk, cognitive deficits, stigma, medication management, and psychosocial interventions.

PART I

Onset (Early Identification and Prevention)

1

USING PSYCHOTHERAPY AND MEDICATIONS TO TREAT A TEENAGER WITH PRODROMAL SYMPTOMS

“Fran” was a 17-year-old conservative Mormon female who was referred to our clinical high-risk for psychosis (CHR) clinic by her private psychiatrist in the context of possible attenuated positive symptoms. She and her family trace their roots back to the first Mormon communities in Western New York. Her ancestors migrated from New York to Ohio to Missouri and then to Utah where they settled in an exclusively Mormon community. Fran’s family lived in Utah for many generations. Fran was born in Utah. She was born at term and without complications. She achieved her developmental milestones on time and was a generally healthy child. Fran enjoyed a life immersed in a conservative Mormon culture and community. She had many friends and a robust social life, along with her family and many other families in her community.

At the age of ten, Fran’s father, who was a Mormon clergyman, was asked to lead a Mormon community in another state. Although unhappy and somewhat frightened about the move since neither had ever lived anywhere except for in Utah and in an exclusively Mormon community, Fran and her mother, a homemaker, were obedient to the requests of the church. Therefore, Fran and her parents left their community in Utah and moved to a small community in another state.

The move was difficult for Fran. She was exposed to different cultures and lifestyles, substantially different from her own. The move was made more difficult by her mother’s very adverse reaction to the move. Away from her family and friends, all of whom were still in Utah, Fran’s mother became very sad and anxious. She felt out of place and was unable to deal with her feelings of isolation. Her depression, anxiety, and feelings of isolation were worsened by the lack of availability of Fran’s father, who was extremely busy, working 7am–10pm seven days a week, building and tending to his young congregation. The difficulties that Fran’s mother faced prevented her from being available, both emotionally and practically, to Fran during the difficult transition period.

By the age of 15, Fran began to experience substantial depression and anxiety. Her depression and anxiety began to affect her performance at school. Therefore, Fran began to see a therapist, and then eventually a psychiatrist. She participated in weekly psychotherapy, as well as monthly medication management. Fran saw her therapist and psychiatrist for approximately two years before she was referred to our clinic. The reason for the referral was that Fran’s therapist and psychiatrist were not sure why their treatments were not having a substantial effect, and they suspected, though were not sure, that “something else may be going on.”

When we first met Fran we were struck by how shy she was, as well as by how intelligent she was. She appeared young for her age. She rarely made eye contact. Her speech was very sophisticated, clear, and eloquent, although she had minimal spontaneous speech. She described her mood as “depressed” and had a blunted affect. She stated that, in the previous two years, people had given her feedback that she looked tired and apathetic, sometimes asking, “Are you okay?” Fran reported anxiety since age ten, characterized by nervousness when having to socialize or be in public places, with some school refusal. She reported a serious period of depression in the tenth grade, characterized by not leaving her room, crying, decreased appetite and subsequent weight loss, low self-esteem, low energy, impaired concentration, and intermittent suicidal ideation, with images of hanging herself or overdosing, with two attempts to drown herself to death, without success, prompting hospitalization. While her mood had improved substantially since this episode, she continued to experience chronic dysphoria and low motivation.

Fran described herself as anxious in social situation, but capable of maintaining a few good friends at a time despite this. In the year before presenting to our clinic, in the context of growing suspiciousness and low self-esteem, she began avoiding all social interactions, making excuses to avoid engagements with friends. She spent most of her time alone or with family, dancing in her room, reading, watching movies with her father, working on her homework, viewing television, and sleeping.

Despite her difficulties, Fran was in talented and gifted classes in elementary school and in honors classes in middle school. She was also a very successful and high achieving student from kindergarten through the ninth grade, earning straight “A”s. Upon entering her current school, her grades declined to mostly “B”s, which she and her family attributed to diminished interest and motivation. She also cited a period of hospitalization for suicidality and difficulty catching up with her work post-discharge. She had never failed a subject. Fran’s goal was to pursue further education in Japanese dance, with hopes of someday dancing for an eminent dance company and touring the country.

