what is a famous case study of schizophrenia

Module 11: Schizophrenia Spectrum and Other Psychotic Disorders

Case studies: schizophrenia spectrum disorders, learning objectives.

• Identify schizophrenia and psychotic disorders in case studies

Case Study: Bryant

Thirty-five-year-old Bryant was admitted to the hospital because of ritualistic behaviors, depression, and distrust. At the time of admission, prominent ritualistic behaviors and depression misled clinicians to diagnose Bryant with obsessive-compulsive disorder (OCD). Shortly after, psychotic symptoms such as disorganized thoughts and delusion of control were noticeable. He told the doctors he has not been receiving any treatment, was not on any substance or medication, and has been experiencing these symptoms for about two weeks. Throughout the course of his treatment, the doctors noticed that he developed a catatonic stupor and a respiratory infection, which was identified by respiratory symptoms, blood tests, and a chest X-ray. To treat the psychotic symptoms, catatonic stupor, and respiratory infection, risperidone, MECT, and ceftriaxone (antibiotic) were administered, and these therapies proved to be dramatically effective. [1]

Case Study: Shanta

Shanta, a 28-year-old female with no prior psychiatric hospitalizations, was sent to the local emergency room after her parents called 911; they were concerned that their daughter had become uncharacteristically irritable and paranoid. The family observed that she had stopped interacting with them and had been spending long periods of time alone in her bedroom. For over a month, she had not attended school at the local community college. Her parents finally made the decision to call the police when she started to threaten them with a knife, and the police took her to the local emergency room for a crisis evaluation.

Following the administration of the medication, she tried to escape from the emergency room, contending that the hospital staff was planning to kill her. She eventually slept and when she awoke, she told the crisis worker that she had been diagnosed with attention-deficit/hyperactive disorder (ADHD) a month ago. At the time of this ADHD diagnosis, she was started on 30 mg of a stimulant to be taken every morning in order to help her focus and become less stressed over the possibility of poor school performance.

After two weeks, the provider increased her dosage to 60 mg every morning and also started her on dextroamphetamine sulfate tablets (10 mg) that she took daily in the afternoon in order to improve her concentration and ability to study. Shanta claimed that she might have taken up to three dextroamphetamine sulfate tablets over the past three days because she was worried about falling asleep and being unable to adequately prepare for an examination.

Prior to the ADHD diagnosis, the patient had no known psychiatric or substance abuse history. The urine toxicology screen taken upon admission to the emergency department was positive only for amphetamines. There was no family history of psychotic or mood disorders, and she didn’t exhibit any depressive, manic, or hypomanic symptoms.

The stimulant medications were discontinued by the hospital upon admission to the emergency department and the patient was treated with an atypical antipsychotic. She tolerated the medications well, started psychotherapy sessions, and was released five days later. On the day of discharge, there were no delusions or hallucinations reported. She was referred to the local mental health center for aftercare follow-up with a psychiatrist. [2]

Another powerful case study example is that of Elyn R. Saks, the associate dean and Orrin B. Evans professor of law, psychology, and psychiatry and the behavioral sciences at the University of Southern California Gould Law School.

Saks began experiencing symptoms of mental illness at eight years old, but she had her first full-blown episode when studying as a Marshall scholar at Oxford University. Another breakdown happened while Saks was a student at Yale Law School, after which she “ended up forcibly restrained and forced to take anti-psychotic medication.” Her scholarly efforts thus include taking a careful look at the destructive impact force and coercion can have on the lives of people with psychiatric illnesses, whether during treatment or perhaps in interactions with police; the Saks Institute, for example, co-hosted a conference examining the urgent problem of how to address excessive use of force in encounters between law enforcement and individuals with mental health challenges.

Saks lives with schizophrenia and has written and spoken about her experiences. She says, “There’s a tremendous need to implode the myths of mental illness, to put a face on it, to show people that a diagnosis does not have to lead to a painful and oblique life.”

In recent years, researchers have begun talking about mental health care in the same way addiction specialists speak of recovery—the lifelong journey of self-treatment and discipline that guides substance abuse programs. The idea remains controversial: managing a severe mental illness is more complicated than simply avoiding certain behaviors. Approaches include “medication (usually), therapy (often), a measure of good luck (always)—and, most of all, the inner strength to manage one’s demons, if not banish them. That strength can come from any number of places…love, forgiveness, faith in God, a lifelong friendship.” Saks says, “We who struggle with these disorders can lead full, happy, productive lives, if we have the right resources.”

You can view the transcript for “A tale of mental illness | Elyn Saks” here (opens in new window) .

• Bai, Y., Yang, X., Zeng, Z., & Yang, H. (2018). A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. BMC psychiatry , 18(1), 67. https://doi.org/10.1186/s12888-018-1655-5 ↵
• Henning A, Kurtom M, Espiridion E D (February 23, 2019) A Case Study of Acute Stimulant-induced Psychosis. Cureus 11(2): e4126. doi:10.7759/cureus.4126 ↵
• Modification, adaptation, and original content. Authored by : Wallis Back for Lumen Learning. Provided by : Lumen Learning. License : CC BY: Attribution
• A tale of mental illness . Authored by : Elyn Saks. Provided by : TED. Located at : https://www.youtube.com/watch?v=f6CILJA110Y . License : Other . License Terms : Standard YouTube License
• A Case Study of Acute Stimulant-induced Psychosis. Authored by : Ashley Henning, Muhannad Kurtom, Eduardo D. Espiridion. Provided by : Cureus. Located at : https://www.cureus.com/articles/17024-a-case-study-of-acute-stimulant-induced-psychosis#article-disclosures-acknowledgements . License : CC BY: Attribution
• Elyn Saks. Provided by : Wikipedia. Located at : https://en.wikipedia.org/wiki/Elyn_Saks . License : CC BY-SA: Attribution-ShareAlike
• A case report of schizoaffective disorder with ritualistic behaviors and catatonic stupor: successful treatment by risperidone and modified electroconvulsive therapy. Authored by : Yuanhan Bai, Xi Yang, Zhiqiang Zeng, and Haichen Yangcorresponding. Located at : https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5851085/ . License : CC BY: Attribution

Schizophrenia case studies: putting theory into practice

This article considers how patients with schizophrenia should be managed when their condition or treatment changes.

DR P. MARAZZI/SCIENCE PHOTO LIBRARY

Treatments for schizophrenia are typically recommended by a mental health specialist; however, it is important that pharmacists recognise their role in the management and monitoring of this condition. In ‘ Schizophrenia: recognition and management ’, advice was provided that would help with identifying symptoms of the condition, and determining and monitoring treatment. In this article, hospital and community pharmacy-based case studies provide further context for the management of patients with schizophrenia who have concurrent conditions or factors that could impact their treatment.

Case study 1: A man who suddenly stops smoking

A man aged 35 years* has been admitted to a ward following a serious injury. He has been taking olanzapine 20mg at night for the past three years to treat his schizophrenia, without any problems, and does not take any other medicines. He smokes 25–30 cigarettes per day, but, because of his injury, he is unable to go outside and has opted to be started on nicotine replacement therapy (NRT) in the form of a patch.

When speaking to him about his medicines, he appears very drowsy and is barely able to speak. After checking his notes, it is found that the nurses are withholding his morphine because he appears over-sedated. The doctor asks the pharmacist if any of the patient’s prescribed therapies could be causing these symptoms.

What could be the cause?

