Patient evaluation on intake

36-year-old man states he “cannot sleep”

He is all “worked up” and his “head is all wrong at night”

Psychiatric history

Has been seen in practice over the last 10 years

Was admitted after two psychotic episodes

During these discrete spells he was noted to

• – Be hyper-religious in a paranoid manner

• – Be responding to internal stimuli

• – Experience occasional catatonic stupors

There is a baseline of mild negative symptoms where he

• – Is concrete in his thoughts and abstractions

• – Laughs at odd times

• – Talks loudly and at close interpersonal space

There are no other psychiatric comorbidities including substance misuse, mania, depression, or anxiety disorder

Social and personal history

Graduated high school

Works in the family business, which is considered a sheltered work environment, otherwise has not been gainfully employed

Single and has no close friendships outside extended family and church members

Has been involved and seems accepted in community volunteer activities

Does not misuse substances, nicotine, or caffeine

Medical history

There are no medical issues

He is routinely screened for metabolic disorders in conjunction with his PCP and currently is healthy

Family history

There is no family history of schizophrenia

Grandparents may have suffered MDD and GAD on both sides

Medication history

During the first two psychotic episodes he was placed on antipsychotics with remission of psychotic symptoms but with continued residual negative symptoms

• – The typical antipsychotic, haloperidol (Haldol) 10 mg/d for the first psychotic episode

• – The atypical antipsychotic, risperidone (Risperdal) 4 mg/d and the BZ clonazepam (Klonopin) 1 mg/d during the second episode

  • This atypical antipsychotic was used to lower the psychotic symptoms, hopefully improve the negative symptoms, lower acute EPS risk and the longitudinal TD risk

Remained without psychosis over the last decade on this last set of medications and now presents as a new patient because his psychiatrist has retired

Psychotherapy history

Attended supportive psychotherapy routinely throughout the last 10 years

Enjoys meeting his therapist

Looks forward to sessions although he is concrete and not psychologically minded regarding the perceived benefits

• – He cannot identify how therapy helps him

Patient evaluation on initial visit

Patient suffers from undifferentiated schizophrenia with paranoid and catatonic features

• – These terms are obsolete in the DSM-5 but do seem to quickly and accurately describe this patient’s schizophrenic presentation over the years

Over last several years, suffers only negative symptoms, making him appear more a residual schizophrenic

There are no other complaints regarding the schizophrenia now and he would like to continue his medications as given

Current medications

Risperidone (Risperdal) 4 mg/d (atypical antipsychotic)

Clonazepam (Klonopin) 1 mg/d (BZ)

Question

Over the last several years, this patient has suffered from only negative symptoms. What do you think will happen next?

He will remain a residual schizophrenic for the rest of his life

He will likely have a paranoid or catatonic relapse sometime

He will likely develop psychiatric comorbidities such as MDD or an anxiety disorder

Attending physician’s mental notes: initial evaluation

This patient has had two schizophrenic psychotic episodes after a classic prodrome

He is now doing well due to excellent medication and visit compliance, as well as his family’s support

Suspect that if his medications are maintained, he will continue only with negative symptoms

Will likely have to contend with movement or metabolic disorder side effects over time

Question

Which of the following would be your next step?

Do nothing as his medications are optimal

Lower his atypical antipsychotic slightly as he has been quite stable and this might lower his risk for long-term side effects

Lower the BZ sedative anxiolytic as he is not anxious or agitated anymore

Attending physician’s mental notes: initial evaluation (continued)

The combination of medications the patient is taking is currently effective and without side effects

As this was his first office visit, it may make sense to develop and maintain a solid rapport instead of making medication changes to a seemingly good regimen

It makes sense to keep in mind that reducing his antipsychotic to its minimally effective dose and lowering his anxiolytic may be worth considering for future visits