Awakenings with the New Antipsychotics

The explosion of neuroscience developments in this "Decade of the Brain" now provides people with schizophrenia a new generation of antipsychotic therapies. For many, these medications (e.g., clozapine [Clozaril], olanzapine [Zyprexa], risperidone [Risperdal], and quetiapine [Seroquel]) produce an improvement over their "old" antipsychotics in terms of side effects and, for some, clinical response. For a select few, however, these medications can produce dramatic improvement, akin to what Sacks (1990) termed an "awakening." These medications create exciting opportunities to use psychotherapy, group work and rehabilitation with a population historically relegated to back wards or triaged to "case management."

As people awaken to a new mental state and a unique set of psychological challenges, our clinical service at the Massachusetts Mental Health Center (MMHC) has become interested in the experience of these robustly responding patients. MMHC has a large population of people on these medications, and the center has a strong tradition of attending to the psychological experience of people with psychotic illness. We interviewed 15 long-term outpatients with schizophrenia or schizoaffective disorder who were living in the community and who had shown significant clinical improvement on these new compounds. Our findings were published in the November/December 1997 issue of the Harvard Review of Psychiatry.

We found that, because of the extent and longevity of their psychotic symptoms, many awakened patients have experienced a process of psychological redefinition and have confronted developmental tasks that were dormant prior to their improvement. When the hallucinations, tangential thinking or delusions are quieted, patients are "free" to reassess their status in life. The internal world that they have known is considerably different, and the external world has changed from the way it was before the last time they were not dominated by psychotic thoughts or experiences. Based on our interviews and observations of patients from this sample, we posit a three-part conceptual scheme for the issues that challenge this population:

• Sense of self
• Sense of connectedness
• Sense of purpose

The psychotherapeutic work at hand for some patients is filled with both grief and hope as they come to reassess themselves, their relationships and their purpose in life. Such work is supportive, reality-based and practical, but is also mindful of the psychodynamic concepts of loss, adaptation and defenses. That agranulocytosis or a change in finances could threaten the loss of these essential medications at any time adds to the challenge for patient and therapist alike.

• Sense of Self

The struggle to redefine oneself as the psychotic process remits is a staggering task for any patient. Assisting in this task requires considerable therapeutic dexterity. If the work of therapy is to "acknowledge, bear and put into perspective" (Semrad, 1966), then a revised sense of self challenges the therapeutic endeavor to integrate the current mental state with the previous illness history, reviewing losses and setting realistic goals.

One 32-year-old man who was diagnosed with schizoaffective disorder 15 years ago told us:

"I had this psychotic pattern of thinking which was usually circular and dealing with one issue at a time, things like what we would agree to be day-to-day reality. My other experience is relating everything to myself subjectively. My brain was preoccupied with discerning whether this is real or this is not real.

"What clozapine has done is to break up this pattern or thought process. I had certain behaviors that I had adopted in dealing with being an inpatient. With clozapine it was... sort of like waking up. In a lot of ways, the psychosis acted as my defense and was my way of relating to the world for so long. It was a relief initially not to be crazy. But it is also painful...like being crazy kept me innocent in a way. Sometimes I can't bear the weight of my own grief."

This process of integration of a healthy identity with a hopeful future is even more difficult when patients hit a ceiling in their recovery. Such is the case with one 33-year-old woman who began to have auditory hallucinations and paranoid delusions in her early 20s and was diagnosed with schizophrenia. She experienced no significant response on conventional antipsychotics but did develop severe tardive dyskinesia while taking these medications. She has shown considerable but finite improvement over two and one-half years on olanzapine.

Her fantasies of a cure had been raised by optimistic researchers and clinicians as her initial improvement kept her out of hospitals for the duration of her treatment. But, she reminds us, she lost the love of her life during her illness and she is still on disability. She is grateful that she is no longer dominated by psychotic processes but is unable to reach her "old level." She often asks if new medications are coming out.

Finally, a young woman who repeatedly starts and stops her atypical antipsychotic treatment explains that the weight gain she experiences on clozapine is sufficiently unpleasant to her that she takes breaks from it. Her mental state is strikingly different on clozapine, and she is also able to avoid using drugs when she takes it. "It seems I can only have a mind or a body," she reports.

• Sense of Connection

The self in connection to others is a second area that is central to our recovering patients. This is the area in which skill deficits are the most apparent. At MMHC we have an ongoing clozapine support group that serves as a forum where patients further along in their recovery teach those patients who are in an earlier stage of recovery. Pragmatic skill-building groups, along with role-playing in a dyad, help patients with this aspect of recovery. In the individual sessions, attending to the therapeutic relationship as an interpersonal process is also important.