Smoking is known to increase the metabolism of several antipsychotics, including olanzapine, haloperidol and clozapine. This increase is linked to a chemical found in cigarettes, but not nicotine itself. Tobacco smoke contains aromatic hydrocarbons that are inducers of CYP1A2, which are involved in the metabolism of several medicines [1] , [2] , [3] . Therefore, smoking cessation and starting NRT leads to a reduction in clearance of the patient’s olanzapine, leading to increased plasma levels of the antipsychotic olanzapine and potentially more adverse effects — sedation in this case.

Patients who want to stop, or who inadvertently stop, smoking while taking antipsychotics should be monitored for signs of increased adverse effects (e.g. extrapyramidal side effects, weight gain or confusion). Patients who take clozapine and who wish to stop smoking should be referred to their mental health team for review as clozapine levels can increase significantly when smoking is stopped [3] , [4] .

For this patient, olanzapine is reduced to 15mg at night; consequently, he seems much brighter and more responsive. After a period on the ward, he has successfully been treated for his injury and is ready to go home. The doctor has asked for him to be supplied with olanzapine 15mg for discharge along with his NRT.

What should be considered prior to discharge?

It is important to discuss with the patient why his dose was changed during his stay in hospital and to ask whether he intends to start smoking again or to continue with his NRT. Explain to him that if he wants to begin, or is at risk of, smoking again, his olanzapine levels may be impacted and he may be at risk of becoming unwell. It is necessary to warn him of the risk to his current therapy and to speak to his pharmacist or mental health team if he does decide to start smoking again. In addition, this should be used as an opportunity to reinforce the general risks of smoking to the patient and to encourage him to remain smoke-free.

It is also important to speak to the patient’s community team (e.g. doctors, nurses), who specialise in caring for patients with mental health disorders, about why the olanzapine dose was reduced during his stay, so that they can then monitor him in case he does begin smoking again.

Case 2: A woman with constipation

A woman aged 40 years* presents at the pharmacy. The pharmacist recognises her as she often comes in to collect medicine for her family. They are aware that she has a history of schizophrenia and that she was started on clozapine three months ago. She receives this from her mental health team on a weekly basis.

She has visited the pharmacy to discuss constipation that she is experiencing. She has noticed that since she was started on clozapine, her bowel movements have become less frequent. She is concerned as she is currently only able to go to the toilet about once per week. She explains that she feels uncomfortable and sick, and although she has been trying to change her diet to include more fibre, it does not seem to be helping. The patient asks for advice on a suitable laxative.

What needs to be considered?

Constipation is a very common side effect of clozapine . However, it has the potential to become serious and, in rare cases, even fatal [5] , [6] , [7] , [8] . While minor constipation can be managed using over-the-counter medicines (e.g. stimulant laxatives, such as senna, are normally recommended first-line with stool softeners, such as docusate, or osmotic laxatives, such as lactulose, as an alternative choice), severe constipation should be checked by a doctor to ensure there is no serious bowel obstruction as this can lead to paralytic ileus, which can be fatal [9] . Symptoms indicative of severe constipation include: no improvement or bowel movement following laxative use, fever, stomach pain, vomiting, loss of appetite and/or diarrhoea, which can be a sign of faecal impaction overflow.

As the patient has been experiencing this for some time and is only opening her bowels once per week, as well as having other symptoms (i.e. feeling uncomfortable and sick), she should be advised to see her GP as soon as possible.

The patient returns to the pharmacy again a few weeks later to collect a prescription for a member of their family and thanks the pharmacist for their advice. The patient was prescribed a laxative that has led to resolution of symptoms and she explains that she is feeling much better. Although she has a repeat prescription for lactulose 15ml twice per day, she says she is not sure whether she needs to continue to take it as she feels better.

What advice should be provided?

As she has already had an episode of constipation, despite dietary changes, it would be best for the patient to continue with the lactulose at the same dose (i.e. 15ml twice daily), to prevent the problem occurring again. Explain to the patient that as constipation is a common side effect of clozapine, it is reasonable for her to take laxatives before she gets constipation to prevent complications.

Pharmacists should encourage any patient who has previously had constipation to continue taking prescribed laxatives and explain why this is important. Pharmacists should also continue to ask patients about their bowel habits to help pick up any constipation that may be returning. Where pharmacists identify patients who have had problems with constipation prior to starting clozapine, they can recommend the use of a prophylactic laxative such as lactulose.

Case 3: A mother is concerned for her son who is talking to someone who is not there

A woman has been visiting the pharmacy for the past 3 months to collect a prescription for her son, aged 17 years*. In the past, the patient has collected his own medicine. Today the patient has presented with his mother; he looks dishevelled, preoccupied and does not speak to anyone in the pharmacy.

His mother beckons you to the side and expresses her concern for her son, explaining that she often hears him talking to someone who is not there. She adds that he is spending a lot of time in his room by himself and has accused her of tampering with his things. She is not sure what she should do and asks for advice.

What action can the pharmacist take?

It is important to reassure the mother that there is help available to review her son and identify if there are any problems that he is experiencing, but explain it is difficult to say at this point what he may be experiencing. Schizophrenia is a psychotic illness which has several symptoms that are classified as positive (e.g. hallucinations and delusions), negative (e.g. social withdrawal, self-neglect) and cognitive (e.g. poor memory and attention).

Many patients who go on to be diagnosed with schizophrenia will experience a prodromal period before schizophrenia is diagnosed. This may be a period where negative symptoms dominate and patients may become isolated and withdrawn. These symptoms can be confused with depression, particularly in younger people, though depression and anxiety disorders themselves may be prominent and treatment for these may also be needed. In this case, the patient’s mother is describing potential psychotic symptoms and it would be best for her son to be assessed. She should be encouraged to take her son to the GP for an assessment; however, if she is unable to do so, she can talk to the GP herself. It is usually the role of the doctor to refer patients for an assessment and to ensure that any other medical problems are assessed. 

Three months later, the patient comes into the pharmacy and seems to be much more like his usual self, having been started on an antipsychotic. He collects his prescription for risperidone and mentions that he is very worried about his weight, which has increased since he started taking the newly prescribed tablets. Although he does not keep track of his weight, he has noticed a physical change and that some of his clothes no longer fit him.

What advice can the pharmacist provide?

Weight gain is common with many antipsychotics [10] . Risperidone is usually associated with a moderate chance of weight gain, which can occur early on in treatment [6] , [11] , [12] . As such, the National Institute for Health and Care Excellence recommends weekly monitoring of weight initially [13] . As well as weight gain, risperidone can be associated with an increased risk of diabetes and dyslipidaemia, which must also be monitored [6] , [11] , [12] . For example, the lipid profile and glucose should be assessed at 12 weeks, 6 months and then annually [12] .

The pharmacist should encourage the patient to attend any appointments for monitoring, which may be provided by his GP or mental health team, and to speak to his mental health team about his weight gain. If he agrees, the pharmacist could inform the patient’s mental health team of his weight gain and concerns on his behalf. It is important to tackle weight gain early on in treatment, as weight loss can be difficult to achieve, even if the medicine is changed.

The pharmacist should provide the patient with advice on healthy eating (e.g. eating a balanced diet with at least five fruit and vegetables per day) and exercising regularly (e.g. doing at least 150 minutes of moderate-intensity activity or 75 minutes of vigorous-intensity activity per week), and direct him to locally available services. The pharmacist can record the adverse effect on the patient’s medical record, which will help flag this in the future and thus help other pharmacists to intervene should he be prescribed risperidone again.

