Mr. B was diagnosed with schizophrenia at age 20 following an overt psychotic episode and suicide attempt by hanging. During his psychotic episodes, he thinks groups of people are plotting to kill him. He hears people talking about him or voices telling him about others’ plots against him. Mr. B probably has experienced these symptoms since early childhood, as evidenced by reports of attention-deficit/hyperactivity disorder, oppositional defiant disorder, conduct disorder, and tics.
Numerous medication trials failed. Antipsychotics were ineffective or poorly tolerated because of motor side effects or intense sedation. Mr. B did not tolerate selective serotonin reuptake inhibitors (SSRIs) because of akathisia or sexual side effects. Mr. B had a history of poor medication compliance until he began clozapine treatment.
Mr. B used cannabis daily until 10 years ago. He smokes cigarettes and reports occasional alcohol use. He has no history of chronic substance or alcohol use, withdrawal symptoms, or complications from intoxication.
Mr. B is unemployed and receives Supplemental Security Income. He has never married or had children.
Medical comorbidities include a white blood cell count and absolute neutrophil count that have been chronically in the lower limit range, and dyslipidemia and diabetes, for which Mr. B receives statins and oral hypoglycemics. He has no history of seizures or brain trauma. His family history includes substance dependence on his mother’s side and schizophrenia in 2 paternal cousins.
The authors’ observations
Mr. B’s anxiety disorder has not been clearly elucidated. He does not seem to meet criteria for:
- panic disorder (only 1 panic attack)
- OCD (no compulsions to diminish anxiety)
- specific phobia (phobias were too broad and lacked fear of an object itself).
Clozapine and OCD: The jury’s still out
In addition, he does not seem to have residual paranoia, akathisia, or drug-seeking behavior. Based on numerous evaluations, Mr. B’s anxiety symptoms seem most consistent with agoraphobia without panic (Table 2).Clozapine has been associated with the emergence or worsening of obsessive-compulsive symptoms, although conclusions of studies that investigated this link are equivocal.7 Most of the literature consists of isolated case reports, some of which advocate clozapine for treating obsessive-compulsive disorder rather than for its role as a causative agent.
A case report has associated clozapine with the development of panic disorder in a 34-year-old woman receiving 400 mg/d for paranoid schizophrenia.8 She developed daily attacks of sudden chest compression, dizziness, fear of dying, and intense anxiety. These symptoms progressively improved and eventually resolved after she was switched to olanzapine, 10 mg/d. Clozapine also has been associated with cardiomyopathy presenting as panic attacks.9
The phenomenology of his symptoms appears to be linked to his psychodynamic development, but previous therapists had not explored this. In addition, his relationships with his therapists, illness, and medications are complex. Mr. B is poorly engaged, lacks motivation toward recovery goals, and does not trust me. However, he holds high expectations of the potential damage or benefits of medication.
Table 2
Anxiety: How to differentiate disorders and symptoms
| Disorder/symptom | Keys to differential diagnosis |
|---|---|
| Panic disorder | ≥2 panic attacks |
| Agoraphobia | Fear of ‘no escape,’ ‘no options,’ ‘loss of control’ |
| Generalized anxiety disorder | Constant worriers |
| Specific phobias | Fear of an object itself, not the response it will elicit within the patient |
| Obsessive-compulsive disorder | Patterns of intrusive thoughts followed by an action to undo or avoid anxiety |
| Residual paranoia | Feeling of insecurity associated with episodes of decompensation that have remained inter-episode |
| Drug-seeking behaviors | Secondary gain, in direct relationship to request for medication |
| Akathisia, other side effects | Inner restlessness that is constant, without trigger |
Mr. B was taking clonazepam when our work began, and discontinuing it would have increased his risk for seizures and the possibility of him seeking illicit benzodiazepines. Furthermore, discontinuing clonazepam might have thwarted an emerging therapeutic relationship that would become key to enhancing his motivation and exploring the antisocial and narcissistic traits that were limiting his recovery.