CASE: Disabling anxiety
Mr. B, age 35, has a history of schizophrenia, chronic paranoid type and has been hospitalized more than 12 times since its onset 10 years ago. He received clozapine during his most recent hospitalization approximately 5 years ago and experienced full symptom response without the motor side effects he developed in response to other medications. He visits a psychiatrist monthly for medications and supportive psychotherapy, and he receives intensive case management and housing from a community mental health center.
When Mr. B is assigned to my (CK) care, his psychotic symptoms are in remission, but he complains of anxiety that leaves him almost homebound. He has intense fear of bridges, upper-floor windows, express buses, subways, riding in speeding vehicles, and having a seizure.
If Mr. B faces any of these triggers, he experiences harmful thoughts—such as jumping out a window or off a bridge—even though he does not endorse suicidality. These thoughts are intrusive, ego-dystonic, and ruminative. He avoids these triggers at all costs, which compromises his housing and employment opportunities. He experienced a single panic attack in the subway 1 year earlier. Mr. B firmly believes that any intense anxiety he experiences will trigger a psychotic episode. When faced with sudden urges, he believes his illness would interfere with his ability to control his impulses.
He reports that these symptoms started when he began clozapine and have worsened. Mr. B says he experiences a feeling of “uneasiness” approximately 2 hours after taking clozapine that is exacerbated if he faces a trigger. He describes the uneasiness as “the feeling of being about to have a seizure” during which he would “lose control” of his body.
When I begin treating Mr. B, he is receiving clozapine, 125 mg bid. In an effort to combat Mr. B’s anxiety, a previous psychiatrist had titrated clonazepam up to 5 mg/d as needed. Mr. B is compliant with his medications and appointments but refuses to change his psychotropic or psychotherapy regimen.
The authors’ observations
Approximately 50% of patients with schizophrenia have at least 1 anxiety disorder, and close to 30% meet criteria for >1 anxiety disorder.1 Social anxiety disorder (SAD), generalized anxiety disorder, panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder (OCD) have been found comorbid with schizophrenia, with rates as high as 30% for each.1
Possible causes of unusually high rates of anxiety disorders in schizophrenia include trauma history, delusional conviction and inflexibility of abstract thought,2 and passive coping mechanisms.
Schizophrenic illnesses may be linked to anxiety antecedents such as panic or social phobia that:
- develop into more profound psychopathology
- or bring about anxiety symptoms, given the severity of the subjective psychotic experience.
Comorbid OCD, panic disorder, and SAD frequently persist after remission of psychotic symptoms. Comorbid anxiety disorders may play a role in the psychotic symptoms themselves (such as panic and social anxiety related to paranoia, OCD, and bizarre behavior) and negatively impact quality of life.4
- increased hallucinations
- poor psychosocial function
Treatment options for comorbid schizophrenia and anxiety
|Psychopharmacology||Antipsychotics ||Favor monotherapy at full dose for full trial period before considering adjunct therapy with a second antipsychotic, for which evidence is still equivocal|
|Antidepressants ||Avoid bupropion because of possible dopamine agonism|
|Benzodiazepines||Weigh risks of sedation and potential for addiction vs benefits of immediate relief|
|Gabapentin||Use high doses to obtain symptomatic response|
|Psychotherapy||CBT (for psychosis and anxiety) |
Supportive (for decompensating psychosis)
Activity and vocational
|CBT: cognitive-behavioral therapy; SSRI: selective serotonin reuptake inhibitor; SNRI: serotonin-norepinephrine reuptake inhibitor|
HISTORY: Propensity for violence
Mr. B was born in a large city and raised by his single mother. He denies childhood physical or sexual abuse. Mr. B reports engaging in violent activity since he was an adolescent, but this activity is undocumented because he has never been arrested. Mr. B still belongs to a gang he joined after being assaulted at age 16.