Clinical Case Conference
Long-Term Care of an Individual With Schizophrenia:
Pharmacologic, Psychological, and Social Factors
S chizophrenia is a complex neuro-
psychiatric disorder that has many ef-
fects on an individual’s ability to lead a
meaningful and satisfying life. Progress
in psychopharmacology has provided
us with an array of compounds that as-
sist in reducing many of the symptoms
of the disease. However, even with op-
timal pharmacologic treatment, many
individuals with schizophrenia are im-
paired in their ability to achieve occu-
pationally and to establish the long-
term intimate human relationships that
provide meaning and context to their
lives. Helping affected individuals and
their families to deal with the dimin-
ished expectations that are often
forced on them by the disease is also an
important treatment issue. I try to il-
lustrate the issues involved in the long-
term management of schizophrenia in
the case of R, with whom I have worked
for over 10 years. R participated ac-
tively in the preparation of this case
history.
PAST HISTORY
No one in R’s family was known to
have had a psychotic illness. His mother
received outpatient treatment for a
“situational depression,” while his fa-
ther had mild eccentricities in de-
meanor and communication pattern.
Received April 14, 1998; revision
received July 16, 1998; accepted Aug. 6,
1998. From the Departments of Psychiatry
and Human Genetics, Virginia Institute for
Psychiatric and Behavioral Genetics, Med-
ical College of Virginia of Virginia Com-
monwealth University, Richmond. Address
reprint requests to Dr. Kendler, P.O. Box
980126, Richmond, VA 23298-0126.
Supported in part by NIMH Research
Scientist Award MH-01277 to Dr. Kendler
The author thanks Patrick Sullivan, M.D.,
Alan Gruenberg, M.D., Elizabeth Gander,
M.A., and R for helpful comments on ear-
lier drafts.
124
Kenneth S. Kendler, M.D.
Although R was born prematurely
and developed neonatal jaundice, his
childhood years were unremarkable. In
adolescence, he played football, ran in
track events, and was outgoing and
popular. He began college as a premed-
ical student.
R recalls that his first psychotic epi-
sode and hospitalization, which oc-
curred when he was 19, began with sad
mood, insomnia, confusion, visual il-
lusions, hallucinations, and “mild”
delusions, the content of which he
could not recall. The hospital record
states that R was admitted for “in-
tense anxiety, sadness, and difficulty
with thoughts.” At admission, he com-
plained of insomnia, thought block-
ing, thought insertion, and thought
withdrawal. He felt that he had been
poisoned by the marijuana and alco-
hol that he had consumed. His mood
was sad and anxious and his affect
somewhat blunted. He was hospital-
ized for 5 weeks and treated with per-
phenazine.
After discharge, R returned to col-
lege, discontinuing the perphenazine
treatment. He remained well over the
next 3 years and returned home after
graduation, working part-time. He
then took an entry-level administrative
position. The job was demanding, and
R fell in love with a co-worker, who re-
jected his advances. The first symptom
of the second psychotic episode was
the feeling that other people could ex-
perience directly the thoughts in his
mind. This soon developed into the
conviction that everyone in the city
knew exactly what he was thinking.
He also began to “receive” thoughts
that seemed to enter directly into his
mind, that were quite distinct from his
own thoughts, and were “thought-
like” and not “voice-like” in quality. R
found that he became able to carry on
two-way conversations by “telepathy.”
R recalls becoming so busy communi-
cating with people through telepathy
that he did not respond to people
around him. R also experienced delu-
sions of reference and recalls passing a
stadium full of people and being sure
they were all watching him. When the
crowd burst into applause, R knew
they were applauding him.
At this time, R also became preoccu-
pied with religious themes, spending
hours reading the Bible, sometimes be-
coming convinced that he was a great
religious leader. Immediately before his
second hospitalization, he stood in one
posture in the backyard of his parents’
house for a long time, believing he was
communicating with others by telepa-
thy. In discussing these symptoms years
later, R noted that they occurred with
great veracity and that at the time it
was “impossible for me to believe that
these experiences were not true.”
