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Clinical Case Conference

Long-Term Care of an Individual With Schizophrenia:

Pharmacologic, Psychological, and Social Factors

Kenneth S. Kendler, M.D.

S chizophrenia is a complex neuro-

psychiatric disorder that has many ef-
Although R was born prematurely
and developed neonatal jaundice, his
cating with people through telepathy
that he did not respond to people
fects on an individual’s ability to lead a childhood years were unremarkable. In around him. R also experienced delu-
meaningful and satisfying life. Progress adolescence, he played football, ran in sions of reference and recalls passing a
in psychopharmacology has provided track events, and was outgoing and stadium full of people and being sure
us with an array of compounds that as- popular. He began college as a premed- they were all watching him. When the
sist in reducing many of the symptoms ical student. crowd burst into applause, R knew
of the disease. However, even with op- R recalls that his first psychotic epi- they were applauding him.
timal pharmacologic treatment, many sode and hospitalization, which oc- At this time, R also became preoccu-
individuals with schizophrenia are im- curred when he was 19, began with sad pied with religious themes, spending
paired in their ability to achieve occu- mood, insomnia, confusion, visual il- hours reading the Bible, sometimes be-
pationally and to establish the long- lusions, hallucinations, and “mild” coming convinced that he was a great
term intimate human relationships that delusions, the content of which he religious leader. Immediately before his
provide meaning and context to their could not recall. The hospital record second hospitalization, he stood in one
lives. Helping affected individuals and states that R was admitted for “in- posture in the backyard of his parents’
their families to deal with the dimin- tense anxiety, sadness, and difficulty house for a long time, believing he was
ished expectations that are often with thoughts.” At admission, he com- communicating with others by telepa-
forced on them by the disease is also an plained of insomnia, thought block- thy. In discussing these symptoms years
important treatment issue. I try to il- ing, thought insertion, and thought later, R noted that they occurred with
lustrate the issues involved in the long- withdrawal. He felt that he had been great veracity and that at the time it
term management of schizophrenia in poisoned by the marijuana and alco- was “impossible for me to believe that
the case of R, with whom I have worked hol that he had consumed. His mood these experiences were not true.”
for over 10 years. R participated ac- was sad and anxious and his affect The records from the second hospi-
tively in the preparation of this case somewhat blunted. He was hospital- talization note that for 2 weeks before
history. ized for 5 weeks and treated with per- admission, R developed staring epi-
phenazine. sodes, withdrawn behavior, inatten-
PAST HISTORY After discharge, R returned to col- tion to work-related tasks, and irrita-
lege, discontinuing the perphenazine bility. He made repeated inappropriate
No one in R’s family was known to treatment. He remained well over the advances to women in the administra-
have had a psychotic illness. His mother next 3 years and returned home after tive program, persisting despite dis-
received outpatient treatment for a graduation, working part-time. He couragement. At admission, he had
“situational depression,” while his fa- then took an entry-level administrative “agitation, emotional withdrawal,
ther had mild eccentricities in de- position. The job was demanding, and blunted affect, unusual behavior, cog-
meanor and communication pattern. R fell in love with a co-worker, who re- nitive disorganization, and auditory
jected his advances. The first symptom and visual hallucinations.” During this
Received April 14, 1998; revision of the second psychotic episode was 5 week hospitalization, he had blunted
received July 16, 1998; accepted Aug. 6, the feeling that other people could ex- and inappropriate affect, posturing
1998. From the Departments of Psychiatry perience directly the thoughts in his with staring spells, and auditory hallu-
and Human Genetics, Virginia Institute for mind. This soon developed into the cinations.
Psychiatric and Behavioral Genetics, Med- conviction that everyone in the city R was initially treated with trifluo-
ical College of Virginia of Virginia Com- knew exactly what he was thinking. perazine, and the delusions and hallu-
monwealth University, Richmond. Address He also began to “receive” thoughts cinations resolved rapidly. Because the
reprint requests to Dr. Kendler, P.O. Box that seemed to enter directly into his trifluoperazine produced blurred vi-
980126, Richmond, VA 23298-0126.
Supported in part by NIMH Research
mind, that were quite distinct from his sion, several other antipsychotic medi-
Scientist Award MH-01277 to Dr. Kendler own thoughts, and were “thought- cations were tried. Eventually, thio-
The author thanks Patrick Sullivan, M.D., like” and not “voice-like” in quality. R thixene at 5 mg/day was decided on.
Alan Gruenberg, M.D., Elizabeth Gander, found that he became able to carry on After discharge, R remained unem-
M.A., and R for helpful comments on ear- two-way conversations by “telepathy.” ployed for several months and then, at
lier drafts. R recalls becoming so busy communi- the age of 24, registered in a 2-year

