is assistant professor, Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, Director of Community Psychiatry Clinics at the Harris Health System, Houston, Texas.

Hai Le, MD

shattered glass_Love the wind/Adobe Stock

TALES FROM THE CLINIC: THE ART OF PSYCHIATRY

Tales From the Clinic: The Art of Psychiatry

, we delve into the world of psychosis and the accompanying suffering from a psychodynamic and suicide risk perspective. Chronic psychotic disorders, exemplified by schizophrenia, bring about terrible suffering and are not fully treatable. Despite advances in psychiatry, we have limited treatment options to offer that can lead to true recovery. Shattered lives ensue, with all the sadness attached. The clinicians who treat this challenging population deserve all our gratitude and support.

“Mr Thomas” was a young male in his late 20s when he first presented at our community clinic to establish care. He was accompanied by his father during the first visit and in all subsequent follow-up appointments. Mr Thomas was visibly shy and anxious during the first appointment. He sat quite close to his father, mostly avoided any eye contact with his psychiatrist, and often deferred to his father for most of the answers. He later revealed the reason for the lack of eye contact was his effort to block the intrusive “inappropriate sexual thoughts” when seeing someone; looking at the psychiatrist would make him think and imagine his naked body. Despite the palpable shyness and anxiety present in the first visit, Mr Thomas gave the impression that he was familiar with outpatient psychiatric care since he had been seeing psychiatrists for years, first for anxiety when he turned 20, and later for bizarre thoughts.

Soon after the fall semester of his junior year, he started having delusional thoughts that he was responsible for the firing of a few employees at a local newspaper because of his hacking into their website and him providing rude feedback on their job performance. In addition, Mr Thomas’ self-esteem and sense of belonging took a major hit because he frequently believed he was causing trouble to others. During one visit, Mr Thomas said he had not slept well the night before because he believed that his neighbor’s dog was barking at him all night to tell him how bad he was and that he would get into trouble. Mr Thomas also talked about his ruminating fear that he would become a pedophile one day due to his intrusive sexual thoughts about children—and, even worse, that his “bad” thoughts could infect others.

The psychotic episodes quickly turned into a distressing experience and sank him further into disorganized thoughts and behaviors. Late in the spring semester of his junior year, Mr Thomas was hospitalized for disorganized behaviors, poor self-care, and suicidal thoughts. Subsequent psychotic episodes and hospitalizations rendered him a harsh reality of a long and seemingly unending struggle with severe schizophrenia.

Nonetheless, despite going through a few more psychotic episodes in the following years, he was able to complete his college degree. In contrast to the sullen look he had when talking about the mental health illness that derailed his life, Mr Thomas spent time during a few visits recalling his childhood and his early years of college with a lot of fondness. Also, behind the flat affect, the self-doubt, and the suffering, Mr Thomas was a deeply caring individual; he regularly donated a significant part of his monthly Social Security check to a local food bank. In one visit, he expressed extreme relief after learning his intrusive thoughts were not contagious and that he was not responsible for others having obsessive compulsive disorder because of his presence. However, when it came to his emotional suffering and daily life struggle, Mr Thomas rarely spontaneously spoke or elaborated when asked.

It has been 5 years since Mr Thomas moved back home after college to live with his father, who has always been a loving and caring figure, but life was not any easier for Mr Thomas. Initially, he was able to find a few labor jobs, but he struggled to hold them: “I do not want to be working around people.” Mr Thomas said he used to be a social person in college, but now he no longer had any meaningful relationships outside of his immediate family. He had not been in touch with his old friends in recent years. The interplay of cognitive, behavioral, and emotional dysfunctions of schizophrenia has led to a long-term impairment of his social and occupational functioning, sinking Mr Thomas into further loneliness, isolation, and a lack of a sense of belonging.

Mr Thomas had been on multiple atypical antipsychotic trials in his earlier years of treatment for psychosis, but the treatment did not make a meaningful impact on his positive symptoms. At the time of his first visit to our clinic, he was already on clozapine; this medication seemed to help with his delusional thoughts of him causing harm to others. However, he still occasionally developed the fear of ruining others’ minds because he believed that they could hear his “bad” thoughts. Also, the intrusive thoughts and images of seeing others in sexual ways continued to torment him, causing a lot of shame and guilt.

