paranoid schizophrenia case study

Case study: a young male with auditory hallucinations in paranoid schizophrenia

Affiliation.

• 1 Adelphi University, Garden City, New York, USA. [email protected]
• PMID: 22613753
• DOI: 10.1111/j.2047-3095.2011.01197.x

Purpose: The purpose of this case study is to demonstrate use of the nursing process and the standardized nursing languages of NANDA International (NANDA-I), the Nursing Outcomes Classification (NOC), and the Nursing Interventions Classification (NIC) to assist a young male with paranoid schizophrenia to deal with auditory hallucinations.

Data sources: Data were obtained from the experience and expertise of the author and published literature.

Data synthesis: This case study demonstrates nurses' clinical decision making in providing care for an adolescent with mental illness.

Conclusion: This case study provides the pertinent nursing diagnosis, patient outcomes, and nursing interventions for a young male with auditory hallucinations in paranoid schizophrenia.

Implications for nursing: The use of NANDA-I, NOC, and NIC can provide the necessary framework for enhancing and improving the management of care with patients who experience auditory hallucinations in paranoid schizophrenia.

© 2011, The Authors. International Journal of Nursing Terminologies and Classifications © 2011, NANDA International.

Publication types

• Case Reports
• Hallucinations*
• Nursing Diagnosis
• Schizophrenia, Paranoid / diagnosis
• Schizophrenia, Paranoid / nursing*

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The Use of Narrative Therapy on Paranoid Schizophrenia

• Research in progress
• Published: 10 May 2023
• Volume 68 , pages 273–280, ( 2023 )

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• Karina Therese G. Fernandez 1 ,
• Anne Therese Marie B. Martin 1 &
• Dana Angelica S. Ledesma 1  

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Research suggests that a clinical diagnosis of schizophrenia is strongly linked with experiencing negative stereotypes and an inability to recover. In challenging the scientific-logical practice of diagnostic labeling, which totalizes the person’s experience around the illness, Narrative therapy offers a unique approach to treating schizophrenia by putting the spotlight on the client’s values, strengths, and beliefs. This allows the client to discover an alternative life narrative beyond their diagnosis. This study presents a case of a 40-year-old woman with paranoid schizophrenia. She felt that the people in her workplace were out to harm her so she would never work in her field again. At home, she had also begun to question herself as a mother. Narrative therapy techniques such as externalization, thickening the landscape of action and identity, and re-membering were used to aid the client’s recovery and helped her to shift from a problematic view of her identity. The present case focuses on providing steps to guide practitioners in using Narrative therapy for a case where the client has internalized their diagnosis as their identity.

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Narrative enhancement and cognitive therapy (NECT) to improve social functioning in people with serious mental illness: study protocol for a stepped-wedge cluster randomized controlled trial

Dissociative Identity Disorder and Narrative

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Abbreviations

Diagnostic and Statistical Manual V

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American Psychiatric Association (APA). (2022). Diagnostic and statistical manual of mental disorders (5th ed., text rev.). https://doi.org/10.1176/appi.books.9780890425787

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Acknowledgements

The authors would like to acknowledge the Ateneo Bulatao Center for its constant encouragement and support to advance academic research alongside clinical practice.

The authors did not receive support from any organization for the submitted work.

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Department of Psychology, Ateneo de Manila University, Katipunan Avenue, 1108, Quezon City, Metro Manila, Philippines

Karina Therese G. Fernandez, Anne Therese Marie B. Martin & Dana Angelica S. Ledesma

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Contributions

All authors contributed to the study. Material preparation, data collection, and analysis were performed by Karina Therese G. Fernandez. The first draft of the manuscript was written by Karina Therese G. Fernandez, Anne Therese Marie B. Martin, and Dana Angelica S. Ledesma. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.

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Correspondence to Karina Therese G. Fernandez .

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Conflicts of interest.

The authors have no conflicts of interest to declare that are relevant to the content of this article.

Ethics Approval

This study received ethical approval from the University Research Ethics Office of the Ateneo de Manila University. This research study was conducted retrospectively from data obtained for clinical purposes. A copy of the approval letter has been provided in Appendix A.

Consent to Participate and Publication

In the informed consent given by the Ateneo Bulatao Center for Psychological Services to its therapy clients, there is a very detailed checklist of the extent of how their information can be used. One specific item is “session notes for the purposes of research (paper publications and paper presentations). We have attached a copy of an unsigned informed consent form for reference (see Appendix B).