124 Am J Psychiatry 156:1, January 1999


master’s degree program in business clerical positions over the ensuing 2 enough to assume the responsibilities
administration. He describes his illness years, during which, he recalls, his ill- of his current job. While R was by
as quiescent and his academic perfor- ness was fairly well controlled with training and intellect capable of hold-
mance as good during this period, medication. ing this position, I was concerned that
while he was taking 5 mg/day of thio- he was not psychiatrically well enough
thixene. Because of side effects, he PRESENTATION to deal with the associated stresses. I
would intermittently reduce the dose suggested an extended medical leave
to 3 or 4 mg daily and would often When I first met R, he was 27 and and, if this was not possible, resigna-
then experience symptoms—particu- living at home and had recently begun tion on health grounds. His parents
larly of “thought transfer.” a demanding administrative leadership were visibly angry at this suggestion
During the second year, R worked position. His medications consisted of and asked whether I wanted to make R
intensely on his master’s thesis, and he 7 mg of thiothixene and 2 mg of benz- an invalid. Wasn’t it my job, they ar-
developed a romantic relationship with tropine per day. At our first meeting, R gued, to help him live up to his poten-
a woman in the program. As the pro- was alert, well oriented, and well tial? The meeting ended without reso-
gram ended, R began to decompensate groomed. His speech was organized, lution of this issue.
in the context of 1) reduction in his goal directed, and without pressure. R’s clinical state was slightly im-
dose of thiothixene, 2) breakup of his Although anxious, he related well and proved the next week with 10 mg/day
social group as people left to take jobs, had good eye contact and a full affect of thiothixene. However, he continued
3) the departure of his girlfriend to a without euphoria or irritability. He re- to experience “soft” psychotic symp-
distant city, 4) increased smoking and ported persistent insomnia, unformed toms, which clearly worsened with job
drinking, and 5) participation in a diet auditory hallucinations, and recurrent stress. His parents told me that they
study during which he lost 20 pounds. brief episodes of “thought transfer.” did not agree with my recommenda-
R realized that he was getting sick These symptoms worsened in response tion about R’s employment and that
again, but he did not know how to halt to job stress. R also reported falling in they felt he could “stick it out.” We
the relapse. He was taken to the hospi- love with a co-worker. R denied symp- discussed R’s adolescent drug use. I
tal emergency room, yelling that he toms of depression or mania. He re- told the family that, in my judgment,
wanted to be the hospital CEO. He re- ported being in good health and denied R’s prior illicit drug use had nothing to
calls a period just before he went to the current drug use except cigarettes and do with his psychotic illness. I also told
hospital during which he was immo- alcohol in moderation. The results of them that R’s presentation and history
bile for some period of time. The tele- standard laboratory reports were unre- suggested that he probably had schizo-
pathic feelings were again pronounced. markable. phrenia but that some features of his
He had feelings that he could commu- When I met with R’s parents, sub- history suggested the possibility of af-
nicate through thought patterns and stantial tension was evident. They fective illness. I reviewed for R and his
