About 2 weeks after discharge from the hospital, the veteran presented for her injection appointment. At this time, she was noted to be disorganized in her thinking and behavior, displaying thought blocking and catatonic behavior. Her parents also described concerning behavior since her discharge. They stated she went to a hotel after her discharge and spent all her available money. She then returned to her parents’ home, where she did not sleep or bathe for several days. She was observed wandering around the house aimlessly and in a confused manner and had become verbally aggressive and threatening toward her parents. The veteran was again psychiatrically admitted due to psychosis and concerns for her safety. She was discharged about 2 weeks later and continued olanzapine injections. She was also referred for outpatient psychotherapy; although she did not initially engage in psychotherapy, she was referred again about 5 months after discharge and began psychotherapy at that time.
The veteran began a course of weekly outpatient psychotherapy employing cognitive behavior therapy for psychosis (CBTp).6 During this time, she described her primary concerns as anxiety and feeling disconnected from others. She reported a history of depression but not of schizoaffective disorder. When asked about this, the veteran stated that she did not feel this diagnosis was accurate and instead believed she had severe depression. When asked why she was prescribed olanzapine, the veteran stated that this medication was for depression. As with her inpatient stays, the veteran demonstrated several negative symptoms during her course of psychotherapy. She presented with noticeably blunted affect, evidenced by lack of facial expression and monotonic speech. She also routinely displayed alogia (ie, lack of speech), often stating that she “did not feel like talking much.” She described difficulty finding motivation to initiate tasks (avolition) as well as a tendency toward social isolation (asociality).
The veteran also described concerns related to neurocognitive and social cognitive symptoms. She reported difficulties in processing speed, cognitive set-shifting (mentally switching between tasks), and inhibition, describing how these concerns interfered with her occupational functioning. She noted difficulty maintaining the expected pace of work at her previous positions, stating that she felt it took her longer to complete tasks compared with others. In addition, she displayed some difficulties with attention and memory. On more than one occasion, she seemed to have forgotten the previous day’s conversations with clinicians. Regarding social cognitive symptoms, she noted difficulties in emotion processing, indicating that it was difficult for her to identify and manage her emotions. This was especially prominent during times of depressed mood.
She also displayed a hostile attribution bias, or tendency to overattribute hostile intent to others’ ambiguous actions. For example, she described an instance where a family member sat too close to her on the couch, stating that she felt this behavior indicated the family member did not care about her. Relatedly, the veteran demonstrated difficulty with perspective taking, which became evident during cognitive restructuring regarding interpretations of her family’s behavior. Finally, the veteran displayed some deficits in social perception, or the ability to identify social context and rules based on nonverbal communication, verbal cues, and vocal intonation. She stated that she often felt conversing with others was difficult for her and indicated that she was “not good at conversations.” This may have in part been due to deficits in social perception.
During the first 2 months of psychotherapy, the veteran regularly attended sessions (conducted over telephone due to the COVID-19 pandemic) and was adherent to twice-weekly olanzapine injections. Despite this, she began experiencing an increase in depressive symptoms accompanied by a noticeable worsening of her blunted affect, alogia, and avolition. After about 2 months of psychotherapy, she described active suicidal ideation and requested to be voluntarily hospitalized. During this hospitalization, the veteran was consulted about the use of clozapine in treatment-refractory conditions and began a trial of clozapine 400 mg. She demonstrated marked improvement in her depressed mood after taking the medication and was discharged about 2 weeks after admission. The veteran completed 10 sessions of CBTp before electing to terminate due to an upcoming move. She was adherent to weekly blood draws per the requirements of clozapine and described intentions to engage in mental health care after her move. The patient’s mother contacted the clinic to inform the treatment team that the patient and her family had moved to a different city and the patient had started receiving care at the VAMC in that city.