Besides taking sertraline for depression, he also had weekly psychotherapy, mostly focusing on cognitive behavioral therapy for psychosis and intrusive thoughts. He found the intervention beneficial, at least partially. At one point, Mr Thomas was able to go to the park and challenge his fear of making eye contact with people by greeting them; however, the intrusive thoughts and imagining others naked never seemed to go away.

Prior to taking sertraline, he was also on fluvoxamine, but it did not have any impact on the intrusive thoughts, even at the highest dose. When the intrusive thoughts became unbearable, Mr Thomas said he sometimes chose to sleep most of the day, so he did not have any awareness of his thoughts and feelings. Mr Thomas’ fears could be more consistent with anxieties higher on the developmental hierarchy. Even though the experience of emerging psychosis during his college years seemed to be devastating, as it burdened the ego with primitive anxieties and deteriorating, his suffering from the psychosis seemed to be much worse in its later stage due to the loss of old self and the confusion of a new one.

Throughout the clinic visits, a sense of loss and grief over the old self was palpable. At one point, Mr Thomas mentioned with a profound sadness that he used to have many hobbies as a teenager. In one visit, he also proudly talked about being selected for his college swim team. These days, he still occasionally went out and swam at a local YMCA, but only when the intrusive thoughts were not troubling him. Otherwise, he spent his time at home checking emails or going to a local library when he did not feel like he was causing problems to others.

Anxiety, guilt, and shame could be unbearable for Mr Thomas at times because of the ruminating thoughts. To him, the thoughts were totally inappropriate; they seemed as if they were part of him, not his illness, especially when he talked about seeing the flash of someone’s genitalia when making eye contact with them. To cope with it, he avoided leaving his house altogether. The only time of the day when he found peace was late at night, walking his family’s dog when there was no one around him.

He never considered using substances to cope with the mental suffering. Mr Thomas belonged to the minority of patients with schizophrenia who never used, misused, or abused any substance, including tobacco, to self-soothe. Research has shown that a history of substance use disorder is associated with a 1.5- to 2-fold increase in suicide rates among patients and can lead to a decrease in executive functioning abilities and a subsequent increase in impulsivity during the course of the disease.

Over the years, the missing sense of belonging and the confusion between his thoughts and reality made him feel increasingly hopeless and helpless. How could he find the future worth looking forward to when he lost his old self? As his psychotic process progressed, more primitive anxieties developed, such as disintegration anxiety and annihilation anxiety. Mr Thomas began to experience the self as formless and diffuse, and thoughts and perceptions became difficult to differentiate.

The container by which patients suffering from severe schizophrenia relate to the outer world has lost its structure. For Mr Thomas, the experience was now not so much of annihilation anxiety, but about himself slipping away and disintegrating. The terror itself can become a companion, providing reassurance that something of the self remains.

Mr Thomas frequently felt indifferent about death because he thought his existence was a burden to himself and everyone else. Mr Thomas drifted further into hopelessness, helplessness, and isolation, despite the love and care from his family, because of the loss of control, the confusion, and the lack of a sense of belonging.

Now, as a young man in his late 20s, Mr Thomas continued the long struggle in his day-to-day existence. The highest risk of completed suicide is recorded among individuals with onset of illness between the ages of 22 and 24 years.

Coupled with the guilt and shame that was exacerbated by his delusional thoughts, the anguish and torment from his suffering became unbearable on multiple occasions. Mr Thomas had been hospitalized 5 times in the 5 years since establishing care at our clinic. Three of these hospitalizations were for having suicidal thoughts, and the other 2 were for serious suicide attempts: one by overdosing on his psychiatric medication, and the other by drowning himself in a swimming pool.

Patients experiencing psychotic symptoms are more likely to exhibit feelings of shame, stigma, guilt, and rejection. Independently, these feelings lead to exacerbation of one’s symptoms, increased social withdrawing, reluctance to seek help, and subsequently a greater risk of completed suicide attempts. Previous suicide attempts are generally considered the number-1 risk factor for subsequent death from suicide. Among patients with schizophrenia, a history of previous attempts early in the treatment period or in the pretreatment period necessitates immediate intervention.

Mr Thomas’ suffering from shame and guilt never seemed to end because of ongoing intrusive sexual thoughts. During one psychotic episode, Mr Thomas felt horrible about himself for having a sexual thought that was transmitted to his right-side neighbor through the vents in his bathroom. The psychotherapy intervention on his delusions and intrusive thoughts was not as effective due to Mr Thomas’ concrete thought process and increasingly poor insight. The effect of insight alone can be paradoxical, as it contributes to the illness’ severity through the mediating effects of depression and hopelessness.