was able both to receive thoughts from were angry about his psychotic illness parents my approach toward medica-
people outside and to communicate and were understandably puzzled about tion management of chronic psychotic
back to them directly through his what had happened to their son. They illness, which was based on two princi-
thoughts. R recalls a bewildering array were strongly encouraging him to con- ples: 1) keeping the dose of antipsy-
of delusions during the first few days in tinue to work at a level commensurate chotics at the lowest effective level,
the psychiatric intensive care unit, in- with his education. While there were which may reduce long-term risk for
cluding the beliefs that he was moving several sources of tension between R tardive dyskinesia, and 2) flexible dos-
backward in time, that there was a and his parents, one of the strongest ing, so that patients can have control
conspiracy to torture him because he was their concern about his adolescent over their own medication level, being
was a Communist insurgent (the lights drug use, which had consisted mostly able to self-titrate within predeter-
in the ceiling being part of the torture of modest amounts of cannabis. His mined limits. I used the model of a dia-
technique), that he had AIDS, and that, parents felt that this drug use had betic who can take best care of himself
because his father had done something strongly contributed to his psychotic by adjusting his insulin dose as a func-
terrible to him when he was a child, R illness. Furthermore, the parents dis- tion of diet, stress, and exercise levels.
had to harm him in some way. R re- agreed about whether R should con- I also stated that there was some evi-
members the first day in the psychiatric tinue to live with them. dence that lithium carbonate could be
intensive care unit as the worst day of During this first family meeting, I usefully added to antipsychotic medi-
his life, that it was “like a living hell.” stated that I was concerned that R was cation for individuals with schizo-
The records from this third hospital- in the early stage of relapse, which phrenia or with a mixture of schizo-
ization were not highly informative but might progress quickly toward a full phrenic and affective symptoms and
note that on admission he had agita- psychotic decompensation if nothing wondered whether a trial of lithium
tion, loosening of associations, delu- was done. I recommended two courses would be indicated.
sions, and homicidal thoughts. He was of action. First, I suggested increasing A few days later, I received a tele-
treated with thiothixene, 15 mg/day. R’s level of thiothixene. There was, I phone call from the woman with
In the months after discharge, R argued, substantial clinical experience whom R had become romantically in-
completed his thesis, passed his oral and some research evidence that in- volved. R’s behavior was, she said,
examinations, and received his mas- creasing antipsychotic medication in “completely out of line,” and if I could
ter’s degree in administration. While the presence of prodromal psychotic not get him to stop, she would call the
instructed to continue thiothixene at symptoms could forestall a full relapse. police. He was constantly harassing
15 mg/day, R refused because of side Second, reviewing with them the her, calling her at all hours by phone,
effects. He was, however, willing to prior association in R’s history be- visiting her house, and leaving mes-
take 10 mg, eventually reduced to 7 tween stress and psychotic episodes, I sages pushed under her door and
mg. He was employed in a series of raised the issue of whether R was well placed on her windshield. She said