Informed Consent

By signing an informed consent form, we obtained permission from the client to share her story. Furthermore, her identifying information was changed to ensure confidentiality. Though the informed consent form already covers the consent for data in the therapy sessions to be published, as recommended by informal discussions with members of the University Research Ethics Committee of the Ateneo de Manila University, a second request for informed consent to publish was made after therapy.

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Fernandez, K.T.G., Martin, A.T.M.B. & Ledesma, D.A.S. The Use of Narrative Therapy on Paranoid Schizophrenia. Psychol Stud 68 , 273–280 (2023). https://doi.org/10.1007/s12646-022-00709-z

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DOI : https://doi.org/10.1007/s12646-022-00709-z

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Violent Crime Arrests and Paranoid Schizophrenia: The White House Case Studies

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David Shore, C. Richard Filson, Wayne E. Johnson, Violent Crime Arrests and Paranoid Schizophrenia: The White House Case Studies, Schizophrenia Bulletin , Volume 14, Issue 2, 1988, Pages 279–281, https://doi.org/10.1093/schbul/14.2.279

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We have previously reported on typically paranoid schizophrenic patients who attempted to see the President or other prominent American political figures based on hallucinations or delusional beliefs. By obtaining arrest records on these White House Cases (WHCs), we were able to determine which individuals had murder or assault arrests before and/or after their WHC hospitalizations. During the 9-12 years following discharge, 31 of the 217 male WHCs (for whom adequate clinical records were available) had murder or assault arrests. Demographic characteristics such as prior violent crime arrest and male gender proved to be much better predictors of future violence than clinical symptom, history, or behavior items. Hospital incidents requiring seclusion and a history of weapons possession were both associated with later violence in WHCs with prior violent crime arrests, while certain clinical symptoms (e.g., persecutory delusions and command hallucinations) may be linked to future violence in WHCs without prior violent crime arrests. These data need replication in other patient samples.

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• schizophrenia, paranoid
• secluding patient

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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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Paranoid Schizophrenia and the Paradoxical Path to Paraphrenia and Affectivity – a Case Study

International Journal of Research -GRANTHAALAYAH

Motivation: Analyzing a case of paranoid schizophrenia is a challenge to understand the mechanisms underlying the mind of a schizophrenic. The study became captivating because in the patient&#39;s delusional cofabulations there were many fingerprints that the communist period of that time left on the woman&#39;s psyche, thus observing the repressions following personal failures that probably led to the current state. Objective: Carrying out an analysis of the life history of a patient with paranoid schizophrenia who, although voluntarily presenting at the hospital, does not recognize her diagnosis and treatment. It presents symptoms that include the delusional ideas of persecution or greatness. It has two possible admissions, currently admitted to the psychiatric department in Bucharest. Results: The patient presents disorders regarding perception, memory, affectivity, observing a disorganized discourse that includes a qualitative perceptual disorder, schizophrenia-specific hypopros...

Related Papers

Iulia-Ioana Enache

Introduction: Disorganized schizophrenia is a subtype of schizophrenia which is not recognized in the updated version of DSM. It is found in ICD-10 with the name of hebephrenic schizophrenia. The paper presents a 27-year-old patient with multiple admissions at psychiatry for schizophrenia with an unknown onset, initially considered to be paranoid; the current level of disorganization of the behavioral acts, of the language, of the thinking, having the intensity of hebephrenic schizophrenia. The paper presents a Ganser syndrome in association with alcohol consumption and prohibited substances use. Methods: hospitalization, psychiatric evaluation under antipsychotic treatment with haloperidol and zuclopenthixol, counseling, social assistance. Results: The patient fulfills all the criteria for the classification in hebephrenic schizophrenia, with a reserved prognosis and an involuntary accentuated potential considering the multiple admissions, the early onset, the lack of social and fa...