*All case studies are fictional.

Useful resources

• Mind — Schizophrenia
• Rethink Mental Illness — Schizophrenia
• Mental Health Foundation — Schizophrenia
• Royal College of Psychiatrists — Schizophrenia
• NICE guidance [CG178] — Psychosis and schizophrenia in adults: prevention and management
• NICE guidance [CG155] — Psychosis and schizophrenia in children and young people: recognition and management
• British Association for Psychopharmacology — Evidence-based guidelines for the pharmacological treatment of schizophrenia: updated recommendations from the British Association for Psychopharmacology

About the author

Nicola Greenhalgh is lead pharmacist, Mental Health Services, North East London NHS Foundation Trust

[1] Chiu CC, Lu ML, Huang MC & Chen KP. Heavy smoking, reduced olanzapine levels, and treatment effects: a case report. Ther Drug Monit 2004;26(5):579–581. doi: 10.1097/00007691-200410000-00018

[2] de Leon J. Psychopharmacology: atypical antipsychotic dosing: the effect of smoking and caffeine. Psychiatr Serv 2004;55(5):491–493. doi: 10.1176/appi.ps.55.5.491

[3] Mayerova M, Ustohal L, Jarkovsky J et al . Influence of dose, gender, and cigarette smoking on clozapine plasma concentrations. Neuropsychiatr Dis Treat 2018;14:1535–1543. doi: 10.2147/NDT.S163839

[4] Ashir M & Petterson L. Smoking bans and clozapine levels. Adv Psychiatr Treat 2008;14(5):398–399. doi: 10.1192/apt.14.5.398b

[5] Young CR, Bowers MB & Mazure CM. Management of the adverse effects of clozapine. Schizophr Bull 1998;24(3):381–390. doi: 10.1093/oxfordjournals.schbul.a033333

[6] Taylor D, Barnes TRE & Young AH. The Maudsley Prescribing Guidelines in Psychiatry . 13th edn. London: Wiley Blackwell; 2018

[7] Oke V, Schmidt F, Bhattarai B et al . Unrecognized clozapine-related constipation leading to fatal intra-abdominal sepsis — a case report. Int Med Case Rep J 2015;8:189–192. doi: 10.2147/IMCRJ.S86716

[8] Hibbard KR, Propst A, Frank DE & Wyse J. Fatalities associated with clozapine-related constipation and bowel obstruction: a literature review and two case reports. Psychosomatics 2009;50(4):416–419. doi: 10.1176/appi.psy.50.4.416

[9] Medicines and Healthcare products Regulatory Agency. Clozapine: reminder of potentially fatal risk of intestinal obstruction, faecal impaction, and paralytic ileus. 2020. Available from: https://www.gov.uk/drug-safety-update/clozapine-reminder-of-potentially-fatal-risk-of-intestinal-obstruction-faecal-impaction-and-paralytic-ileus (accessed April 2020)

[10] Leucht S, Cipriani A, Spineli L et al. Comparative efficacy and tolerability of 15 antipsychotic drugs in schizophrenia: a multiple-treatments meta-analysis. Lancet 2013;382(9896):951–962. doi: 10.1016/S0140-6736(13)60733-3

[11] Bazire S. Psychotropic Drug Directory . Norwich: Lloyd-Reinhold Communications LLP; 2018

[12] Cooper SJ & Reynolds GP. BAP guidelines on the management of weight gain, metabolic disturbances and cardiovascular risk associated with psychosis and antipsychotic drug treatment. J Psychopharmacol 2016;30(8):717–748. doi: 10.1177/0269881116645254

[13] National Institute for Health and Care Excellence. Psychosis and schizophrenia in adults: prevention and management. Clinical guideline [CG178]. 2014. Available from: https://www.nice.org.uk/guidance/cg178 (accessed April 2020)

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Case Study: Schizophrenia and Work: Martin’s Story

Martin had been out of work for several years following a prolonged psychotic episode which began when he was studying at university. He desperately wanted to get into work but found that employers treated his prolonged absence “on the sick” with suspicion. He thought that if he could do a period of work experience that would show prospective employers that he was capable of working again but he was afraid that if he did it might affect his benefits.

So Martin made an appointment to see the Disability Employment Advisor at the Jobcentre to discuss his plans. She was understanding and helpful and explained that a work placement would not affect his benefits as long as it was done as part of the Jobcentre’s own scheme. She also told him that the scheme would pay his travel-to work expenses while he was on the placement.

Job-searching

Next Martin researched local employers using the internet and the local press, looking for companies that might have vacancies in the sort of clerical and administrative work he thought he could do. Then he called the companies by ‘phone and speaking to the person on the switchboard checked that he had the correct postal address for them and asked the name of the person in charge of recruiting. It is vital to be able to write to a named person rather than just the Human Resources Manager.

Martin had already spent a lot of time on his CV so now he compiled a covering letter to go with it. It took him about a month to work up his CV and covering letter using books that he got from the local library. He also managed to get advice from a local back-to-work scheme recommended by the Disability Employment Advisor at the Jobcentre. Martin knew that it was essential that his letter and CV had the maximum impact.

Martin sent his CV and letter off to six employers and then waited about a week before calling them up on the ‘phone. He asked to speak to the person he had written to but if the person on the switchboard asked the reason for his call he simply said that he was calling to follow up a letter he had written.

After approaching about 20 employers in this way he finally found one who said there could be an opening for work experience in a couple of months time. So over the next three months Martin kept in touch with the company by ‘phone once a month just to let them know that he was still keen on coming to work for them.

The interview

Finally the company asked him in for an interview. Before going to the interview Martin prepared really well in advance by researching the company well and trying to anticipate the sorts of questions he would be asked. He also went to the local library and took out some books on interview techniques and managed to get on a one day course on interview skills that the Jobcentre had told him about. This included a mock interview which he found particularly useful.

The day of the interview arrived and Martin was very nervous but he was up early and washed and dressed. To be sure of being on time he left an hour early and checked out the location of the office. Then he went to Starbucks for a coffee while he waited. This gave him an opportunity to flick through his notes and prepare on some of the answers he had been working on. He made sure that he was punctual and well groomed and did his best to present himself well at the interview.

Despite being really well prepared walking through the front door of the office was one of the hardest things that he had done for years. But the receptionist was polite and could not have been more helpful. She made him feel welcome and even offered him a coffee (which he declined).

The Human Resources Manager who interviewed Martin was very professional but quickly put him at his ease. He asked questions about his education at school, his hobbies and pastimes and his qualifications and then came the bit that Martin had been dreading when the HR Manager asked him why he had dropped out of college. Martin explained that he had had a breakdown caused by too much stress while he was at college. He went on to explain that although it was a bad breakdown it was behind him now and that with the help of his family and friends and his doctor he had been able to make a really strong recovery. He also explained that in some ways the experience had made him a stronger person and that he had matured as a result of it.

As the end of the interview approached Martin was sure that he had flunked it but the interviewer told him that he had been successful and asked him to start on Monday. Martin was delighted to be offered a period of three months unpaid work experience during which he would work for two days a week at their local office doing clerical and administrative work.

Martin was walking on air when he left the office. All his hard work had been worth it.

The next day Martin called the Disability Employment Advisor at the local Jobcentre to tell them about the offer and see how his benefits would be affected. She confirmed that his benefits wouldn’t be affected as long as he only worked for 16 hours a week.