Am J Psychiatry 156:1, January 1999 125


that, although she knew he was men- best and said that I would support his During these early years, I urged R
tally ill, she was scared. I said that I application for disability benefits on to keep up his mental and physical ac-
would immediately meet with R and the condition that he would participate tivity. Several times, he wanted to quit
try to get him to stop this behavior. She actively in an available day program or his volunteer work and I had to remind
agreed that if there was no escalation, in a planned course of volunteer work. him of our agreement, stressing the im-
she would wait a week before calling However, R and his parents felt that he portance of keeping up his “people
the police. should continue to look for work. We skills.” I encouraged him to read. He
I called R for an emergency meeting. also discussed R’s living arrange- liked chess, and this became a frequent
He had no insight into how his behav- ments. I felt that the emotional atmo- subject of discussion. At one session he
ior was affecting this woman and in- sphere in the home was not good for R showed up with a chess set, and for
sisted that he was just being romantic. and suggested he get his own apart- nearly a year we played a game at the
I told him that she certainly did not see ment, as he would have, in my opin- end of each session.
it that way and that he had to stop this ion, no difficulty with the tasks of in- R saw himself as a religious person.
behavior immediately to avoid police dependent living. We spoke of our shared interest in the
involvement. The soft psychotic symp- In the next month, R found work in Bible and the “healthy” uses of reli-
toms had increased over the last week, the trust department of a local bank gion to help us find our place in the uni-
and we agreed to a further increase in and moved out of his parents’ house. verse and to serve as a source of values
thiothixene to 12 mg/day. I told him He continued to describe soft psy- and a guide for life decisions. We con-
that I was quite concerned with his chotic-like ideas, which tended to oc- trasted this with the less “healthy” uses
state of mental health and again sug- cur when things became stressful at R had made of religion during his psy-
gested that he take a leave of absence. work. Instead of the “thought trans- chotic episodes. R was surprised that I
He said that his parents would not sup- fer” phenomenon, however, he de- encouraged his religious interests.
port that, but he did agree to stop hav- scribed delusion-like preoccupations R often spoke of his loneliness and
ing contact with the woman in ques- about his parents. Things got worse at sense of failure. “Look at what my
tion. I ordered baseline tests of thyroid his bank job, and he decided to resign friends from college and grad school
and renal function in anticipation of and seek disability benefits. His par- are doing. They all have good jobs and
the beginning of lithium therapy. ents accepted this decision. Without wives and kids, and look at me.” R
At our next meeting, R told me that the job stressors, we were able to re- was prone to form “crushes” on women
he had been fired. His increasingly dis- duce his dose of thiothixene to 7 mg/ with whom he would have contact.
organized behavior had become evi- day. He and I agreed that, when feel- Usually, these were in situations in
dent to his employer. He had stopped ing stressed he could increase this up which it was unrealistic to expect any
harassing his co-worker and had had to 10 mg/day without consulting me. romantic relationship to emerge. While
no further contact with her. However, He reported that the increased medi- painful, I would suggest to R that he
his parents felt that he should con- cation definitely helped him cope with not act on his feelings.
tinue to support himself. At their urg- bad days. At a lithium dose of 900 Three years after we began working
ing, he was job hunting again. We mg/day, R had no side effects and had together, he met M at the day program.
agreed to a trial of lithium carbonate, blood levels ranging from 0.4 to 0.6 M, a few years younger than R, had in-
and R began taking 900 mg/day of meq/liter. tractable grand mal epilepsy and mild
lithium carbonate. I requested another mental retardation. R was quite at-
family meeting. COURSE OF TREATMENT tracted to her but anxious and fright-
When R returned, he was ebullient. ened at the strength of these feelings.
After 2 days of lithium treatment, the Over the next 9 years, R and I usu- We spent hours discussing how he
“thought transfer” experiences had ally met monthly, for a 30–45-minute might approach M and win her trust
stopped. “You cannot imagine how session. He has continued to receive and affection. Having been sexually as-
distracting it is to feel that the thoughts disability benefits and received special saulted by several male patients in the
of thousands of people, some from cit- housing through a county program. R past, she was initially put off by R’s at-
ies far away, are being routed into your has never demonstrated symptoms of tention. However, over a period of
mind.” tardive dyskinesia. He has had a series months, they started to date and R
In the subsequent family meeting, I of outside activities, beginning with slowly earned both her trust and that
stated more forcefully my belief that R several years’ attendance at a local of her guardians.
was not now ready to work at the high- day program. Unfortunately, R found As they became closer, R was fre-
level administrative jobs for which he this program to be oriented toward quently troubled by feelings of jealous
was trained. We discussed three op- “sicker” patients and of limited rele- rage. When he saw M talking with
tions. He could continue to try to ob- vance for him. He enjoyed the social other men, he was often overwhelmed
tain jobs commensurate with his intel- contact but felt uncomfortable with with anger and on several occasions
ligence and education, try to get “lower- the widespread illicit drug use of some acted on these feelings, with an ensuing
level” jobs that would be less stressful, of the clients. While he returned to bitter argument with M. After much
or apply for Social Security Disability this facility at times, his activities discussion, R gradually became able to
Insurance benefits and focus on im- shifted to volunteer jobs at a nearby accept the fact that M enjoyed male at-
proving his psychiatric condition. I ar- nursing home and the local Red Cross. tention and might flirt because it made
gued strongly against the first option, In addition, he participated in the her feel good about herself.
stating that R did not need additional Master’s Swimming Program at the More than a year after they met,
failures and pointed to his last experi- YMCA. Although R has experienced they started spending nights together,
ence, in which I felt that he had come several exacerbations of his psychotic and R eventually received permission
close to psychotic decompensation. I illness, rehospitalization has never to live with M. He assumed an increas-
felt the third option was probably the been required. ing proportion of her care: checking