 Living with a diagnosis can make it hard for him to separate his identity from it, leading to feelings of hopelessness, loss of autonomy, negative views of oneself, and demoralization. These factors, combined with maladaptive coping mechanisms and lack of social support, can lead to depressive feelings and internalized stigma at a later stage of the disease.

Although a hospital stay can have positive effects on one’s illness, by ensuring adequate management, symptomatic control, and greater security, studies have shown a higher rate of completed suicide in the week following discharge. Patients lacking adequate support outside of a health care facility could be faced with more hardships upon discharge. Some could also view their illness as more debilitating when it requires a longer course of hospitalizations, leading to less adherence with the course of treatment.

A deeper understanding of patients’ suffering—especially through the view of the often-ignored psychodynamic lens—and early recognition of suicide risk factors specific to patients with schizophrenia are important in clinical settings. The effective intervention relies on detection and treatment tailored to each patient’s needs, rendering the healing journey more bearable and less challenging.

is an assistant professor in the Menninger Department of Psychiatry and Behavioral Sciences, Baylor College of Medicine, and director of Community Psychiatry Clinics at the Harris Health System in Houston, Texas. 

is a medical student at the University of Balamand, Lebanon, who plans to pursue a residency in psychiatry. 

 is a clinical assistant professor at Baylor College of Medicine and a child, adolescent, and adult psychiatrist in private practice in Houston, Texas.

Psychodynamic Psychiatry in Clinical Practice. 5th ed

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Morbidity and mortality in schizophrenia with comorbid substance use disorders

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Psychodynamic Diagnostic Manual – 2nd edition: PDM-2

Predictors of suicide at time of diagnosis in schizophrenia spectrum disorder: a 20-year total population study in Ontario, Canada

Association of an early intervention service for psychosis with suicide rate among patients with first-episode schizophrenia-spectrum disorders

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Painful insight vs. usable insight in schizophrenia. Do they have different influences on suicidal behavior?

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How can looking at the suffering of patients with schizophrenia through a psychodynamic lens help clinicians develop effective interventions and treatment plans?

Shattered Self: Schizophrenia Suffering, Beyond Logic and Reason 

 Tales From the Clinic: The Art of Psychiatry, 

we follow a psycho-oncology case of lung cancer, compounded by depressive and anxiety symptoms. Faced with fear of death, individuals go through stages of grief, as described by Elisabeth Kübler-Ross, MD, in 1969. This discussion highlights the psychotherapeutic, pharmacological, and diagnostic considerations of this comorbidity.

“Mr Arnold” is a 67-year-old retired teacher with no past psychiatric or medical history. He was referred to a psychiatry clinic for sadness and anxiety shortly after being diagnosed with metastatic adenocarcinoma of the lower lobe of the left lung. The devastating diagnosis caught Mr Arnold off guard just months into his retirement, as the only symptoms he experienced were cough and progressive fatigue. Besides these complaints, he had no past medical issues, always stayed committed to a healthy lifestyle, and underwent regular screenings and physical exams. Mr Arnold did not have any history of tobacco smoking, alcohol drinking, or any other substance use. He felt numb when he first heard the diagnosis because he was overwhelmed with a range of strong emotions: disbelief, anger, fear, anxiety, and sadness. Mr Arnold’s retirement plan now had to be put on hold so he could focus on cancer treatment. He had already suffered tremendous grief a few years earlier after the loss of his wife of 30 years to cancer. This time, he was traumatized by 

A Love Letter to the Patient-Physician Relationship

Roberto D. Sanchez, DO; Benjamin Li, MD; Nidal Moukaddam, MD, PhD

During the initial visit to the psychiatry clinic, he complained predominantly of fear of death, hopelessness, insomnia, social isolation, anger, guilt, and worry for his girlfriend if the treatment fails: “What will she do without me? Who will take care of her after I die?” Mirtazapine was started to target depression, anxiety, poor sleep, and low appetite; however, Mr Arnold found the medication too sedating. Sertraline was subsequently started and was much more tolerable and helpful with alleviation of anxiety and depression.