IOSR Journals

Background: Chronic paranoid schizophrenia involves over time moments of emotional decompensation, in which the person in question, overlaps manic coloring over all the implicit symptoms of positive, negative dimensions and disorganization. Materials and Methods: The methods used were the initial psychological evaluation, the progressive one, the structured and unstructured clinical interview, psychoanalytic psychotherapy cure, periodical psychiatric evaluation and treatment monitoring, psychoanalytic interpretations, analysis of transference and countertransference dynamics, the transgenerational analysis, the analysis of his social functioning, psychological monitoring, as well as the psychiatric treatment. Results: The present case exposes the psychiatric pathology of a 56-year-old patient, in whom the disease started around the age of 20, the one in question being partially treated. It presents a multiple fragmentary delusional ideation based on pseudo-reminiscences gathered from memories of his youth and cryptomnesia, along with fantastic and dreamy conspiracies. The shift to the affective pole of paranoid schizophrenia is felt from the joviality and exaltation both ideational and emotional. Social functioning is severely affected, the patient losing the coherence of her actions and actions. To these is added the social dimension of the case, the one in question has lost its home and no longer has a social support network. As defense mechanisms from the primitive psychotic register are involved: denial, projection and projective identification, the cleavage of the Self and the Self, found in delusional fragments, in the delusional idea of denying filiation and in the emotional inversion towards the family. Conclusion: Suicidal behavior sometimes occurs in response to hallucinatory commands of self-or hetero-aggression. The risk may increase, being higher immediately after discharge or in the period following a psychotic episode.

Open Journal of Social Sciences

Diana Istrate

Alexandra Militaru

Motivation: A psychiatric patient should be looked at in the longitudinal dynamics of their life because it is possible that during youth, mental suffering has a certain tone to it, which is later erased, transformed or moved, through a greater or lesser contact with the ideas or the affect. Objective: We want to present the life history and dynamics of a subject whose first episode of mental illness of a depressive nature was around the age of 20, and to emphasize how over the years, this nature has faded. Currently, there is an absence of connection between the symptoms and the possible causalities. Material and methods: psychiatric and psychoanalytic interviews in dynamics, analysis of the life map, interpretations, the symptom’s evolution under medication, social support, identification of positive and negative prognostic factors, differential diagnoses, performing the diagnostic tree. Results: The patient presented a first depressive episode in youth with a trigger related to a...

Background: Schizophrenia is characterized by symptoms such as delirium, hallucinations, disorganized behavior, which affects the entire personality. All these symptoms are found in a high-intellect patient, but highly suggestable, which makes the disease more complex, especially over such a long period (20 years). Materials and Methods: The present case presents quasi-psychotic episodes. The present paper aims to evaluate a current profile of a schizophrenia and quasi-psychotic episodes in a 40-year-old patient. The methods that were used are the interview (with both the patient and his father), the observation, the administration of psychological tests and psychiatric treatment. The symptoms specific to a schizophrenia filled with quasi-psychotic episodes are well outlined in the light of disorganized ideas, the presence of certain pseudo reminiscences, the internal reality being distorted by the external one. Results: The patient received treatment to stabilize the mental state that led to a decrease in the delirious ideology, but at some point, the medication was interrupted as a result of his father's decision. Conclusion: There are several factors that affects the social functioning of the patient such as medical treatment unauthorized manipulation, the lack of social support, the non-involvement of the relevant authorities.

Angela Enache

International Journal of Research

NAOMI-EVELINA SOARE

Motivation/Background: Historically speaking, the distinction between manic-depressive disorders and schizophrenia finds itself in an unclear and vast spectrum bordered by the two illnesses. In this paper, we will present a case study that raises a question of diagnosis: bipolar disorder or schizoaffective disorder? Following the description of the symptoms and diagnosis criteria of each of the disorders, along with the personal data of the patient (the ones that are available to us), we will attempt analyzing the case as thoroughly as possible. The paper introduces the case of a 40-year-old woman who presents affective/mood related symptoms. Method: psychiatric evaluation, psychiatric interview, psychodynamic interview and psychodynamic interpretation. Results: The subject has a pathology of attachment developed over a structure with homosexual attachment choices. The multiple psychotraumas of childhood and the busy life history overlap with a vulnerability for emotional manifestat...