126 Am J Psychiatry 156:1, January 1999


her antiseizure medications, bathing himself. He would develop delusion- that he is chronically “at risk” for ac-
her, washing her long hair, and brush- like ideas such as the staff were against tive psychosis that can be precipitated
ing her teeth to control the diphenyl- him or were trying to break up his rela- either by psychosocial stressors or re-
hydantoin-induced gum hypertrophy. tionship with M or that his parents had duction in medication.
In the early years of their relationship, done something terrible to him as a However, there are several atypical
before new medications brought her child (e.g., tortured him on a rack). features in R’s illness that suggest a
seizures under better control, R would The “thought transfer” experiences schizoaffective syndrome. Grandiose
get up with M several times each would return but without their prior in- delusions and excited behavior were
week to change the sheets after she tensity. He never displayed any thought evident in his second and third psy-
had urinated on them during a noc- disorder nor did he completely lose in- chotic episodes. Catatonic symptoms,
turnal seizure. sight into the possibility that these long recognized as a possible concomi-
M would accompany R to see me ev- were “sick thoughts.” In each instance, tant of affective illness (2), were also
ery couple of months. She and I devel- with increased thiothixene, more fre- present. He has had a positive response
oped an agreement whereby she was to quent meetings, and sometimes a meet- to lithium, although the effect seems to
call me when R developed worrying ing with R and M to discuss issues, the be predominantly antipsychotic in na-
symptoms. Over nearly 8 years, she disturbance would pass within 1 to 2 ture. Although noted during his earlier
called me three times to report prob- weeks. admissions, he has never, in the course
lems, always appropriately. As R as- R and I discussed new pharmaco- of our therapy, had any more than the
sumed more and more responsibilities logic treatments. Shortly after the pub- mildest levels of avolition, and he has
for the care of M and for the apart- lication of the Kane et al. study (1), I never demonstrated alogia, apathy, or
ment, he became less willing to spend raised the issue of a clozapine trial. emotional blunting. His grooming and
time at volunteer work as he felt that While not an ideal candidate for this self-care have always been excellent.
caring for M was “his job.” treatment (his positive symptoms hav- The major problem with the diagno-
Each of my more than 100 sessions ing responded well to thiothixene), its sis of schizoaffective disorder is the
with R followed a similar pattern. I low side effect profile, possibly re- absence of any evidence for substan-
would ask about his mental health, duced risk for tardive dyskinesia, and tial depressive or manic symptoms. I
specifically asking about psychotic greater efficacy with negative symp- have watched closely for these and
symptoms and medication side effects. toms suggested that a trial might be in- never noted more than mild dysphoria
We would discuss the relationship with dicated. R read up on clozapine and without substantial neurovegetative
M and any problems that might be decided he did not want to take the symptoms.
emerging. R wanted both to care for M risk of agranulocytosis. About a year I would conclude that R has a form
but not to make her too dependent on after risperidone became available, we of schizophrenia that is dominated by
