Cases That Test Your Skills

Descent after a missed flight

Current Psychiatry. 2010 November;9(11):89-A

Psychotic, sleepless, and depressed, Mr. F decides to make a new start in another country. When his travel plans are interrupted, his psychosis worsens. What could be exacerbating his symptoms?

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References

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CASE: Psychotic and sleepless

Mr. F, age 30, is referred to our psychiatric outpatient clinic for follow-up care after hospitalization to treat a psychotic episode. His psychotic symptoms started 2 years ago without an identifiable trigger. Mr. F complains of episodic mood symptoms, such as depression, irritability, and angry outbursts; persistent auditory hallucinations (voices calling him names); and persecutory delusions. While in the hospital he was diagnosed with psychotic disorder not otherwise specified and started on olanzapine titrated to 30 mg/d.

During evaluation, Mr. F is depressed and exhibits motor retardation, slow speech, bland affect, impaired short-term memory, and auditory hallucinations. He describes social anxiety and has ideas of reference and problems interpreting facial expressions. He is guarded and suspicious. Although auditory hallucinations and depression affect Mr. F’s daily activities, he is attempting to find a job.

Mr. F has used alcohol since age 16 to escape social difficulties. He says he last used alcohol 1 year ago, but refuses to provide details about how much alcohol he typically consumed. Sporadic cannabis use also started when Mr. F was in his teens.

Mr. F’s symptoms improve with olanzapine, but he complains of weight gain and sedation, so we switch him to aripiprazole, 10 mg/d. Two weeks later he reports feeling jittery and anxious, so we discontinue aripiprazole and start loxapine, 25 mg/d at night, and propranolol, 60 mg/d, for residual akathisia. Despite limited clinical improvement, Mr. F irrationally says he wants to join the Navy. After a week, his psychotic symptoms improve but anxiety persists, so we start clonazepam, 1 mg/d, and oxcarbazepine, 600 mg/d. After 2 weeks he says he feels calmer, but has gained 20 lbs and is constantly tired. Against our advice, Mr. F decides to discontinue loxapine and propranolol, but continues clonazepam and oxcarbazepine.

At his next visit 4 weeks later, Mr. F is in good spirits. He says he is looking for a job as a dental assistant, and shows no apparent signs of psychosis. Mr. F misses his next appointment but returns 3 months later with evident deterioration in his general appearance. He says he is having difficulty sleeping and is depressed, stating “I just lay in bed; I don’t want to deal with life.” He is withdrawn and unwilling to elaborate on his personal problems but asks for a refill of clonazepam and oxcarbazepine, which we provide.

The authors’ observations

Sleep disturbances, including poor sleep efficiency, increased sleep-onset latency, decreased rapid eye movement (REM) sleep latency, and decreased stage 4 of non-REM sleep, occur in 16% to 30% of patients with schizophrenia and are associated with reduced quality of life and poor coping skills.¹ Sleep-onset and sleep maintenance problems and sleep-wake reversal generally persist despite antipsychotic treatment.^2,3

Slow-wave sleep deficiency can lead to negative symptoms and memory deficits in patients with schizophrenia because⁴:

declarative and procedural memory consolidation are associated with slow-wave and stage 2 sleep, respectively
procedural learning and visual spatial memory are correlated with delta power in slow-wave sleep.^3,8

Clinical Point

Acute psychosis exacerbations are associated with restless, agitated sleep; insomnia often is an early warning sign of clinical relapse

Acute psychosis exacerbations are associated with restless, agitated sleep. Insomnia often is an early warning sign of clinical relapse.⁵ The etiology of sleep dysfunction in schizophrenia is unknown, but glutamatergic action through N-methyl-d-aspartate receptors, the GABA system,⁶ and the serotonin system⁷ have been implicated.

Relapse to alcohol could trigger an exacerbation of Mr. F’s illness; however, he continues to deny alcohol or drug use and we could not identify any evidence of alcohol use at his last visit.

HISTORY: Strange behavior

Mr. F is a first-generation immigrant from Venezuela. He has a general educational development diploma and an associate’s degree. He says he has worked as a dental assistant but lost his job after a driving under the influence charge a year ago. Subsequently, he could not remain employed for long. He lives with his parents.

When Mr. F returns to the clinic 5 months later, he has lost 20 lbs and complains of anxiety and lack of sleep. With stooped posture, slow movements, and a mood-incongruent smile, he admits he ran out of medications and asks for refills, which we provide. He appears somewhat bizarre, wearing a loosely fitting baseball cap that covers his direct field of vision. Mr. F admits that he has been pulling out his hair. His thought process is impoverished and his answers are guarded and evasive. He rejects our recommendation of an antipsychotic; the only medications he is willing to continue are oxcarbazepine and clonazepam.