The records from the second hospi-
talization note that for 2 weeks before
admission, R developed staring epi-
sodes, withdrawn behavior, inatten-
tion to work-related tasks, and irrita-
bility. He made repeated inappropriate
advances to women in the administra-
tive program, persisting despite dis-
couragement. At admission, he had
“agitation, emotional withdrawal,
blunted affect, unusual behavior, cog-
nitive disorganization, and auditory
and visual hallucinations.” During this
5 week hospitalization, he had blunted
and inappropriate affect, posturing
with staring spells, and auditory hallu-
cinations.
R was initially treated with trifluo-
perazine, and the delusions and hallu-
cinations resolved rapidly. Because the
trifluoperazine produced blurred vi-
sion, several other antipsychotic medi-
cations were tried. Eventually, thio-
thixene at 5 mg/day was decided on.
After discharge, R remained unem-
ployed for several months and then, at
the age of 24, registered in a 2-year
Am J Psychiatry 156:1, January 1999

master’s degree program in business
administration. He describes his illness
as quiescent and his academic perfor-
mance as good during this period,
while he was taking 5 mg/day of thio-
thixene. Because of side effects, he
would intermittently reduce the dose
to 3 or 4 mg daily and would often
then experience symptoms—particu-
larly of “thought transfer.”
During the second year, R worked
intensely on his master’s thesis, and he
developed a romantic relationship with
a woman in the program. As the pro-
gram ended, R began to decompensate
in the context of 1) reduction in his
dose of thiothixene, 2) breakup of his
social group as people left to take jobs,
3) the departure of his girlfriend to a
distant city, 4) increased smoking and
drinking, and 5) participation in a diet
study during which he lost 20 pounds.
R realized that he was getting sick
again, but he did not know how to halt
the relapse. He was taken to the hospi-
tal emergency room, yelling that he
wanted to be the hospital CEO. He re-
calls a period just before he went to the
hospital during which he was immo-
bile for some period of time. The tele-
pathic feelings were again pronounced.
He had feelings that he could commu-
nicate through thought patterns and
was able both to receive thoughts from
people outside and to communicate
back to them directly through his
thoughts. R recalls a bewildering array
of delusions during the first few days in
the psychiatric intensive care unit, in-
cluding the beliefs that he was moving
backward in time, that there was a
conspiracy to torture him because he
was a Communist insurgent (the lights
in the ceiling being part of the torture
technique), that he had AIDS, and that,
because his father had done something
terrible to him when he was a child, R
had to harm him in some way. R re-
members the first day in the psychiatric
intensive care unit as the worst day of
his life, that it was “like a living hell.”
The records from this third hospital-
ization were not highly informative but
note that on admission he had agita-
tion, loosening of associations, delu-
sions, and homicidal thoughts. He was
treated with thiothixene, 15 mg/day.
In the months after discharge, R
completed his thesis, passed his oral
examinations, and received his mas-
ter’s degree in administration. While
instructed to continue thiothixene at
15 mg/day, R refused because of side
effects. He was, however, willing to
take 10 mg, eventually reduced to 7
mg. He was employed in a series of
Am J Psychiatry 156:1, January 1999
clerical positions over the ensuing 2
years, during which, he recalls, his ill-
ness was fairly well controlled with
medication.
PRESENTATION
When I first met R, he was 27 and
living at home and had recently begun
a demanding administrative leadership
position. His medications consisted of
7 mg of thiothixene and 2 mg of benz-
tropine per day. At our first meeting, R
was alert, well oriented, and well
groomed. His speech was organized,
goal directed, and without pressure.
Although anxious, he related well and
had good eye contact and a full affect
without euphoria or irritability. He re-
ported persistent insomnia, unformed
auditory hallucinations, and recurrent
brief episodes of “thought transfer.”
These symptoms worsened in response
to job stress. R also reported falling in
love with a co-worker. R denied symp-
toms of depression or mania. He re-
ported being in good health and denied
current drug use except cigarettes and
alcohol in moderation. The results of
standard laboratory reports were unre-
markable.
