History: A secluded life
Mr. K, 31, immigrated to Brooklyn as a child with his family. At age 19, he was working as an auto mechanic in a relative’s garage when he had his first psychotic episode. He was hospitalized and diagnosed with paranoid schizophrenia, which was confirmed by his subsequent course of illness and a recent structured diagnostic interview.
Since becoming ill, Mr. K almost never leaves his house and socializes only with his mother and sister. Unable to work, he helps around the house and often cares for his nieces and nephews. He has no history of substance abuse and has been faithfully taking his medication since his last hospitalization 8 years ago.
Mr. K’s outpatient clinic chart reflects concern about persistent negative symptoms. He hardly speaks in session. Even when “stable,” his social and vocational functioning has been poor. Therapeutic dosages of oral haloperidol, haloperidol decanoate, and fluphenazine have not worked, and trials of risperidone and olanzapine—administered in therapeutic dosages for at least 3 months—were only slightly more effective. Attempts to treat his social withdrawal as a depressive symptom equivalent, with use of adjunctive selective serotonin reuptake inhibitors, also have been disappointing.
We eventually discovered that his so-called negative symptoms were in fact the manifestation of persistent positive symptoms (Table 1). His social withdrawal stemmed not from lack of motivation but from ideas of reference and constant paranoid fears. He believed that if he left the house, a street gang would kill him or his family. When he did venture outdoors, he thought that strangers were ridiculing or insulting him or intended to brutally attack him.
Mr. K spent much of his time at home reading, occasionally visiting the public library just long enough to check out a few books. Family members convinced him to attend church services, but he could not interact with other parishioners because he feared they would find out something was “wrong” with him.
How would you address Mr. K’s positive symptoms? Would you try another antipsychotic after lack of response to five other agents?
Drug treatment: A clinical trial
After a thorough evaluation, Mr. K entered a clinical trial during which he began taking another antipsy-chotic. But after 4 months at high therapeutic dosages, his positive symptoms showed no change from baseline.
We then recommended that Mr. K try clozapine. His persistent paranoid delusions and lack of response to other antipsychotics made him an ideal candidate for this agent. Because he was compliant, motivated, and had available family support, we were confident that he could surmount the vicissitudes of a clozapine trial.
Mr. K refused to try clozapine, however. After so many unsuccessful medication trials over the years, he said he felt some (albeit minor) benefits from his current study medication and wanted to stick with it.
What treatment options remain for Mr. K?
Dr. Weiden’s and Burkholder’s observations
Although the newer antipsychotics have greatly improved outcomes in schizophrenia over the past decade, many patients still battle persistent psychotic (positive) symptoms despite compliance with these medications.1 While clozapine remains the treatment of choice for positive symptoms, some patients cannot—or will not—take it because of its burdensome side-effect profile.
It is well accepted that supportive psychotherapy can help a person with schizophrenia confront the secondary issues of loss, disability, and stigma. But psychotherapy is rarely considered as an adjunct therapy for treatment-resistant positive symptoms. Skepticism about the role of psychotherapy is understandable, because older studies that demonstrated psychoanalytic psychotherapy’s lack of effect on schizophrenia’s positive symptoms2 have driven psychiatric medical education and practice for the past half-century. Other non-psychoanalytic therapeutic approaches had not been studied until recently, so most of us generalized from the disappointing results of the psychoanalytic psychotherapy research.
Still, there is a resurgence of interest in using cognitive-behavioral principles to treat core schizophrenia symptoms. Several randomized, controlled studies—almost all performed in the United Kingdom—have demonstrated that a cognitive-behavioral therapy (CBT) approach, modified for schizophrenia, is superior to more traditional supportive therapies in treating persistent positive and negative symptoms.3-5 Until recently, CBT for schizophrenia has generated little interest or research on this side of the Atlantic.
Continued treatment: A new approach
At this point, we decided to address Mr. K’s paranoid symptoms with CBT-based psychotherapy. The patient, whom we’d been seeing twice monthly for medication management, agreed to weekly 45-minute CBT sessions across 3 months. A third-year resident who had treated Mr. K during the antipsychotic clinical trial administered the therapy as described in the literature.4-6
During the first sessions, we found that some of Mr. K's fears of leaving the house stemmed from living in a poor inner-city neighborhood with a high rate of violent crime. A few sessions later, Mr. K was able to question some of his beliefs that assassins had targeted his family.