Four ways to build an alliance with a chronically ill patient
- Respect the patient’s goals. You fear psychotic symptoms will resurface, but the patient is more concerned about weight gain or other side effects. When possible, choose an agent that targets symptoms without causing the feared side effects.
- Enhance motivation for change. Remind the patient of past successes. Break the broad goal into smaller, achievable goals. Find out the patient’s unique motivations for change.
- Become the patient’s advocate. Accept responsibility for patient care problems. Refer the patient to needed social services.
- Keep an open mind about diagnosis and prognosis. Despite being the definitive diagnostic reference, DSM-IV-TR does not neatly fit all patients, nor account for all human suffering.
Twelve days later, Mr. M made an unplanned visit. He was angry because our pharmacy had not refilled his prescriptions and no one had returned his call asking about the refills. He was irritable but nonthreatening, although he planned to complain to the psychiatric center’s medical director.
I had received no phone messages, and my notes indicated the prescriptions were refilled. Nonetheless, my assuming responsibility for this problem was key to preserving our therapeutic alliance (Box). I resolved the matter and apologized for the miscommunication. Mr. M accepted my apology and scheduled a return visit.
About 1 month later, Mr. M’s self-esteem had increased. He stopped using marijuana, went on a low-calorie diet, and exercised at least 1 hour daily at a local gym. He lost 27 lbs. over 2 months, dropping his weight to 170 lbs. (BMI 28.3). He finished group (15 sessions) and individual (four sessions) psychotherapy, and avoided his mother when she became aggressive.
Before his next monthly visit, Mr. M had called the state vocational rehabilitation department to begin employment. I tapered lorazepam to 0.5 mg nightly while continuing ziprasidone and bupropion. His weight was near normal (150 lbs., BMI 25).
Six months into treatment, Mr. M. applied for a job and moved out of his parents’ home to live with another brother, who does not take drugs. He said that he “felt at peace” for the first time in years. His weight stayed in the 140s. I stopped lorazepam and he requested to see me 3 months later.
Dr. Fraser’s observations
Many patients with schizophrenia or schizoaffective disorder struggle with weight gain, substance use, employment problems, and family conflict, and some make slow progress with one or more of these issues. Mr. M’s rapid improvement on all fronts was striking, however.
Recovery from schizophrenia has been documented,3 and the prognosis for schizoaffective disorder is often more positive than for schizophrenia or severe bipolar disorder.4 Still, Mr. M’s apparent recovery seemed incredible.
To prevent symptom recurrence, I left the bupropion/ziprasidone regimen unchanged. Even after a chronically ill patient responds to medication, I feel dosages should be maintained unless side effects occur or a medication loses effectiveness.
Table
PTSD symptoms that suggest other diagnoses
| PTSD symptoms | Similar to | Diagnosis suggested |
|---|---|---|
| Depersonalization, derealization, dissociation | Psychosis | Schizophrenia, schizoaffective disorder |
| Anxiety, hypervigilance, insomnia | Anxiety | Exacerbations of schizophrenia, schizoaffective disorder, bipolar disorder (mania) |
| Flashbacks, fear of trauma recurrence | Paranoia | Schizophrenia, schizoaffective disorder |
Follow-up: Mr. M’s story
Since the mix-up with Mr. M’s medications, our therapeutic alliance grew stronger. He told me more about himself with each visit. Four months into treatment, he revealed that he is gay and feels “liberated” after years of keeping it secret.
Five months later, Mr. M confided that an older male partner had physically, sexually, and emotionally abused him for about 10 years, starting when Mr. M was 16—about the time his auditory hallucinations began. The abusive relationship ended when the partner died of an unspecified overdose.
Mr. M’s gay friends advised him to seek closure. He visited his ex-partner’s grave, placed a rose, said goodbye, and left vowing he’d never again become an abuse victim. He said he had never told any health professional this story.
Mr. M then asked to be tapered off medications. I was afraid his psychotic symptoms could resurface, although I now wondered whether his schizoaffective disorder diagnosis had been correct. We tapered bupropion and ziprasidone over the next month.
Twenty-four months later, his schizoaffective symptoms had not resurfaced. He worked as a security guard, maintained an apartment, and continued exercising and eating right. His weight stayed normal (140 lbs., BMI 23.3). No signs of hypomania were present, and he was finding fulfillment in nonabusive relationships.
Dr. Fraser’s observations
Some patients progress to schizophrenia’s residual “burnout” phase and become asymptomatic. Mr. M, however, was much younger than other patients with residual schizophrenia, and his mental and physical health were more robust.