Fran described positive relationships with both of her parents, although she described some guilt about having been irritable with them at times across her lifetime. She also generally felt that they were not paying enough attention to her because she was a failure and was letting them down as a result of her dream to pursue Japanese dance, as well as because of her psychiatric condition. Her perception was that her parents would not approve of her wanting to pursue Japanese dance as a profession, but would have preferred her to pursue a career in academia. In addition, although her family was educated and knowledgeable about mental illness, she was self-conscious about it given the stigma surrounding mental illness.

The clinic to which Fran was referred was for individuals at clinical high-risk for psychosis. Schizophrenia usually develops in the mid- to late-teens or early twenties (1). It often begins with a period of attenuated symptoms (2). This period before schizophrenia fully develops is referred to as a “prodrome.” During this period, people experience delusions and hallucinations like people with full psychosis, though they are attenuated in nature, meaning that people who have them can still be convinced that their delusions or hallucinations are not real, i.e., they have less than 100% conviction. For example, prodromal individuals may have persecutory thoughts, such as that they are being watched, or the FBI is out to get them. However, they will maintain at least some insight, so that they can be convinced, for example, that the FBI is not out to get them, or that they may not be watched. Prodromal individuals may also have abnormal perceptual experiences like hallucinations, but understand that they are actually coming from their mind and are not real phenomena. For example, a prodromal person may hear a muffled voice, but understand that it is coming from their own mind.

Similarly, many prodromal individuals experience negative symptoms and cognitive deficits. These deficits are similar in quality to individuals with syndromal schizophrenia, though of a lesser intensity (2). For example, prodromal individuals may experience anhedonia, anergia, amotivation, alogia, apathy, and avolition. However, all of these would generally be experienced with less intensity than how someone with syndromal schizophrenia would experience them. Similarly, individuals with prodromal psychosis may experience cognitive impairments such as impaired attention, short-term memory, or executive functioning. These cognitive deficits tend to be milder than those experienced by individuals with schizophrenia.

Prodromal individuals also often experience a decline in academic and social functioning (2). However, this impairment in functioning is generally not as severe as that experienced by individuals with schizophrenia and may not be apparent until very close to when they actually develop syndromal schizophrenia. Furthermore, prodromal individuals very often experience other nonspecific symptoms such as depression and anxiety. Many of these people will have already received psychiatric care for comorbid conditions, such as major depressive disorder, obsessive compulsive disorder, or other anxiety disorders, before their diagnosis of prodromal psychosis. This period can last between days and years, though very uncommonly lasts more than two to two-and-a-half years (2, 3).

The prodrome is, however, a retrospective diagnosis as it can only be made once it is certain that someone has schizophrenia or psychosis, since not everyone with attenuated delusions and hallucinations develops schizophrenia. In fact, upwards of almost 8%–20% of the population has attenuated or full psychotic symptoms at some point in their lifetime (4, 5). Many of these people simply have schizotypal personality disorder or other conditions. Therefore, when someone is prospectively, or in real time, identified as having attenuated delusions and hallucinations, they are considered to be at “clinical high-risk” for psychosis, or CHR. Approximately 30% of CHR individuals actually develop a full, syndromal schizophrenia (2, 3). The word “prodromal,” then, can only be given after it is known that someone has developed a psychotic disorder.

This raises three very important questions. The first is if 20% of the population has at least attenuated positive symptoms at some point in their lives, how are CHR individuals diagnosed? The second is, once someone is diagnosed as being CHR, how would one determine whether a CHR individual is more likely than another to develop a syndromal schizophrenia? Third, what becomes of the 70% of CHR individuals who do not develop a syndromal psychotic disorder?

Regarding the first question, there are two main criteria used to distinguish people who are actually at high-risk for psychosis, which is actually a very uncommon diagnosis, and people who are not. First, people are generally only considered high-risk for psychosis if their attenuated positive symptoms develop between the ages of approximately 14–30. While it is possible for someone to develop schizophrenia at another age, it is much less likely. Therefore, people are only considered high risk for psychosis if these symptoms develop between the ages of 14–30.

The second criterion has to do with time course of symptoms. As described above, many people, such as individuals with schizotypal personality disorder, have attenuated positive symptoms that began when they were very young, even as children, and basically stay stable throughout their lives. Meanwhile, we know very well that the prodromal period is a very dynamic time when symptoms develop and progress relatively quickly (i.e., within two years) to schizophrenia. Therefore, only people with attenuated positive symptoms that are new or worsening in the previous year, and between the ages of 14–30, are considered to be at high-risk for transition to a syndromal psychotic disorder (6). Further, once identified as being at high-risk for psychosis, the vast majority of individuals who will transition to a full psychotic disorder will do so within two to two-and-a-half years (~95%) (2, 3).