The placement

For the next three months Martin worked hard at his placement. He made sure that he got all the basics right: being punctual and well groomed every day. At work he was helpful and got on well with the other workers. Although he was very shy at first he soon learned the importance of making small talk with his colleagues and building good working relationships.

As the end of his placement approached Martin wondered if he would be offered a permanent position. He asked the HR Manager about this but sadly he was told that there were no permanent vacancies at that time so when the end of his placement came Martin had mixed feelings. On the one hand he was disappointed that the work experience had not turned into a permanent job but on the other hand he had had three months experience in the workplace and had something to put on his CV to demonstrate to other employers that he could work. And most importantly he had that all important reference from a well respected local employer.

But that isn’t quite the end of the story. Martin continued searching for a job without success for another six months but continued to keep in touch with the HR Manager he had worked for during his work experience. One day he saw in the local press that they were advertising for a clerical assistant so he called them and explained that he was still jobsearching and would be available for this position. The HR Manager was very pleased to hear from him and said that he would call him back. The next day Martin got a call asking him to go in for an interview straight away and was offered the job.

Martin called the Jobcentre Plus helpline and found out what benefits he would be entitled to while he was working and was pleased to find out that he would be better off in work.

Martin has now been employed in his new job for two years and is delighted to be living an independent lifestyle free of the benefits culture he was in before. It has had its difficulties though. For instance Martin found that his illness had left him emotionally very sensitive and that he found it difficult to cope if his work was criticised. But he knew that this was something he had to learn to live with and gradually he managed to learn new social skills that helped him to cope better and at the same time helped him in other areas of his life.

Martin has enjoyed the structure that the new job has brought to his life. He enjoys the work and the social contact that the job entails. He has made new friends and above all his self-esteem has grown vastly. Now when people ask him what he does for a living he no longer has to say that he is unemployed.

Some Key Points from Martin’s Story:

• Research the local job market really well
• Before writing to a firm call to check the postal address.
• Find out the name of the person in charge of recruitment. Writing to a named person makes sure your letter gets read.
• You can’t spend enough time preparing your CV and cover letter. Get as much help as you can from books, the library etc.
• When making follow up calls avoid Mondays and Fridays as these are busy days for people in business. Similarly don’t call too early in the morning or after 3.30 pm and don’t call around lunchtime.
• When making follow up calls be prepared for few false starts but use these to develop your technique. Treat the first half a dozen calls as practice calls.
• Don’t pester firms with too frequent follow up calls. Once every three weeks is about right.
• Be prepared for disappointment and don’t feel let down by it.
• Before going for an interview research the firm really well. Google and Google News and the local press are useful sources.
• It is perfectly normal to be nervous at an interview. Try to minimise the nerves by making sure you have planned and prepared well and getting a good night’s sleep beforehand.
• At the interview you may be asked about your illness. Be honest but there is no need to disclose your diagnosis at this stage unless you are asked directly: a broad brush explanation such as “a breakdown” is sufficient.

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CASE REPORT article

Early-onset schizophrenia with predominantly negative symptoms: a case study of a drug-naive female patient treated with cariprazine.

• Institute of Genomic Medicine and Rare Disorders, Semmelweis University, Budapest, Hungary

Schizophrenia is a chronic and severe mental disorder characterized by positive, negative, and cognitive symptoms. Negative symptoms are usually present from the prodromal phase; early diagnosis and management of negative symptoms is a major health concern since an insidious onset dominated by negative symptoms is associated with a worse outcome. Antipsychotic medications, which are effective for treating positive symptoms, are generally ineffective for treating negative or cognitive symptoms. We present a 23-year-old woman showing severe symptoms at her first visit to our department. The patient’s parents reported that their daughter had experienced several years of psychosocial decline and putative psychiatric symptoms, but no medical attention had been previously sought; as such, the diagnosis of schizophrenia with predominantly negative symptoms was very much delayed. Early onset of schizophrenia, longer duration of untreated psychosis, and severe negative symptoms, which have limited treatment options, suggested a poor prognosis. We initiated monotherapy with cariprazine, a novel antipsychotic that has recently been proven efficacious in treating schizophrenia with predominantly negative symptoms. This report describes a 52-week cariprazine treatment regimen and follows the patient’s impressive clinical improvement confirmed by PANSS and CGI scores, and psychological tests.

Schizophrenia is a severe, chronic, and heterogeneous mental disorder that often has debilitating long-term outcomes. Its lifetime prevalence rate is estimated to be approximately 1% worldwide in the adult population ( Lehman et al., 2010 ). Onset generally occurs in late adolescence or early adulthood, with an average age of 18 years for men and 25 years for women. 1 The term early-onset schizophrenia (EOS) is used to refer to patients who are diagnosed with the disorder before this age. EOS is a severe, frequently disabling, and chronic condition with a prevalence approaching 0.5% in those younger than 18 years ( Hafner and Van der Heiden, 1997 ).

Schizophrenia is accompanied by a distortion of personality that affects fundamental mental and social functions, making everyday life extremely difficult for patients. Clinical symptoms are often classified in three main domains: positive symptoms, such as hallucinations, delusions, suspiciousness/persecution; negative symptoms, such as emotional withdrawal, blunted affect, and passive social withdrawal; and cognitive symptoms, such as impaired perception, learning, thinking, and memorizing. EOS may be accompanied by greater symptom severity, premorbid developmental impairment, ‘soft’ neurological signs (eg, clumsiness, motor incoordination), and a higher rate of substance abuse ( Hsiao and McClellan, 2008 ; Clemmensen et al., 2012 ; Immonen et al., 2017 ). Accordingly, diagnosis of EOS is often difficult and frequently delayed since onset is more commonly insidious than acute, which makes it difficult to differentiate EOS from underlying cognitive deficits, premorbid functional impairment, or other abnormalities ( Russell, 1994 ; Bartlet, 2014 ). Given this common delay in recognition of the disorder, the duration of untreated psychosis is often very long, further contributing to a poor outcome ( Penttila et al., 2014 ).

Although various hypotheses have been developed, the etiopathogenesis of schizophrenia and EOS is not fully understood ( McGuffin, 2004 ; Klosterkotter et al., 2011 ). 2 Among the rising and falling neurochemical theories, the dopamine hypothesis has remained a primary hypothesis guiding the treatment of schizophrenia. There are four dopaminergic pathways in the human brain: the mesolimbic, the mesocortical, the tuberoinfundibular, and the nigrostriatal. Positive symptoms of schizophrenia are associated with the hyperdopaminergic state of D 2 receptors in the mesolimbic area, while negative and cognitive symptoms are believed to be related to the hypodopaminergic dysregulation of the prefrontal cortex ( Stahl, 2003 ).

Negative symptoms of schizophrenia, which affect up to 60% of patients with schizophrenia ( Rabinowitz et al., 2013 ), form a complex clinical constellation of symptoms that challenge both diagnosis and treatment. By definition, negative symptoms mean the absence of normal functions. Negative symptoms are classified by their etiology as primary negative symptoms, which are core features of the disease itself, and secondary negative symptoms, which are consequences of positive symptoms, antipsychotic treatment, depression or extrapyramidal side effects. Five constructs have been accepted by general consensus as key aspects of negative symptoms: blunted affect, alogia, anhedonia, asociality, and avolition ( Marder and Galderisi, 2017 ). Patients with predominant negative symptoms lose their motivation, cannot function at school or work, and their interpersonal relationships severely decay. Due to impaired daily functioning and social amotivation, they may need constant care.