He was started on chemotherapy and radiation treatment soon after diagnosis. During the early stages of 

, he had difficulty coping with the treatment burden and reported worsening symptoms of anxiety. He was affected not only by the cancer diagnosis, but also by the treatment and its side effects, which worsened his depression and anxiety, lowered his quality of life, and exacerbated his loneliness and social isolation. Besides pharmacological intervention for depression and anxiety, he was concurrently seen by a psychotherapist to work on relaxation techniques, deep breathing exercises, and cognitive behavioral therapy. After persevering through almost 2 years of cancer treatment, Mr Arnold felt extremely relieved when the PET scan showed no evidence of active disease. Subsequent CT scans were negative as well. Mr Arnold later continued maintenance oral chemotherapy. While he felt relieved and hopeful for the future, a part of him still felt anxious that the cancer might recur.

Lung cancer is second only to breast cancer in prevalence. Older adults with lung cancer face a range of challenging issues, including demoralization, 

, treatment distress, anxiety, and depression. Some issues relate to loss of control and dignity, whereas others stem from problems related to quality of life. Smokers, or individuals who feel their cancer stemmed from negative behaviors of their own doing, often experience shame and worse depression.

 In therapy, fear of mortality and psychosocial decline need to be addressed. Stages of grief must also be highlighted and worked through, although stages do not have to occur in clean, predictable order.

For Mr Arnold, it was hard to imagine a worse time for him to receive the news of this devastating diagnosis because, after decades of working hard, he had been looking forward to spending the post-retirement years traveling. Like other patients, Mr Arnold found himself in shock (the denial/shock stages of grief). He now had to face the dreadful transition from anticipating years with joyful activities to navigating the uncharted waters of a deadly illness and difficult treatment. Mr Arnold experienced demoralization similar to Erik Erikson’s concept of despair in the final stage of one’s life, where he partially felt regret over the life he had lived and the feeling of 

Compared to other malignancies, lung cancer is associated with a higher rate of mortality and symptom burden, which can cause serious psychological suffering. Facing a terminal illness, Mr Arnold felt devastated and in despair; he now believed he had only a slim chance of being able to do the meaningful things that he had worked and planned for all his life (ie, traveling around the world). Although he reflected on the life he had lived with pride, having raised 2 successful children, he felt regret for not doing enough of what he felt would have brought him happiness (the depression stage of grief). During the course of his cancer treatment, Mr Arnold constantly found himself in a tug of war between hope for a full recovery (so he could travel) and, in his words, “make peace” (achieving ego integrity, the bargaining stage of 

) with the life that he had led and the fear of death.

Reflecting on his life, Mr Arnold felt that being diagnosed with lung cancer was unfair for him since he never had medical problems and had been committed to a healthy lifestyle (the anger stage of grief). He never smoked tobacco, drank alcohol, or abused any substance. Like most lung cancer patients, Mr Arnold was diagnosed when the cancer was in the late stage because his early symptoms—dry cough and fatigue—were nonspecific and dismissed without further work-up. He also reported feeling guilty about the possibility of becoming a burden on his girlfriend, who herself had chronic conditions. 

 is key in improving outcome at this stage in treatment.

 In aging patients, this is a common concern that needs to be addressed in multimodal treatment planning, as there is increasing recognition that caregiver health and patient health are interdependent.

During his first visit with psychiatry, Mr Arnold reiterated tearfully that he had saved money all his life for retirement and planned to travel extensively in the last meaningful years of his life. The addition of psychotherapy was essential in guiding the patient through the stages of grief. Although lung cancer is the most frequently occurring cancer and the leading cause of cancer death in men,

 it is essential to help patients realize that many cancer occurrences do not lead to death (the acceptance stage of grief). He was psychologically tormented by the 

, especially in the aftermath of the diagnosis and early stages of treatment.

As the lung cancer treatment progressed, Mr Arnold started to worry more about his financial situation since his retirement savings were quickly depleted by medical bills. He felt resentful that a significant portion of his retirement savings was now drained, and he could not help his girlfriend. Alleviating the burden of treatment in this situation was integral to improving the patient’s anxiety and depression. Considerations for patients in this situation include 

 of disease/cancer staging, likelihood of poor prognosis, and uncertainty in treatment and outcome.