When I met with R’s parents, sub-
stantial tension was evident. They
were angry about his psychotic illness
and were understandably puzzled about
what had happened to their son. They
were strongly encouraging him to con-
tinue to work at a level commensurate
with his education. While there were
several sources of tension between R
and his parents, one of the strongest
was their concern about his adolescent
drug use, which had consisted mostly
of modest amounts of cannabis. His
parents felt that this drug use had
strongly contributed to his psychotic
illness. Furthermore, the parents dis-
agreed about whether R should con-
tinue to live with them.
During this first family meeting, I
stated that I was concerned that R was
in the early stage of relapse, which
might progress quickly toward a full
psychotic decompensation if nothing
was done. I recommended two courses
of action. First, I suggested increasing
R’s level of thiothixene. There was, I
argued, substantial clinical experience
and some research evidence that in-
creasing antipsychotic medication in
the presence of prodromal psychotic
symptoms could forestall a full relapse.
Second, reviewing with them the
prior association in R’s history be-
tween stress and psychotic episodes, I
raised the issue of whether R was well
CLINICAL CASE CONFERENCE
enough to assume the responsibilities
of his current job. While R was by
training and intellect capable of hold-
ing this position, I was concerned that
he was not psychiatrically well enough
to deal with the associated stresses. I
suggested an extended medical leave
and, if this was not possible, resigna-
tion on health grounds. His parents
were visibly angry at this suggestion
and asked whether I wanted to make R
an invalid. Wasn’t it my job, they ar-
gued, to help him live up to his poten-
tial? The meeting ended without reso-
lution of this issue.
R’s clinical state was slightly im-
proved the next week with 10 mg/day
of thiothixene. However, he continued
to experience “soft” psychotic symp-
toms, which clearly worsened with job
stress. His parents told me that they
did not agree with my recommenda-
tion about R’s employment and that
they felt he could “stick it out.” We
discussed R’s adolescent drug use. I
told the family that, in my judgment,
R’s prior illicit drug use had nothing to
do with his psychotic illness. I also told
them that R’s presentation and history
suggested that he probably had schizo-
phrenia but that some features of his
history suggested the possibility of af-
fective illness. I reviewed for R and his
parents my approach toward medica-
tion management of chronic psychotic
illness, which was based on two princi-
ples: 1) keeping the dose of antipsy-
chotics at the lowest effective level,
which may reduce long-term risk for
tardive dyskinesia, and 2) flexible dos-
ing, so that patients can have control
over their own medication level, being
able to self-titrate within predeter-
mined limits. I used the model of a dia-
betic who can take best care of himself
by adjusting his insulin dose as a func-
tion of diet, stress, and exercise levels.
I also stated that there was some evi-
dence that lithium carbonate could be
usefully added to antipsychotic medi-
cation for individuals with schizo-
phrenia or with a mixture of schizo-
phrenic and affective symptoms and
wondered whether a trial of lithium
would be indicated.
A few days later, I received a tele-
phone call from the woman with
whom R had become romantically in-
volved. R’s behavior was, she said,
“completely out of line,” and if I could
not get him to stop, she would call the
police. He was constantly harassing
her, calling her at all hours by phone,
visiting her house, and leaving mes-
sages pushed under her door and
placed on her windshield. She said
125
CLINICAL CASE CONFERENCE
that, although she knew he was men-
tally ill, she was scared. I said that I
would immediately meet with R and
try to get him to stop this behavior. She
agreed that if there was no escalation,
she would wait a week before calling
the police.
I called R for an emergency meeting.
He had no insight into how his behav-
ior was affecting this woman and in-
sisted that he was just being romantic.
I told him that she certainly did not see
it that way and that he had to stop this
behavior immediately to avoid police
involvement. The soft psychotic symp-
toms had increased over the last week,
and we agreed to a further increase in
thiothixene to 12 mg/day. I told him
that I was quite concerned with his
state of mental health and again sug-
gested that he take a leave of absence.
He said that his parents would not sup-
port that, but he did agree to stop hav-
ing contact with the woman in ques-
tion. I ordered baseline tests of thyroid
and renal function in anticipation of
the beginning of lithium therapy.