Regarding the second question, once someone is diagnosed as being CHR, how would one determine whether a CHR individual is more likely than another to develop a syndromal schizophrenia? Many different criteria, calculators, algorithms, and variables have been examined and developed with little consensus or true distinguishing characteristic found. However, recent research suggests that not only does the recency and intensification of positive symptoms determine who is CHR, these criteria also serve as the best prognostic indicators for the development of syndromal schizophrenia. In particular, the more positive symptoms that someone has, which are new or worsening within the previous year, the more likely someone is to develop a syndromal condition (6).

What becomes of the 70% of CHR individuals who do not develop a syndromal psychotic disorder? Many of them have persistent, attenuated positive symptoms, as observed in the so-called “Cluster A” personality disorders from the DSM-IV – namely, schizoid personality disorder, paranoid personality disorder, and, most commonly, schizotypal personality disorder (7). Attenuated positive symptoms are also occasionally observed in the so-called “Cluster B” personality disorders, especially borderline personality disorder. In a substantial minority of cases, the positive symptoms remit and the patients are left with mood and anxiety disorders (8, 9). A small minority of patients completely remit from any psychiatric condition, although this is less common.

Fran had a number of attenuated positive symptoms. She reported a longstanding sense of the world feeling unreal, with thoughts that she might actually be unconscious but alive somewhere, dreaming what appeared to be the world around her. She reported 10% conviction about this idea, at peak. In the most recent several months, these experiences prompted thoughts that she might actually have been a host for a computer, or possibly another organism, with about 10% conviction at peak. Fran reported that, across her lifetime, she had the sense that her pet fish may actually have been aliens from another planet, controlling the channels on her television, with about 30% conviction at peak. This idea had increased in the previous year to occur daily with about 50% conviction at peak. Fran reported intrusive violent images over the previous nine months of running over baby deer or shooting an arrow through a person’s head, stating emphatically that she rapidly dismissed these images, which were ego-dystonic, and that she had no specific desire to act upon them. Since the eighth grade, she had the daily concern that she needed to censor her thoughts, because the pet fish in her home were transmitting her thoughts via radio waves to other planets. This concern had increased in the previous year, in terms of intensity and conviction, to 30% at peak. Fran reported daily concerns, since the tenth grade, that she might be infested with worms which cause occasional stomach upset, diarrhea, cramps, and occasional anal bleeding. This prompted anxious discussions with her parents who were uniformly able to encourage her to abandon this worry. Her conviction level had been about 25% about this idea with no increase in the previous year.

Fran did not present as guarded at any point throughout the interview process and was uniformly engaged and forthcoming. She reported concern over the previous year that other people disliked her and wished to harm her. She suggested they may have been plotting to harm her and may have been working with her pet fish. She suggested that the pet fish may have been supplying her classmates and other people in public areas with special guns that would disintegrate her hair and clothes, leaving her naked and bald, thereby exposing her to the world. She had increasing thoughts about this over the previous few months, to become daily, with about 30% conviction at peak and avoidance of some social interactions.

Fran reported several instances around age 13 of feeling that leaders of other religions were talking to her through the radio, trying to get her to change her religion, with about 50% conviction. Fran also described daily thoughts, starting about one year before presentation, with 90% conviction at peak that she would become a famous Geisha. She reported that she performed as a Geisha daily.

Fran also reported longstanding hypersensitivity to sound, especially low-pitched sounds that many other people would not hear, such as bass. Twice per week over the previous month she had heard her name called when nobody was around. One time she heard the word “ugly” and one time she heard a sound “like someone sneezing on me.” Several months before her presentation she saw something in the corner of her eye which she thought was one of her pet fish flying, though she understood that would have been impossible. About two months before her presentation she began feeling a warm sensation in her stomach and hips about two times per week.

Based on her symptoms, Fran met criteria for someone at clinical high-risk for psychosis. She agreed to enroll in our clinic and began receiving weekly psychotherapy and medication management. At the time she was considering college with a goal to attend a premier dance conservatory. However, the patient’s symptoms were debilitating and affecting her functioning. Fran still had her senior year of high school to complete. At the time of her presenta...