A 23-Year-Old Man With Schizophrenia

DR REYNOLDS: Mr X is a 23-year-old man with a 5-year history of schizophrenia. He lives near Boston and has state health insurance. Mr X began to have social withdrawal and isolation around age 16, when he dropped out of school sports, went from being an excellent student to barely passing, and began spending much of his free time alone watching videos. He was using alcohol, cannabis, and LSD (lysergic acid diethylamide). He had progressively paranoid delusions: he believed that the Mafia was going to make him a movie star, that bystanders stared at him because they knew he was famous, and that the Mafia was broadcasting to him and controlling his mind. He also believed that his family members were out to get him, that he might not be related to them, and that others questioned his sexual orientation. When one day, at age 18 years, he told his mother of his increasingly tortured thoughts, she brought him to the emergency department, where he was admitted to an inpatient psychiatric hospital. Mr X’s first psychiatric admission lasted 9 days. He was diagnosed with bipolar disorder and polysubstance abuse and treated with perphenazine and divalproex sodium. While he was taking the medications, his auditory hallucinations decreased somewhat but did not disappear. He stopped taking his medications after discharge and was readmitted 1 week later to the same facility. On the second admission, he was treated with perphenazine and lorazepam as needed. Then, however, he was transferred to another facility where the diagnosis of paranoid schizophrenia was made. There, all his medication was discontinued for a washout period, and he was enrolled in the First Episode Study after providing informed consent. He was given a study drug, which was either clozapine or haloperidol, and continued in the study for 5 years. During the next year, Mr X was transferred to transitional living and later moved to an apartment. He was employed as a construction worker around the city. His hallucinations and delusions quieted over time; about twice each week he could feel one coming on, which he was able to identify and avert. He declined substance abuse treatment and continued to drink a moderate amount of alcohol, usually only on weekends. His treating physicians noted mild, persistent negative symptoms. In the summer of 2001, Mr X began using ecstasy, cocaine, and alcohol. He tapered and then discontinued his study medication. One week later, he was floridly psychotic. He tracked down family members and threatened to kill them for the child abuse he imagined they had inflicted. He rampaged through his old neighborhood. He was arrested at the airport for stealing luggage and for lewd behavior. He was admitted to a psychiatric hospital for his second episode of acute paranoid schizophrenia. Mr X has been out of the hospital for several months. His initial medications were tapered off, and he is taking clozapine, which was his study drug. He reports that the clozapine works much better when he is not drinking alcohol. He again has declined substance abuse treatment but reports that he has not used drugs or alcohol since his hospitalization. He has returned to working the night shift in construction. He lives with a roommate (a family friend) and has friends and the support of his family. Mr X continues being treated by the same psychiatrist he met 5 years ago, although now he will need to transition from the study to community-based care. His medical history is significant for mild childhood asthma. The only medication he takes is clozapine, 200 mg/d. He is a high school graduate and hopes to take writing classes. His parents are divorced; his mother has remarried. His father and stepfather were both alcoholics, and there is no family history of schizophrenia. His physical examination findings are normal. His mental status examination shows a pleasant young man wearing a ski hat. He has fluent speech and appropriate affect. He currently denies cognitive dysfunction and is having only