Although early intervention is associated with improvement in negative symptoms ( Boonstra et al., 2012 ), this may be challenging since negative symptoms develop slowly and may be difficult to detect or differentiate from other clinical features ( Kirkpatrick et al., 2001 ; Galderisi et al., 2018 ). Moreover, a more insidious onset predicts poorer outcome and more severe negative symptoms ( Kao and Liu, 2010 ; Immonen et al., 2017 ; Murru and Carpiniello, 2018 ). Diagnosis of patients with predominantly negative symptoms (lacking manifest psychotic signs) is often delayed, resulting in a longer duration of untreated psychosis. The length of untreated psychosis is closely related to poorer functional outcome ( Perkins et al., 2005 ).

Negative symptoms have traditionally had minimal response to antipsychotic treatment. First-generation antipsychotics are effective in treating positive symptoms, but negative symptom improvement is only evident when symptoms are secondary to positive symptoms. It was initially hoped that second-generation antipsychotics would target both positive and negative symptoms, but efficacy data have been disappointing. This was a large meta-analysis where only four second-generation drugs (amisulpride, risperidone, olanzapine, and clozapine) resulted to be more efficacious than first-generation antipsychotics in the overall change of symptoms, including positive and negative symptoms. The other examined second-generation antipsychotics were only as efficacious as first-generation antipsychotic agents ( Leucht et al., 2009 ). These studies were mainly conducted in patients with general symptoms of schizophrenia, therefore a secondary effect on negative symptoms could not be ruled out. Therefore negative symptom improvement cannot be considered a core component of atypicality ( Veerman et al., 2017 ). Previous studies have demonstrated that no drug had a beneficial effect on negative symptoms when compared to another drug ( Arango et al., 2013 ; Millan et al., 2014 ; Fusar-Poli et al., 2015 ), meaning that head to head comparisons of different agents among each other did not result in superiority of one drug to another. The latest comparison ( Krause et al., 2018 ) evaluated all studies that have been performed in the negative symptom population so far, and has found that amisulpride claimed superiority only to placebo, olanzapine was superior to haloperidol, but only in a small trial (n = 35), and cariprazine outperformed risperidone in a large well-controlled trial.

Hence cariprazine emerged as an agent of particular interest in regard to negative symptoms. Cariprazine is a dopamine D 3 /D 2 receptor partial agonist and serotonin 5-HT 1A receptor partial agonist. It has been hypothesized that cariprazine is the only antipsychotic that can block D 3 receptors in the living brain, thereby exhibiting functions that are related to D 3 blockade (e.g., improvement of negative symptoms) ( Stahl, 2016 ). In that large clinical trial including 460 patients with predominant negative symptoms and stable positive symptoms of schizophrenia, cariprazine was significantly more effective than risperidone in improving negative symptoms and patient functioning ( Nemeth et al., 2017 ).

Case Description

The 23-year-old female patient visited the Institute of Rare Diseases at our university with her parents. They had suspected for a long time that something was wrong with their daughter, but this was the first time they had asked for medical help. The patient was quiet and restrained since she did not speak much, her parents told us her story instead. Initially, the patient had done very well in a bilingual secondary school and was socially active with friends and peers. At the age of 15 years, her academic performance started to deteriorate, with her first problems associated with difficulty learning languages and memorizing. Her school grades dropped, and her personality started to gradually change. She became increasingly irritated, and was verbally and physically hostile toward her classmates, resorting to hitting and kicking at times. She was required to repeat a school year and subsequently dropped out of school at the age of 18 because she was unable to complete her studies. During these years, her social activity greatly diminished. She lived at home with her parents, did not go out with friends, or participate in relationships. Most of the time she was silent and unsociable, but occasionally she had fits of laughter without reason. Once the patient told her mother that she could hear the thoughts of others and was probably hearing voices as well. Slowly, her impulse-control problems faded; however, restlessness of the legs was quite often present.

Our patient’s medical history was generally unremarkable. She lacked neurological or psychiatric signs. She had a tonsillectomy and adenotomy at age 7 years. Epilepsy was identified in the patient’s family history (father’s uncle). On physical examination, there were no signs of internal or neurological disease; body mass index was 21.5 (normal weight).

During the first psychiatric interview and examination, we found that our patient was alert and vigilant, but had trouble relating due to decreased integrity of consciousness. Her attention could be aroused or partially directed, and she had difficulty keeping a target idea. Autopsychic and allopsychic orientations were preserved. Longer thinking latencies and slowed movement responses were observed, sometimes with even cataleptic impressions. Cognitive functions, such as thinking, memory, and concept formation, were severely impaired, and we were unable to carry out some of our neurocognitive tests -such as the Addenbrooke’s Cognitive Examination ( Hsieh et al., 2013 ), the Toulouse-Pieron attention test (Kanizsa G1951), Bells test ( Gauthier et al., 1989 ) and the Trail Making Test- because of the patient’s denial of symptoms and refusal to cooperate.

She often looked aside and laughed frequently, suggesting the presence of perceptual disturbances, but she denied her symptoms when asked. In contrast to the periodic inappropriate laughing, apathy and anhedonia were markedly present. During the examination, the patient could not recall anything she would do or even think of with pleasure. According to the heteroanamnesis, she lost her interest in activities she used to like, did not go out with friends anymore, and showed no signs of joy or intimacy towards her family members either.

Along with the affective hyporesponsiveness, amotivation and a general psychomotor slowing were observed. Hypobulia, void perspectives, and lack of motivation were explored. Parental statements indicated that the patient’s social activity had continued to diminish, and her appearance and personal physical hygiene had deteriorated. When we initiated a conversation, the patient was negativistic and agitated. Her critical thinking ability was reduced, which led to inappropriate behavior (she, e.g., unexpectedly stood up and left the room while the examination was still ongoing). Considering her status, she was admitted to the clinic after her first visit.

After several differential diagnostic tests were performed (e.g., routine diagnostic laboratory parameters, immune serological analyses, electroencephalogram, magnetic resonance imaging, genetic testing), all the possible common and rare disorders, such as Huntington’s disease, Niemann Pick C disease, mitochondrial disorders, and autoimmune diseases, were ruled out.

At first contact, to differentiate the symptoms and severity of putative schizophrenia, we mapped the positive, negative, and general symptoms, as well as a clinical impression, using the Positive and Negative Syndrome Scale (PANSS), the Scale for Assessment of Negative Symptoms, and the Clinical Global Impressions-Severity (CGI-S) ( Groth-Marnat, 2009 ).

The patient had a very high PANSS total score, which corresponded to being considered “severely ill” or “among the most severely ill’ on the CGI-S ( Leucht et al., 2005 ). The PANSS score was derived dominantly from the negative items of the scale. Overall, her negative symptoms fulfilled criteria for predominantly negative symptoms, meaning that positive symptomatology was reduced, while negative symptoms were more explicit and dominated the clinical picture ( Riedel et al., 2005 ; Olie et al., 2006 ; Mucci et al., 2017 ). Baseline rating scale sores are presented in Table 1 .

Table 1 Summary of symptom scale scores at the time of admission to the hospital.