Procedia - Social and Behavioral Sciences

Ana-Maria Dragut

Yugashini Paramaswaran

Annals of Psychiatry and Treatment

Giulio Perrotta

The psychotic spectrum is the category that groups together a series of disorders linked to symptomatology in which we witness the fragmentation of the plane of reality until it is completely broken. According to the DSM-V nosography, the disorders under examination are schizophrenia, delusional disorder, paranoid disorder, schizoid disorder, schizotypic disorder, schizoaffective disorder, brief psychotic disorder, psychotic break, and catatonia. In this work, theoretical and practical profiles were analyzed, paying attention to neurobiological content and therapeutic profiles, both psychotherapeutic and psychopharmacological. A note of disappointment has been made in the nosographic categorization of dissociative disorders that currently would not be included in the psychotic spectrum disorders, although from the elements that emerged it would be interesting to revise them, precisely because of the clinical nature of the psychopathological category.

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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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String of killings have put spotlight on adequacy of mental health care in UK

Hainault attack may be latest incident linked to mental ill-health, at a time when NHS services are struggling

While the full picture of the Hainault attack is yet to emerge, the early briefings from the Metropolitan police were clear: a key line of inquiry, in terms of possible motive, was whether the suspect has a history of mental ill-health.

If the police hunches are correct, the tragedy may turn out to be the latest in a series of high-profile killings that have focused public attention on the adequacy of mental health treatment and care.

These include the horrific random killings of Barnaby Webber, Grace O’Malley-Kumar and Ian Coates in Nottingham in June 2023 by Valdo Calocane, who had been diagnosed with paranoid schizophrenia but had been “unmedicated and out of touch with psychiatric services for almost 12 months” when he carried out the attacks.

That case had worrying similarities to that of Zephaniah McLeod, who stabbed to death 23-year-old Jacob Billington and injured seven others in Birmingham in September 2020 . McLeod had been diagnosed with schizophrenia but received no supervision despite experiencing delusions and refusing to take medication.

This month an inquest in Swansea found serious failings in the NHS care of Daniel Harrison, who killed his father, Dr Kim Harrison, in March 2022 after escaping from hospital where he had been detained under the Mental Health Act after being diagnosed with paranoid schizophrenia.

An internet search of similar incidents in the UK throws up many other recent cases: reports of attacks and arrests, court hearings and inquest findings. Julian Hendy, of the charity Hundred Families , says these are all examples of problems with psychiatric care provision not being taken seriously enough – until it is too late.

Each tragedy is shocking and appalling in its own way, though there are common themes: medical supervision is often haphazard or barely existent; warnings of the perpetrator’s behaviour (often from family members) are ignored; police and health services fail to share vital information; and substance abuse is often a factor.

“The offenders are often people who are dangerous when they are unwell, who can be unwilling or unable to access care,” Hendy says. “They aren’t getting the right treatment. And it’s often only after the event [the attack or killing] that they get the treatment they need.”

Hendy set up Hundred Families after his father was killed in Bristol in 2007 in an unprovoked attack by a psychotic man known to local mental health services. It provides support to families after mental health-related killings and advises the NHS on what it can learn from such tragedies.

Hendy argues there are far too many so-called patient homicides. Although robust up-to-date figures are not available – NHS funding of this research was cancelled in 2019 – he estimates that of about 600 homicides in the UK each year, about 10-20% on average involve a killer who is mentally ill.

A study by London’s Violence Reduction Unit of 50 homicides, selected by researchers from Metropolitan police files, found mental illness was a “key factor” in 29 cases. It said most killings were “potentially preventable” . Some killers had withdrawn from treatment and others had untreated mental health problems, it found.

While numbers of general homicides have fallen in recent years, there has been a rise in the proportion linked to serious conditions such as schizophrenia-related disorders.

Prof Seena Fazel , of Oxford University, says people with schizophrenia are at increased risk of violent and homicidal behaviour. He says about 35 homicides a year in the UK are committed by a person with schizophrenia. Most victims are family members, while the risk of being killed by a severely mentally ill stranger is one in 14m. Prevention is key, and high-quality and consistent medical support would lead to a 50% reduction in these crimes, Fazel estimates.

Hendy argues NHS mental health services need to be more proactive and “assertive” in their treatment of severely ill individuals at risk of harming others. Issues around patient consent need to be debated. Above all, he says, “proper care and treatment” is vital if violence and homicides are to be prevented.

Meanwhile, NHS mental health services are struggling to cope with resource shortages and increasing demand for care. The Care Quality Commission, the NHS care regulator, said last year there had been a “notable decline” in the quality of care provided by specialist mental health services.

• Mental health

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