Pretest self-assessment question (answer at the end of the case)
Which of the following antidepressants is also formally approved for treating insomnia?
A. Quetiapine
B. Diphenhydramine
C. Hydroxyzine
D. Trazodone
E. Amitriptyline
F. Doxepin
G. All of the above
H. None of the above
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
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
Further investigation
Is there anything else you would especially like to know about this patient?
Some of the patient’s negative symptoms seem atypical
– He speaks in close proximity to people
– He often has an odd affect and odd prosody of speech
– In discussions with his family at the initial visit, “he has always been that way”
He has had few friends, but has been content
He has not exhibited anxiety about missing a clear, distinct peer group
After his positive symptoms developed, these premorbid social interaction deficits have remained the same but have been labeled as “negative symptoms” instead of his premorbid personality style
Were these negative symptoms really present since childhood?
– It is unlikely that these negative schizophrenia symptoms were a 20-year prodrome
– The patient may have a developmental disorder such as an ASD which predates his first psychotic break
– He does not meet ASD criteria formally
– His IQ is likely low-average, e.g., 85–100, but has never been formally tested
– There are no clear chromosomal abnormality stigmata nor maternal infectious exposure stigmata
– He is a likeable, straightforward, socially awkward, talkative man
Case outcome: first interim follow-up visits through six months
Clinically continues without change
Risperidone (Risperdal) is lowered to 3 mg/d to avoid long-term movement disorder and metabolic risk, and due to the fact that he has been largely asymptomatic
Later reports an increase in anxiety over interpersonal interactions and states he now has insomnia
There are no re-emergent positive psychotic symptoms
Clonazepam (Klonopin) is increased to 2 mg/d taken at night to cover these anxiety and insomnia symptoms, with good effect
Later, risperidone (Risperdal) is lowered to 2 mg/d without incident
Question
Can traditional BZ sedative–anxiolytics be used as sedative–hypnotics too?
No, these are separate approvals and only sedative–hypnotics should be used to treat insomnia
No, sedative–anxiolytics are less sedating and tend not to promote sleep
Yes, both classes are BZs, which are PAMs at the GABA-A receptor and may promote fatigue, somnolence, and induce sleep
Yes, although off-label, the sedative–anxiolytics are less sedating than the sedative–hypnotics, but increasing the dose of the anxiolytic is often accompanied by increasing sedation and ultimately hypnosis
Case outcome: second interim follow-up visits through 12 months
There is no psychosis but an increase in insomnia is reported again
– This stresses the patient as he is worrying about his lack of sleep and has the clinical feel of classic, primary insomnia
– He is more irritable
– He dislikes doing his usual activities as he is tired and not his usual self
– He enjoys things less as such
– He has no other worries outside his pending insomnia every night
Denies depression feelings and reports there are no acute stressful events at home or work
– There is a possibility that the insomnia is the sentinel symptom of a depressive episode or a third psychotic episode
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