At our next meeting, R told me that
he had been fired. His increasingly dis-
organized behavior had become evi-
dent to his employer. He had stopped
harassing his co-worker and had had
no further contact with her. However,
his parents felt that he should con-
tinue to support himself. At their urg-
ing, he was job hunting again. We
agreed to a trial of lithium carbonate,
and R began taking 900 mg/day of
lithium carbonate. I requested another
family meeting.
When R returned, he was ebullient.
After 2 days of lithium treatment, the
“thought transfer” experiences had
stopped. “You cannot imagine how
distracting it is to feel that the thoughts
of thousands of people, some from cit-
ies far away, are being routed into your
mind.”
In the subsequent family meeting, I
stated more forcefully my belief that R
was not now ready to work at the high-
level administrative jobs for which he
was trained. We discussed three op-
tions. He could continue to try to ob-
tain jobs commensurate with his intel-
ligence and education, try to get “lower-
level” jobs that would be less stressful,
or apply for Social Security Disability
Insurance benefits and focus on im-
proving his psychiatric condition. I ar-
gued strongly against the first option,
stating that R did not need additional
failures and pointed to his last experi-
ence, in which I felt that he had come
close to psychotic decompensation. I
felt the third option was probably the
126
best and said that I would support his
application for disability benefits on
the condition that he would participate
actively in an available day program or
in a planned course of volunteer work.
However, R and his parents felt that he
should continue to look for work. We
also discussed R’s living arrange-
ments. I felt that the emotional atmo-
sphere in the home was not good for R
and suggested he get his own apart-
ment, as he would have, in my opin-
ion, no difficulty with the tasks of in-
dependent living.
In the next month, R found work in
the trust department of a local bank
and moved out of his parents’ house.
He continued to describe soft psy-
chotic-like ideas, which tended to oc-
cur when things became stressful at
work. Instead of the “thought trans-
fer” phenomenon, however, he de-
scribed delusion-like preoccupations
about his parents. Things got worse at
his bank job, and he decided to resign
and seek disability benefits. His par-
ents accepted this decision. Without
the job stressors, we were able to re-
duce his dose of thiothixene to 7 mg/
day. He and I agreed that, when feel-
ing stressed he could increase this up
to 10 mg/day without consulting me.
He reported that the increased medi-
cation definitely helped him cope with
bad days. At a lithium dose of 900
mg/day, R had no side effects and had
blood levels ranging from 0.4 to 0.6
meq/liter.
COURSE OF TREATMENT
Over the next 9 years, R and I usu-
ally met monthly, for a 30–45-minute
session. He has continued to receive
disability benefits and received special
housing through a county program. R
has never demonstrated symptoms of
tardive dyskinesia. He has had a series
of outside activities, beginning with
several years’ attendance at a local
day program. Unfortunately, R found
this program to be oriented toward
“sicker” patients and of limited rele-
vance for him. He enjoyed the social
contact but felt uncomfortable with
the widespread illicit drug use of some
of the clients. While he returned to
this facility at times, his activities
shifted to volunteer jobs at a nearby
nursing home and the local Red Cross.
In addition, he participated in the
Master’s Swimming Program at the
YMCA. Although R has experienced
several exacerbations of his psychotic
illness, rehospitalization has never
been required.
During these early years, I urged R
to keep up his mental and physical ac-
tivity. Several times, he wanted to quit
his volunteer work and I had to remind
him of our agreement, stressing the im-
portance of keeping up his “people
skills.” I encouraged him to read. He
liked chess, and this became a frequent
subject of discussion. At one session he
showed up with a chess set, and for
nearly a year we played a game at the
end of each session.
R saw himself as a religious person.
We spoke of our shared interest in the
Bible and the “healthy” uses of reli-
gion to help us find our place in the uni-
verse and to serve as a source of values
and a guide for life decisions. We con-
trasted this with the less “healthy” uses
R had made of religion during his psy-
chotic episodes. R was surprised that I
encouraged his religious interests.
R often spoke of his loneliness and
sense of failure. “Look at what my
friends from college and grad school
are doing. They all have good jobs and
wives and kids, and look at me.” R
was prone to form “crushes” on women
with whom he would have contact.
Usually, these were in situations in
which it was unrealistic to expect any
romantic relationship to emerge. While
painful, I would suggest to R that he
not act on his feelings.