The diagnosis of EOS with predominantly negative symptoms was given and treatment with the antipsychotic agent cariprazine was initiated. The patient was hospitalized for 2 weeks following her arrival at the clinic. Cariprazine was started at the dose of 1.5 mg/day and titrated up to 4.5 mg/day over a 2-week period: the patient received 1.5 mg/day for the first 3 days, 3 mg/day from day 4 to day 12, and eventually 4.5 mg/day from day 13 onward. During these 2 weeks, which were spent in hospital, the patient’s explicit negative symptoms such as poverty of speech, psychomotor retardation, poor eye contact, and affective nonresponsiveness improved; however, delusions and hallucinatory perceptions did not fade significantly.

Two weeks after discharge, we saw the patient for her first outpatient visit. Significant clinical improvement was observed. The patient calmly cooperated during the examination, with no signs of agitation. She was oriented to time, place, and self, attention could be drawn and directed, and she was able to keep a target idea and change the subject. Although according to the family, perceptual disturbances were still present, laughing with no reason and looking aside were much less frequent, and restlessness of the legs had stopped; these symptoms were not observed during the examination. Psychomotoric negativism had improved greatly, the patient was more communicative, and she paid more attention to the activities of family members. The pace of speech was close to normal: the thinking latencies and slowed movement responses as observed at admission were not seen anymore. The patient had adequate reaction time to questions asked and could focus in the interview. Mild obstipation and somnolence in the evening were her main complaints. Apart from some tick-like eye closures, there was no pathological finding during physical and neurological examination. At this point, cariprazine was reduced to 3 mg per day.

At her second outpatient visit, which occurred 8 weeks after treatment initiation, further improvement was observed. According to her mother, the patient was more active and open at home. Neurological examination found that the alternating movements of her fingers were slightly slowed. Cariprazine 3 mg/day was continued with concomitant anticholinergic medication.

At the third outpatient visit, which occurred 16 weeks after the first contact, the patient’s overall symptoms, including cognitive functions, such as memory and abstract thinking, as well as functions in activities of daily living, had improved remarkably. She had started to participate in the family’s daily life, even taking responsibility for some household duties; further, she went to the hairdresser for the first time in years, a step forward from her previous state of self-neglect. She was probably still having auditory hallucinations, which she considered natural, and some extrapyramidal symptom (EPS)-like ruminating movements, like to-and-fro swinging of her trunk, were observed. She did not look aside any more and tics were no longer present. Compared with previous visits overall, she was very relaxed, retained eye contact, cooperated, and communicated adequately during the interview. She started to develop insight into her condition, and she told us that her “thoughts were not healthy.” At the last two visits, the synkinesis of the arms was reduced.

After 16 weeks of treatment, the patient’s PANSS Negative Subscale Score and PANSS factor score for negative symptoms (PANSS-FSNS) score were reduced by 44.44% and 41.31%, respectively. Recent studies have demonstrated that linking the percentage improvement of PANSS with CGI-S and -Improvement (CGI-I) scores shows that a 25–50% reduction of PANSS scores corresponds to clinically meaningful change ( Correll et al., 2011 ; Fusar-Poli et al., 2015 ). In acutely ill patients with predominantly positive symptoms who are more likely to respond well to treatment, the 50% cutoff would be a more clinically meaningful criterion; however, since even slight improvement might represent a clinically significant effect in a patient with atypical schizophrenia, the use of 25% cutoff is justified ( Correll et al., 2011 ; Fusar-Poli et al., 2015 ).

In this regard, the 44.44% (change from baseline: −20) and 41.31% (change from baseline: −19) improvement demonstrated on PANSS Negative Symptom subscale and PANSS-FSNS, respectively, are considered a clearly clinically relevant change. Beyond the impaired synkinesis and alternating movement of the arms and fingers, there were no other treatment-related physical dysfunctions. Change from baseline on the PANSS and CGI scales are shown over the course of treatment in Table 2 .

Table 2 Summary of symptom scale scores at weeks 16, 32, and 52.

Since our patient’s symptoms demonstrated strong improvement and tolerability was favorable, cariprazine therapy was continued. Improvement in both negative and positive symptoms was maintained over the course of treatment. At her later visits (32 and 52 weeks), PANSS total score was reduced to a level that was close to the minimum, and the decrease in negative symptom scores was considerable (PANSS-NSS=66.67% and PANS-FSNS=70.00% at both time points). The patient’s progress was also reflected in clinical and functional measurements, with the CGI-S score reduced to 2 (borderline mentally ill) and a CGI-I score of 1 (very much improved) indicating notable improvement.

Cariprazine has demonstrated broad spectrum efficacy in the treatment of positive and negative symptoms of schizophrenia. In a field where no treatment is available for difficult-to-treat negative symptoms, this case is unique and may have important implications for schizophrenia treatment. Despite experiencing approximately 8 years of untreated symptoms and functional impairment associated with predominantly negative symptom EOS, our 23-year-old female patient showed considerable symptomatic and functional improvement after several weeks of treatment with cariprazine. Given that the duration of untreated negative symptoms is associated with worse functional outcomes ( Boonstra et al., 2012 ), the remarkable improvement seen in this case shows how valuable cariprazine could be for patients with similar symptom presentations. Although it is not possible to generalize the observations and findings of this single case, it has the novelty of detecting a potential effect of cariprazine in a drug-naïve patient with marked negative symptoms of early-onset schizophrenia. To our knowledge, no cariprazine-related data has been published in this type of patients. A single case study is obviously far from being predictive for the efficacy of a drug, however, the results seen with this case are promising. With a dose recommended for patients with negative symptoms, our patient’s clinical condition, including positive, negative, and cognitive symptoms, as well as social functioning have improved notably, with the effect maintained for over 12 months. Generally, cariprazine has been well tolerated, with mild EPS observed after 8 weeks, but no metabolic, cardiac, or other side effects.

This case report suggests that the management of patients with EOS and prominent negative symptoms is achievable in everyday practice with cariprazine. More real-world clinical experience is needed to support this finding.

Data Availability Statement

All datasets generated for this study are included in the article/supplementary material.

Ethics Statement

Written informed consent was obtained from the individual(s), and minor(s)’ legal guardian/next of kin, for the publication of any potentially identifiable images or data included in this article.

Author Contributions

All authors listed have made substantial, direct, and intellectual contribution to the work and approved it for publication.

This work was supported from Research and Technology Innovation Fund by the Hungarian National Brain Research Program (KTIA_NAP_ 2017-1.2.1-NKP-2017-00002). Editorial support for this case report was supported by funding from Gedeon Richter. The funder was not involved in the study design, collection, analysis, interpretation of data, the writing of this article or the decision to submit it for publication.

Conflict of Interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be constructed as a potential conflict of interest.

Acknowledgments

We are thankful to the patient and her family for giving us the opportunity to share her story in the form of a publication. Also, we acknowledge editorial assistance was provided by Carol Brown, MS, ELS, of Prescott Medical Communications Group, Chicago, Illinois, USA, a contractor of Gedeon Richter plc.

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Keywords: cariprazine, schizophrenia, negative symptoms, early-onset schizophrenia, second-generation antipsychotic

Citation: Molnar MJ, Jimoh IJ, Zeke H, Palásti Á and Fedor M (2020) Early-Onset Schizophrenia With Predominantly Negative Symptoms: A Case Study of a Drug-Naive Female Patient Treated With Cariprazine. Front. Pharmacol. 11:477. doi: 10.3389/fphar.2020.00477

Received: 24 October 2019; Accepted: 26 March 2020; Published: 23 April 2020.