A 52-year-old man with paranoid schizophrenia, who had been hospitalized more than 10 times, had been living a profoundly isolated life while conventional antipsychotics poorly controlled his positive and negative symptoms. He lived marginally in his own apartment and refused offers of group living or day programs. Following a 14-month trial on olanzapine his grooming improved, as did his ability to describe his affective experiences, and he became romantically involved with a woman at a day treatment center.

After living 20 years without an intimate relationship, he felt overwhelmed with the newfound stresses of this connection. He discussed the pressures of being in this relationship and twice switched back between his old medications and the newer medications. Most recently he chose to move to a living situation that gives him more access to other high-functioning members of the MMHC community. He now has a pet for the first time in his life and cares for it lovingly. He reports pleasure in these connections and reports that for now, at least, he is not yet ready for a more intimate relationship.

A 38-year-old woman, who had a diagnosis of schizophrenia with long-standing paranoid symptoms, had been hospitalized more than five times. She talked about her difficulty finding a peer group now that she had become more social:

"I don't have a lot of friends, but my parents are with me. They stood by me through all the illness I had. I want to meet normal people...[but] I've been with so many mentally ill people that it's hard for me to make up things to talk about. I used to know a lot of people from church, but now I know nobody. I never had my teenage years. That's why I don't seem mature."

The loss of a sense of continuous development or uninterrupted narrative is a common sorrow for these patients. Time spent in the "sick role" with an active illness may limit the development of mutual relationships. The patient describes a nether world of relationships that is neither well nor sick. We know of no magic formula to aid in this process but would rely on her support group, clinician and her own strength to experiment with different kinds of connections, learning from each one.

• Sense of Purpose

We observe that people often search for a sense of purpose and spirituality as their symptoms remit to a substantial degree. A large number of them understandably yearn to return to their former hopes of what they had wanted to become, but instead must grieve this loss and attempt to find meaning and purpose in their reconfigured lives. As they work through their grief, rehabilitation and/or occupational training can solidify a sense of purpose and competence in these patients (Arns and Linney, 1993).

A 46-year-old married woman diagnosed with schizoaffective disorder more than 25 years ago, who survived more than 10 suicide attempts and a long history of cocaine abuse, talks about how her beliefs have changed over the years since she started taking clozapine:

"Every night in the past when I went to bed, I would ask God to take away my life. Things have changed now that I am better. Now I feel that there is a God. There is a divine spark in all of us...He has His own agenda. My life is only tragic if I am not on clozapine. When I was on the other antipsychotic, my thinking was slowed. I couldn't concentrate on my writing. My purpose in life is to do God's will. He gave me a gift for language and writing. I have to use them to help those still suffering to write about their...our...suffering."

There's little doubt that the growth of therapies for schizophrenia will continue to open complex psychological doors for our patients. Convincing payers that these developmental and existential issues are worthy of payment will become a policy challenge for caregivers.

Research demonstrating the cost-effectiveness of psychotherapeutic efforts for this population (e.g., in terms of improved medication compliance), coupled with data indicating that clozapine is a cost-effective intervention (Meltzer et al., 1993), could help to establish the need for individual psychotherapy, support groups and intensive vocational training for these patients. With or without such data, we believe that this study upholds the notion that the psyche in persons with psychotic disorders warrants psychotherapeutic care. By learning from the people who have managed this transition well, we can better utilize the next wave of pharmacological successes.

(Dr. Duckworth wishes to acknowledge his coauthors--Vijaya Nair, MMed [Psych]; Jayendra K. Patel, M.D.; and Stephen M. Goldfinger, M.D.--and especially the patients of MMHC who shared their experiences with us--Ed.)

References:

• References 1.Arns PG, Linney JA (1993), Work, self, and life satisfaction for persons with severe and persistent mental disorders. Psychosoc Rehab J 17:63-79.
  2.Meltzer HY, Cola P, Way L, Thompson PA et al. (1993), Cost-effectiveness of clozapine in neuroleptic- resistant schizophrenia. Am J Psychiatry 150(11):1630-8.
  3.Sacks O (1990), Awakenings. New York: Harper.
  4.Semrad EV (1966), Long-term therapy of schizophrenia: psychoneuroses and schizophrenia. Philadelphia: Lippincott.