Three years after we began working
together, he met M at the day program.
M, a few years younger than R, had in-
tractable grand mal epilepsy and mild
mental retardation. R was quite at-
tracted to her but anxious and fright-
ened at the strength of these feelings.
We spent hours discussing how he
might approach M and win her trust
and affection. Having been sexually as-
saulted by several male patients in the
past, she was initially put off by R’s at-
tention. However, over a period of
months, they started to date and R
slowly earned both her trust and that
of her guardians.
As they became closer, R was fre-
quently troubled by feelings of jealous
rage. When he saw M talking with
other men, he was often overwhelmed
with anger and on several occasions
acted on these feelings, with an ensuing
bitter argument with M. After much
discussion, R gradually became able to
accept the fact that M enjoyed male at-
tention and might flirt because it made
her feel good about herself.
More than a year after they met,
they started spending nights together,
and R eventually received permission
to live with M. He assumed an increas-
ing proportion of her care: checking
Am J Psychiatry 156:1, January 1999

her antiseizure medications, bathing
her, washing her long hair, and brush-
ing her teeth to control the diphenyl-
hydantoin-induced gum hypertrophy.
In the early years of their relationship,
before new medications brought her
seizures under better control, R would
get up with M several times each
week to change the sheets after she
had urinated on them during a noc-
turnal seizure.
M would accompany R to see me ev-
ery couple of months. She and I devel-
oped an agreement whereby she was to
call me when R developed worrying
symptoms. Over nearly 8 years, she
called me three times to report prob-
lems, always appropriately. As R as-
sumed more and more responsibilities
for the care of M and for the apart-
ment, he became less willing to spend
time at volunteer work as he felt that
caring for M was “his job.”
Each of my more than 100 sessions
with R followed a similar pattern. I
would ask about his mental health,
specifically asking about psychotic
symptoms and medication side effects.
We would discuss the relationship with
M and any problems that might be
emerging. R wanted both to care for M
but not to make her too dependent on
him. We discussed their sexual rela-
tionship. I would ask after his family,
how his parents were doing and how
he was getting along with them. If the
weather was nice, in the early years, we
would sometimes take a walk and talk
rather than sit in the office.
One topic we discussed at length,
which illustrates the nature of our in-
teractions, began with a flirtation be-
tween R and a staff member at the Red
Cross where he was volunteering. Ini-
tially, R was uncertain how to respond
to her apparent interest in him, and he
initially concluded that he should quit
the volunteer job. We talked about the
difficulty everyone has in accurately
perceiving the “signals” that men and
women send each other. Perhaps, I sug-
gested, he was misinterpreting her in-
terest. Regardless, I urged R to be po-
lite to her but not otherwise encourage
any personal relationship. It became
clear, however, that he was quite at-
tracted to her, and we spoke of issues
of fidelity. Eventually, he decided that
he could keep the job, did not want to
try to have an affair with her, and
could act professionally with her with-
out risking losing his composure.
Four times over 10 years R had ex-
acerbations of his illness. These would
begin by his spending hours pacing,
muttering, yelling, and laughing to
Am J Psychiatry 156:1, January 1999
himself. He would develop delusion-
like ideas such as the staff were against
him or were trying to break up his rela-
tionship with M or that his parents had
done something terrible to him as a
child (e.g., tortured him on a rack).
The “thought transfer” experiences
would return but without their prior in-
tensity. He never displayed any thought
disorder nor did he completely lose in-
sight into the possibility that these
were “sick thoughts.” In each instance,
with increased thiothixene, more fre-
quent meetings, and sometimes a meet-
ing with R and M to discuss issues, the
disturbance would pass within 1 to 2
weeks.
R and I discussed new pharmaco-
logic treatments. Shortly after the pub-
lication of the Kane et al. study (1), I
raised the issue of a clozapine trial.