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Copyright © 2020 Molnar, Jimoh, Zeke, Palásti and Fedor. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

*Correspondence: Maria Judit Molnar, [email protected]

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Our Most Troubling Madness: Case Studies in Schizophrenia across Cultures (Ethnographic Studies in Subjectivity)

Schizophrenia has long puzzled researchers in the fields of psychiatric medicine and anthropology.  Why is it that the rates of developing schizophrenia—long the poster child for the biomedical model of psychiatric illness—are low in some countries and higher in others? And why do migrants to Western countries find that they are at higher risk for this disease after they arrive? T. M. Luhrmann and Jocelyn Marrow argue that the root causes of schizophrenia are not only biological, but also sociocultural.   This book gives an intimate, personal account of those living with serious psychotic disorder in the United States, India, Africa, and Southeast Asia. It introduces the notion that social defeat—the physical or symbolic defeat of one person by another—is a core mechanism in the increased risk for psychotic illness. Furthermore, “care-as-usual” treatment as it occurs in the United States actually increases the likelihood of social defeat, while “care-as-usual” treatment in a country like India diminishes it.

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Case Study Illustrates How Schizophrenia Can Often Be Overdiagnosed

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Study author Russell Margolis, director of the Johns Hopkins Schizophrenia Center, answers questions on misdiagnosis of the condition and reiterates the importance of thorough examination.

It’s not uncommon for an adolescent or young adult who reports hearing voices or seeing things to be diagnosed with schizophrenia, but using these reports alone can contribute to the disease being overdiagnosed, says  Russell Margolis , clinical director of the Johns Hopkins Schizophrenia Center. 

Many clinicians consider hallucinations as the sine qua non, or essential condition, of schizophrenia, he says. But even a true hallucination might be part of any number of disorders — or even within the range of normal. To diagnose a patient properly, he says, “There’s no substitute for taking time with patients and others who know them well. Trying to [diagnose] this in a compressed, shortcut kind of way leads to error.”

A case study he shared recently in the  Journal of Psychiatric Practice  illustrates the problem. Margolis, along with colleagues Krista Baker, schizophrenia supervisor at Johns Hopkins Bayview Medical Center, visiting resident Bianca Camerini, and Brazilian psychiatrist Ary Gadelha, described a 16-year-old girl who was referred to the Early Psychosis Intervention Clinic at Johns Hopkins Bayview for a second opinion concerning the diagnosis and treatment of suspected schizophrenia.

The patient made friends easily but had some academic difficulties. Returning to school in eighth grade after a period of home schooling, she was bullied, sexually groped and received texted death threats. She then began to complain of visions of a boy who harassed her, as well as three tall demons. The visions waxed and waned in relation to stress at school. The Johns Hopkins consultants determined that this girl did not have schizophrenia (or any other psychotic disorder), but that she had anxiety. They recommended psychotherapy and viewing herself as a healthy, competent person, instead of a sick one. A year later, the girl reported doing well: She was off medications and no longer complained of these visions.

Margolis answers  Hopkins Brain Wise ’s questions.

Q: How are anxiety disorders mistaken for schizophrenia?

A:  Patients often say they have hallucinations, but that doesn’t always mean they’re experiencing a true hallucination. What they may mean is that they have very vivid, distressing thoughts — in part because hallucinations have become a common way of talking about distress, and partly because they may have no other vocabulary with which to describe their experience. 

Then, even if it  is  a true hallucination, there are features of the way psychiatry has come to be practiced that cause difficulties. Electronic medical records are often designed with questionnaires that have yes or no answers. Sometimes, whether the patient has hallucinations is murky, or  possible —  not yes or no. Also, one can’t make a diagnosis based just on a hallucination; the diagnosis of disorders like schizophrenia is based on a constellation of symptoms. 

Q: How often are patients in this age range misdiagnosed?

A:  There’s no true way to know the numbers. Among a very select group of people in our consultation clinic where questions have been raised, about half who were referred to us and said to have schizophrenia or a related disorder did not. That is not generalizable.

Q:   Why does that happen?

A:  There is a lack of attention to the context of symptoms and other details, and there’s also a tendency to take patients literally. If a patient complains about x, there’s sometimes a pressure to directly address x. In fact, that’s not appropriate medicine. It is very important to pay attention to a patient’s stated concerns, but to place these concerns in the bigger picture. Clinicians can go too far in accepting at face value something that needs more exploration. 

Q: What lessons do you hope to impart by publishing this case?

A:  I want it to be understood that the diagnosis of schizophrenia has to be made with care. Clinicians need to take the necessary time and obtain the necessary information so that they’re not led astray. Eventually, we would like to have more objective measures for defining our disorders so that we do not need to rely totally on a clinical evaluation. 

Learn more about Russell Margolis’ research regarding the challenges of diagnosing schizophrenia .

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• Published: 19 November 2020

Effectiveness of antipsychotic drugs in schizophrenia: a 10-year retrospective study in a Korean tertiary hospital

• Sanghoon Oh   ORCID: orcid.org/0000-0002-7394-5211 1 , 2 ,
• Tae Young Lee   ORCID: orcid.org/0000-0002-0238-8147 2 ,
• Minah Kim   ORCID: orcid.org/0000-0001-8668-0817 2 ,
• Se Hyun Kim 2 ,
• Suehyun Lee 3 , 4 ,
• Sunwoo Cho 5 ,
• Ju Han Kim   ORCID: orcid.org/0000-0003-1522-9038 3 &
• Jun Soo Kwon   ORCID: orcid.org/0000-0002-1060-1462 1 , 2 , 6  

npj Schizophrenia volume  6 , Article number:  32 ( 2020 ) Cite this article

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• Pharmacology
• Schizophrenia

Extensive research has been carried out on the comparative effectiveness of antipsychotic medications. Most studies, however, have been performed in Western countries. The purpose of this study was to compare the effectiveness, indicated by time to any-cause discontinuation, of antipsychotic drugs in a large number of patients with schizophrenia in South Korea. We identified 1458 patients with schizophrenia or schizophreniform disorder who were treated with antipsychotic medications using a clinical data warehouse at the Seoul National University Hospital between March 2005 and February 2014. Kaplan–Meier survival analyses were used to estimate the time to discontinuation of antipsychotic drugs. We compared the survival curves of different antipsychotics using log-rank tests. Overall, the median time to discontinuation for any cause was 133 days (95% CI, 126–147). The longest time to discontinuation was observed for clozapine, followed by aripiprazole, paliperidone, olanzapine, amisulpride, risperidone, quetiapine, ziprasidone, and haloperidol. Specifically, clozapine was significantly different from all other antipsychotic drugs (all p  < 0.001). Aripiprazole also had a significantly longer time to discontinuation than amisulpride ( p  = 0.001), risperidone ( p  < 0.001), quetiapine ( p  < 0.001), ziprasidone ( p  < 0.001), and haloperidol ( p  < 0.001). In Asian patients with schizophrenia, clozapine was the most effective antipsychotic in terms of time to discontinuation, followed by aripiprazole. This study extends the findings of previous effectiveness studies from Western populations and suggests the need to develop guidelines for the pharmacotherapy of schizophrenia tailored to Asian individuals.

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Introduction.

Pharmacotherapy with antipsychotic medication is a keystone of treatment for schizophrenia. Since the introduction of chlorpromazine in the 1950s, many antipsychotics have been developed, and 15–40 of these drugs are available across the world 1 , 2 . Along with this growth in antipsychotics, the comparative effectiveness of antipsychotic treatment has become a major area of interest within the field of clinical psychiatry. Several meta-analyses have shown that some antipsychotics, such as clozapine and amisulpride, are more efficacious than others 3 , 4 . However, antipsychotic efficacy measured by symptom scales is not sufficient to reflect the effectiveness of antipsychotics for the treatment of schizophrenia in real-world clinical practice 5 , 6 .