Screening for depression among patients with lung cancer can be tricky as multiple confounding factors present as neurovegetative symptoms, mostly related to the cancer and its treatment; for example, low energy, poor appetite, decreased motivation, loss of interest, and decreased concentration. Research has shown that the level of distress experienced by lung cancer patients is not correlated with the type or stage of cancer, but that individuals with 

 may have higher health resource utilization and worse outcomes.

The best management of lung cancer and treatment distress requires early and comprehensive care coordination involving a multidisciplinary team to address physical suffering, spiritual needs, psychosocial stressors, nutritional needs, and psychological suffering. The goal is to provide adequate control of physical symptoms, psychosocial support, and management of anxiety and depression.

Another benefit of this antidepressant, and the reason it was selected as first line, is that it alleviates gastrointestinal symptoms (nausea) induced by chemotherapy and poor sleep related to distress and anxiety.

 for depression; the medication was also helpful for anxiety. Another benefit of this antidepressant, and the reason it was selected as first line, is that it alleviates gastrointestinal symptoms (nausea) induced by chemotherapy and poor sleep related to distress and anxiety. Mr Arnold had a good response to mirtazapine; however, the sedation caused by its side effect was a major issue because he already struggled with fatigue and low energy. Sertraline was later started and proved to be a better choice for his depressive symptoms. However, in treating patients with cancer, drug interactions have to carefully considered because selective serotonin reuptake inhibitors are sometimes associated with increased cytotoxicity when combined with certain chemotherapy agents.

Because of fatigue, depression, and anxiety, Mr Arnold notably lost interest in his routine activities. For the treatment of fatigue, he needed only conservative care such as physical therapy and energy conservation; no pharmacological intervention was required. During the course of 

, it was important to focus on Mr Arnold’s mood improvement based on depression symptoms that are psychologically based, rather than neurovegetative ones that are related to lung cancer such as fatigue, pain, dyspnea, weakness, insomnia, and poor concentration. Distinguishing physical symptoms due to cancer treatment is essential in this patient group.

The depression symptoms that were considered markers of depression response include feeling hopeless/helpless or unmotivated, easy crying, irritability, self-blaming, social isolation, and mood/affect change. The patient’s quality of life and other meaningful elements of his life were also important to consider when following up on the treatment of depression and anxiety. Helping the patient’s mood serves a dual purpose, both as a success in mental health treatment and a way to improve the patient’s immune system and improve adherence to the lengthy cancer treatment program. 

When evaluating anxiety among patients with lung cancer, it is also important to distinguish physiologically based dyspnea and anxiety from a psychological state.

Mr Arnold’s anxiety could have started with a respiratory deficit, but it was later exacerbated by the fear of death, catastrophizing, as well as feeling hopeless and helpless. Besides the psychological trauma, going through 20 months of radiation and chemotherapy was an ordeal for Mr Arnold, as he struggled with poor quality of life due to severe pain induced by the treatment. Because pain is a multidimensional and complex experience, it was imperative to explore the psychospiritual dimension of his suffering during follow-up visits. Discussing his pain, fear, concern, loss of autonomy, and dignity helped relieve Mr Arnold’s distress. Fortunately, he was not reluctant to talk about these concerns.

With a good response to the cancer treatment, Mr Arnold’s grieving mostly resolved after successfully completing his treatment, with residual intermittent anxiety of disease recurrence.

is Assistant Professor, Department of Psychiatry, Division of Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, Texas.

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Depressive symptoms among patients with lung cancer: elucidating the roles of shame, guilt, and self-compassion.

2. Ketcher D, Otto AK, Vadaparampil ST, et al. 

The psychosocial impact of spouse-caregiver chronic health conditions and personal history of cancer on well-being in patients with advanced cancer and their caregivers.

3. Bray F, Ferlay J, Soerjomataram I, et al. 

Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries.

4. Sullivan DR, Ganzini L, Duckart JP, et al. 

Treatment receipt and outcomes among lung cancer patients with depression.

5. Ester M, Culos-Reed SN, Abdul-Razzak A, et al. 

Feasibility of a multimodal exercise, nutrition, and palliative care intervention in advanced lung cancer.

The selective serotonin reuptake inhibitors enhance the cytotoxicity of sorafenib in hepatocellular carcinoma cells.

Comorbid depression in surgical cancer patients associated with non-routine discharge and readmission.

A patient, faced with a lung cancer diagnosis and the fear of death, goes through the stages of grief. How can you as clinicians lead them through?

Hai Le, MD

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