While not an ideal candidate for this
treatment (his positive symptoms hav-
ing responded well to thiothixene), its
low side effect profile, possibly re-
duced risk for tardive dyskinesia, and
greater efficacy with negative symp-
toms suggested that a trial might be in-
dicated. R read up on clozapine and
decided he did not want to take the
risk of agranulocytosis. About a year
after risperidone became available, we
tried this agent, proceeding with a slow
double taper, increasing the risperi-
done while decreasing, in approxi-
mately equal increments, the thiothix-
ene. When we got down to 4 mg/day
of thiothixene and 4 mg/day of risperi-
done, R experienced a clear exacerba-
tion of his symptoms. He was fright-
ened, and we agreed to discontinue the
risperidone and reinstate his full dose
of thiothixene. He recovered within 2
weeks. We have recently been discuss-
ing the possibility of another trial of
one of the new atypical antipsychotics.
His negative experience with risperi-
done has made him hesitant, but he has
been expressing more interest in this
idea lately.
DIAGNOSIS
“By the book,” R meets the DSM-IV
criteria for schizophrenia. He had bi-
zarre delusions and hallucinations for
at least several weeks before the second
and third hospitalizations, and these
symptoms ceased only with neurolep-
tic treatment. For more than 6 months
after his third hospitalization, he had
“soft” psychotic-like phenomena that
would meet criteria for residual symp-
toms. He has experienced substantial
occupational dysfunction as a result of
his illness. Indeed, his history indicates
CLINICAL CASE CONFERENCE
that he is chronically “at risk” for ac-
tive psychosis that can be precipitated
either by psychosocial stressors or re-
duction in medication.
However, there are several atypical
features in R’s illness that suggest a
schizoaffective syndrome. Grandiose
delusions and excited behavior were
evident in his second and third psy-
chotic episodes. Catatonic symptoms,
long recognized as a possible concomi-
tant of affective illness (2), were also
present. He has had a positive response
to lithium, although the effect seems to
be predominantly antipsychotic in na-
ture. Although noted during his earlier
admissions, he has never, in the course
of our therapy, had any more than the
mildest levels of avolition, and he has
never demonstrated alogia, apathy, or
emotional blunting. His grooming and
self-care have always been excellent.
The major problem with the diagno-
sis of schizoaffective disorder is the
absence of any evidence for substan-
tial depressive or manic symptoms. I
have watched closely for these and
never noted more than mild dysphoria
without substantial neurovegetative
symptoms.
I would conclude that R has a form
of schizophrenia that is dominated by
positive symptoms with little if any
negative symptomatology. From nei-
ther a symptomatic nor a psychosocial
perspective has he been able to make
complete interepisode recoveries, so a
schizophreniform diagnosis is proba-
bly not appropriate. While some atypi-
cal features are present in his illness
course, the absence of prominent affec-
tive symptoms rules out the diagnosis
of schizoaffective disorder.
REVIEW OF TREATMENT COURSE
In writing this article, R and I inde-
pendently listed features of our work
together that were particularly helpful.
Some items appeared on both lists;
others on only one. Here is a sampling.
1. R recalled more clearly than I the
discussion with his parents about the
etiologic role of adolescent drug use in
his psychotic illness. I was surprised to
hear him say, “One of the most impor-
tant things you ever did for me was to
tell my parents that the marijuana I
smoked as a kid did not cause my
schizophrenia. You were an authority
for my parents, so when you said that,
they stopped blaming me. That was re-
ally important.”
2. We both agreed that encouraging
R to stop getting high-level jobs com-
mensurate with his education was im-
127
CLINICAL CASE CONFERENCE
portant. While I recalled that both R
and his parents resisted my suggestion,
R remembered that he and I had both
agreed and it was his parents that
needed convincing. This is the one area
in my work with R about which I am
still ambivalent. R has not had paid
employment since he began receiving
disability payments. When I suggest he
seek low-stress employment, he resists,
in part because too much outside in-
come would threaten his benefits. Fur-
thermore, he argues that he needs to be
with M to supervise her during most
daytime hours. Caring for her, he
states, is his job.
3. We both agreed that much of the
satisfaction that R feels with his life de-
rives from his relationship with M. He
surprised me by stating that he could
not have established and maintained
this relationship without my guidance.
