I carefully and slowly change Mr. B’s medications. First I increase his clozapine to 300 mg/d in 150 mg divided doses in an attempt to cover the possibility of residual paranoia, and for anxiolytic sedation without introducing a new medication. However, Mr. B’s anxiety symptoms worsen, so I resume the baseline dosage (125 mg bid). I choose not to switch to another antipsychotic because the risk for psychotic decompensation outweighs the potential benefits. I lower clonazepam to 2 mg/d in split doses. I teach Mr. B anxiety management techniques, including distraction, exposure, and anxiety tolerance training.
Because Mr. B refuses to start an SSRI for his anxiety symptoms, I prescribe bupropion and monitor him closely for dopamine agonism as evidenced by a re-emergence of psychosis. Once again, his anxiety symptoms worsen.
I stop bupropion and switch Mr. B to gabapentin, titrated to 400 mg tid. I chose this medication because of its sedation properties and relatively safe side effect profile. Mr. B was willing to try gabapentin—which was first approved to treat epilepsy—because he was afraid of having a seizure and also because it is not associated with sexual side effects. Furthermore, its GABA-mimetic actions made it a plausible alternative to replicate the benefits he was getting from clonazepam.
TREATMENT: An effective drug
Mr. B tolerates gabapentin well and his anxiety symptoms are much more sporadic, shorter, and more easily controlled by conscious exercise. The content of his thoughts is less disastrous and less ego-dystonic. He feels less dysphoria associated with clozapine and does not need as much clonazepam. He overcomes his avoidance of all fear-provoking triggers except walking across bridges.
Mr. B continues his regimen of clozapine, clonazepam, and gabapentin. He moves to independent housing and applies for employment.
Related resource
- Garrett M, Lerman M. CBT for psychosis for long-term inpatients with a forensic history. Psychiatr Serv. 2007;58(5):712-713.
- Aripiprazole • Abilify
- Bupropion • Wellbutrin
- Clonazepam • Klonopin
- Clozapine • Clozaril
- Gabapentin • Neurontin
- Olanzapine • Zyprexa
- Ziprasidone • Geodon
The authors report no financial relationship with any company whose products are mentioned in this article or with manufacturers of competing products.