him. We discussed their sexual rela- tried this agent, proceeding with a slow positive symptoms with little if any
tionship. I would ask after his family, double taper, increasing the risperi- negative symptomatology. From nei-
how his parents were doing and how done while decreasing, in approxi- ther a symptomatic nor a psychosocial
he was getting along with them. If the mately equal increments, the thiothix- perspective has he been able to make
weather was nice, in the early years, we ene. When we got down to 4 mg/day complete interepisode recoveries, so a
would sometimes take a walk and talk of thiothixene and 4 mg/day of risperi- schizophreniform diagnosis is proba-
rather than sit in the office. done, R experienced a clear exacerba- bly not appropriate. While some atypi-
One topic we discussed at length, tion of his symptoms. He was fright- cal features are present in his illness
which illustrates the nature of our in- ened, and we agreed to discontinue the course, the absence of prominent affec-
teractions, began with a flirtation be- risperidone and reinstate his full dose tive symptoms rules out the diagnosis
tween R and a staff member at the Red of thiothixene. He recovered within 2 of schizoaffective disorder.
Cross where he was volunteering. Ini- weeks. We have recently been discuss-
tially, R was uncertain how to respond ing the possibility of another trial of REVIEW OF TREATMENT COURSE
to her apparent interest in him, and he one of the new atypical antipsychotics.
initially concluded that he should quit His negative experience with risperi- In writing this article, R and I inde-
the volunteer job. We talked about the done has made him hesitant, but he has pendently listed features of our work
difficulty everyone has in accurately been expressing more interest in this together that were particularly helpful.
perceiving the “signals” that men and idea lately. Some items appeared on both lists;
women send each other. Perhaps, I sug- others on only one. Here is a sampling.
gested, he was misinterpreting her in- DIAGNOSIS 1. R recalled more clearly than I the
terest. Regardless, I urged R to be po- discussion with his parents about the
lite to her but not otherwise encourage “By the book,” R meets the DSM-IV etiologic role of adolescent drug use in
any personal relationship. It became criteria for schizophrenia. He had bi- his psychotic illness. I was surprised to
clear, however, that he was quite at- zarre delusions and hallucinations for hear him say, “One of the most impor-
tracted to her, and we spoke of issues at least several weeks before the second tant things you ever did for me was to
of fidelity. Eventually, he decided that and third hospitalizations, and these tell my parents that the marijuana I
he could keep the job, did not want to symptoms ceased only with neurolep- smoked as a kid did not cause my
try to have an affair with her, and tic treatment. For more than 6 months schizophrenia. You were an authority
could act professionally with her with- after his third hospitalization, he had for my parents, so when you said that,
out risking losing his composure. “soft” psychotic-like phenomena that they stopped blaming me. That was re-
Four times over 10 years R had ex- would meet criteria for residual symp- ally important.”
acerbations of his illness. These would toms. He has experienced substantial 2. We both agreed that encouraging
begin by his spending hours pacing, occupational dysfunction as a result of R to stop getting high-level jobs com-
muttering, yelling, and laughing to his illness. Indeed, his history indicates mensurate with his education was im-