He was, he said, “able to talk to you
about this man to man and could al-
ways trust your advice.” In retrospect,
I can see that R was ill equipped to
navigate the strong feelings of attrac-
tion, love, and jealousy that accom-
pany enduring love relationships. Two
of his psychotic episodes involved ro-
mantic breakups. Given his vulnerabil-
ity to a breakdown in reality testing
when confronted with the vicissitudes
of a romantic relationship, R’s ability
to establish and maintain an intimate
and mutual loving relationship with M
is a major triumph. He recently wrote,
“As a result of many years of therapy,
it is very clear to me that fantasy and
limited personal involvement with
other women is OK, but actual infidel-
ity is clearly wrong. I have always been
very confused on this point.”
4. R saw my giving him “permis-
sion” to alter his dose of thiothixene as
vital to the success of his therapy. “I
would have had probably half a dozen
relapses over these last years if you
hadn’t taught me that—at the first sign
of problems—I should increase my
128
dose. I only wish that I had known that
earlier. It might have prevented some
of my previous breakdowns. But then,
it took me a pretty long while to learn
that these medicines were really my
friends and that I needed them. I guess
I was a slow learner.”
5. We both agreed that the lithium
therapy, in particular its effect on re-
ducing the “thought transfers,” had
been helpful.
6. R recalled more than I did our
discussions about religion. He said
that he felt that I have helped him to
develop a “healthy religious life.” He
had wanted to have a religious and
prayer-full life that brought him close
to God. Yet he knew that too much fo-
cus on religion and the Bible could
make him get sick again. He said that
our discussions helped him find a way
to “more lightly pray” and to “ pursue
religion with reasonable zest” but not
to become preoccupied and risk “get-
ting sick again.”
7. Finally, R spoke about his learn-
ing the “proper attitude toward a life
of chronic mental illness.” He said this
had two main parts. The first was the
importance of habit. He referred here
to my oft-repeated insistence on his
keeping himself busy with intellectual
and physical activity and being in-
volved in activity outside the home.
The second was the “right attitude.”
Here, I think he was reflecting on the
many discussions we had about how to
deal with the disability of schizophre-
nia—about how to accept but not
“give in” to these problems and how to
avoid bitterness. In one of our most re-
cent meetings, I asked him if he had
thought about why he had developed
schizophrenia. He replied,
Yes, I have thought about that a
lot. At first, I was mad at God be-
cause I know all the things that I
have missed—the job that I had been
trained for all those years in school,
a normal wife, and kids. I couldn’t
make sense of it. But, in these last
few years, I have come to feel that I
was meant to get schizophrenia. God
had something to do with it. If I had
never developed schizophrenia, who
would have taken care of M?
CONCLUSIONS
This course of therapy with R illus-
trates the multifaceted nature of the
treatment of chronic psychotic illness
(3). Interventions were made at the
level of pharmacology (flexible neuro-
leptic dosing and lithium carbonate
augmentation), social factors (moving
out from a conflictual home environ-
ment and reduction of occupational
stress), psychological issues (intimacy
in love relationships), and spiritual
concerns (developing a “healthy ap-
proach” toward religion). I did not be-
gin my work with R with an overarch-
ing theoretical perspective of how to
treat schizophrenia. Rather, I tried to
deal with the range of issues that con-
fronted us in as pragmatic a way as I
could given the available resources. In
reflecting on my work with R, I have
realized that my relationship with him
has had two facets that have interwo-
ven with one another over time. I have
tried to be for him both a “physician-
expert” who has helped to “manage”
his schizophrenia and an “advisor-col-
league” who has tried to provide guid-
ance and counsel on a range of very
human problems.
REFERENCES
1. Kane J, Honigfeld G, Singer J, Meltzer H:
Clozapine for the treatment-resistant
schizophrenic: a double-blind comparison
with chlorpromazine. Arch Gen Psychiatry
1988; 45:789–796
2. Kirby GH: The catatonic syndrome and its
relation to manic-depressive insanity. J
Nerv Ment Dis 1913; 40:694–704
3. American Psychiatric Association: Practice
Guideline for the Treatment of Patients
With Schizophrenia. Am J Psychiatry 1997;
154(April suppl)
Am J Psychiatry 156:1, January 1999