Am J Psychiatry 156:1, January 1999 127


portant. While I recalled that both R dose. I only wish that I had known that a normal wife, and kids. I couldn’t
and his parents resisted my suggestion, earlier. It might have prevented some make sense of it. But, in these last
R remembered that he and I had both of my previous breakdowns. But then, few years, I have come to feel that I
agreed and it was his parents that it took me a pretty long while to learn was meant to get schizophrenia. God
needed convincing. This is the one area that these medicines were really my had something to do with it. If I had
in my work with R about which I am friends and that I needed them. I guess never developed schizophrenia, who
still ambivalent. R has not had paid I was a slow learner.” would have taken care of M?
employment since he began receiving 5. We both agreed that the lithium
disability payments. When I suggest he therapy, in particular its effect on re- CONCLUSIONS
seek low-stress employment, he resists, ducing the “thought transfers,” had This course of therapy with R illus-
in part because too much outside in- been helpful. trates the multifaceted nature of the
come would threaten his benefits. Fur- 6. R recalled more than I did our treatment of chronic psychotic illness
thermore, he argues that he needs to be discussions about religion. He said (3). Interventions were made at the
with M to supervise her during most that he felt that I have helped him to level of pharmacology (flexible neuro-
daytime hours. Caring for her, he develop a “healthy religious life.” He leptic dosing and lithium carbonate
states, is his job. had wanted to have a religious and augmentation), social factors (moving
3. We both agreed that much of the prayer-full life that brought him close out from a conflictual home environ-
satisfaction that R feels with his life de- to God. Yet he knew that too much fo- ment and reduction of occupational
rives from his relationship with M. He cus on religion and the Bible could stress), psychological issues (intimacy
surprised me by stating that he could make him get sick again. He said that in love relationships), and spiritual
not have established and maintained our discussions helped him find a way concerns (developing a “healthy ap-
this relationship without my guidance. to “more lightly pray” and to “ pursue proach” toward religion). I did not be-
He was, he said, “able to talk to you religion with reasonable zest” but not gin my work with R with an overarch-
about this man to man and could al- to become preoccupied and risk “get- ing theoretical perspective of how to
ways trust your advice.” In retrospect, ting sick again.” treat schizophrenia. Rather, I tried to
I can see that R was ill equipped to 7. Finally, R spoke about his learn- deal with the range of issues that con-
navigate the strong feelings of attrac- ing the “proper attitude toward a life fronted us in as pragmatic a way as I
tion, love, and jealousy that accom- of chronic mental illness.” He said this could given the available resources. In
pany enduring love relationships. Two had two main parts. The first was the reflecting on my work with R, I have
of his psychotic episodes involved ro- importance of habit. He referred here realized that my relationship with him
mantic breakups. Given his vulnerabil- to my oft-repeated insistence on his has had two facets that have interwo-
ity to a breakdown in reality testing keeping himself busy with intellectual ven with one another over time. I have
when confronted with the vicissitudes and physical activity and being in- tried to be for him both a “physician-
of a romantic relationship, R’s ability volved in activity outside the home. expert” who has helped to “manage”
to establish and maintain an intimate The second was the “right attitude.” his schizophrenia and an “advisor-col-
and mutual loving relationship with M Here, I think he was reflecting on the league” who has tried to provide guid-
is a major triumph. He recently wrote, many discussions we had about how to ance and counsel on a range of very
“As a result of many years of therapy, deal with the disability of schizophre- human problems.
it is very clear to me that fantasy and nia—about how to accept but not
limited personal involvement with “give in” to these problems and how to REFERENCES
other women is OK, but actual infidel- avoid bitterness. In one of our most re- 1. Kane J, Honigfeld G, Singer J, Meltzer H:
ity is clearly wrong. I have always been cent meetings, I asked him if he had Clozapine for the treatment-resistant
very confused on this point.” thought about why he had developed schizophrenic: a double-blind comparison
4. R saw my giving him “permis- schizophrenia. He replied, with chlorpromazine. Arch Gen Psychiatry
1988; 45:789–796
sion” to alter his dose of thiothixene as 2. Kirby GH: The catatonic syndrome and its
vital to the success of his therapy. “I Yes, I have thought about that a relation to manic-depressive insanity. J
would have had probably half a dozen lot. At first, I was mad at God be- Nerv Ment Dis 1913; 40:694–704
relapses over these last years if you cause I know all the things that I 3. American Psychiatric Association: Practice
Guideline for the Treatment of Patients
hadn’t taught me that—at the first sign have missed—the job that I had been With Schizophrenia. Am J Psychiatry 1997;
of problems—I should increase my trained for all those years in school, 154(April suppl)

128 Am J Psychiatry 156:1, January 1999