Time to all-cause medication discontinuation is widely used in the psychiatric field as a proxy measure of antipsychotic effectiveness because it integrates both patient and clinician perspectives on drug efficacy, safety, and tolerability 7 . There have been numerous reports regarding the time to medication discontinuation among antipsychotic drugs 8 , 9 , 10 , 11 , 12 . The Clinical Antipsychotics Trials of Intervention Effectiveness (CATIE) project, a large, randomized, double-blind trial, is the most famous of comparative studies on the effectiveness of antipsychotics. CATIE investigators found that olanzapine had a significantly longer time to all-cause discontinuation than quetiapine or risperidone but not perphenazine or ziprasidone 13 . Since the CATIE study, the time to discontinuation of antipsychotic drugs has been mainly investigated in naturalistic treatment settings. A recent nationwide cohort study of 29,823 patients with schizophrenia in Sweden reported that clozapine and long-acting injectable (LAI) antipsychotics were the most effective in preventing treatment discontinuation 14 .

However, there has been relatively little information in Asian populations regarding the comparative effectiveness of antipsychotic medications. The issue of ethno-psychopharmacology, defined as dramatic cross-ethnic variations in dosing and side effects in response to psychotropics, has received considerable critical attention 15 . Previous studies have investigated the influence of ethnicity on the metabolism 16 , pharmacogenetics 17 , dosing 18 , and side effects of antipsychotic medications 19 in addition to medication adherence 20 . Ethnic differences in these factors may eventually lead to differences in antipsychotic effectiveness or overall treatment response 9 , 21 , 22 . For example, Azekawa et al. 9 suggest that aripiprazole is more effective than other antipsychotics, such as olanzapine and risperidone, in Japanese patients with schizophrenia or schizoaffective disorder. This finding was somewhat contradictory to the existing Western literature.

The aim of this study was to try and establish the comparative effectiveness of antipsychotic medications for the prevention of treatment discontinuation in our Asian population. We hypothesized that the hierarchy for the effectiveness of antipsychotic drugs in our sample would be different from in Western countries. We conducted this 10-year retrospective study to investigate the effectiveness of widely used antipsychotic medications (one typical and eight atypical antipsychotics) in patients with schizophrenia using a large, naturalistic clinical sample in South Korea, with time to all-cause discontinuation as the comparator outcome.

Sample description

This study included 3257 antipsychotic episodes of 1458 patients who were prescribed oral antipsychotic medications between 1 March 2005, and 28 February 2014. Patients had an average of 2.2 antipsychotic episodes during the study period. Of 1458 patients, 32.5% had one antipsychotic episode, 34.9% had two antipsychotic episodes, 17.5% had three antipsychotic episodes, and 15.1% had four or more antipsychotic episodes. The patient characteristics of each antipsychotic group are shown in Table 1 . The most frequently prescribed antipsychotic medication was risperidone ( n  = 730), followed by aripiprazole ( n  = 556) and olanzapine ( n  = 441) during the study period. Haloperidol ( n  = 83) was the least frequently used drug. In terms of the time trend of oral antipsychotic prescription, the use of risperidone decreased dramatically over time. This position was replaced by paliperidone with a relatively high proportion in the most recent years. Aripiprazole consistently occupied a considerable proportion regardless of the year, and olanzapine also remained third on average (Supplementary Fig. 1 in the Supplementary Material).

The mean daily doses in each antipsychotic group were as follows: 356.8 ± 298.0 mg for amisulpride; 14.0 ± 9.4 mg for aripiprazole; 252.7 ± 136.2 mg for clozapine; 7.5 ± 7.8 mg for haloperidol; 13.2 ± 9.1 mg for olanzapine; 7.2 ± 5.6 mg for paliperidone; 224.4 ± 254.4 mg for quetiapine; 3.0 ± 2.1 mg for risperidone; and 72.8 ± 41.0 mg for ziprasidone. The average daily antipsychotic doses in Korean patients are generally within or slightly below the target dose range recommended by the international consensus study 23 .

Discontinuation of treatment

Of a total of 3257 antipsychotic episodes, 2659 (81.6%) were discontinued during the study period, with the median time to discontinuation for each antipsychotic drug shown in Table 2 . Kaplan–Meier survival curves for time to discontinuation by antipsychotic medication are displayed in Fig. 1 . It is apparent from this figure that at any point along the follow-up time, the survival probability of clozapine is consistently higher than that of all other antipsychotics. The log-rank test revealed significant differences in time to all-cause discontinuation among antipsychotic drugs (Table 3 ). Clozapine was found to have a significantly longer time to discontinuation than all other antipsychotics (all p  < 0.001). Even after a Bonferroni correction was applied, clozapine and aripiprazole differed significantly from other antipsychotic medications in the time to discontinuation. For example, aripiprazole had a significantly longer time to discontinuation than amisulpride ( χ 2  = 11.8, df = 1, p  = 0.001), risperidone ( χ 2  = 31.3, df = 1, p  < 0.001), quetiapine ( χ 2  = 42.2, df = 1, p  < 0.001), ziprasidone ( χ 2  = 26.7, df = 1, p  < 0.001), and haloperidol ( χ 2  = 12.2, df = 1, p  < 0.001). Although the median time to discontinuation of haloperidol was the shortest, no statistically significant difference was observed among amisulpride, risperidone, quetiapine, ziprasidone, and haloperidol. Furthermore, the above results remained similar in an exploratory analysis in which we excluded the 1514 overlapping antipsychotic episodes to rule out polypharmacy bias (Supplementary Table 1 and Supplementary Fig. 2 in the Supplementary Material).

Median overall time to discontinuation for any cause was 133 (95% CI, 126–147) days. The ranking of the longest time to discontinuation was clozapine, aripiprazole, paliperidone, olanzapine, amisulpride, risperidone, quetiapine, ziprasidone, and haloperidol.

The incidence rates of all-cause discontinuation are also presented in Table 2 . Clozapine had the lowest incidence rate of discontinuation (0.23 per person-years [PYs]), followed by aripiprazole (0.59 per PYs). In contrast, quetiapine, ziprasidone and haloperidol (1.31, 1.28 and 1.09 per PYs, respectively) had relatively high incidence rates of discontinuation.

Concomitant medications

There were significant differences among the antipsychotic groups in the proportions or types of concomitant medications (Table 4 ). Clozapine was the most likely to have concomitant mood stabilizers and antidepressants (range 0.3–19.9% and 0.3–30.7%, respectively). Antidepressant use in patients on quetiapine was the lowest (range 0.6–11.3%). The proportions of anxiolytic/hypnotic use had few substantial differences among antipsychotic groups. In the case of anticholinergics/propranolol, haloperidol showed the highest (range 27.7–53.0%), and quetiapine showed the lowest (range 17.7–29.9%) proportion of usage.

To the best of our knowledge, this is the largest study examining the comparative effectiveness of antipsychotic medications as measured by time to any-cause discontinuation in an Asian sample. The present results indicate that clozapine demonstrated the best effectiveness for treatment continuation among antipsychotics. Apart from clozapine, the following two drugs—aripiprazole and paliperidone—have been shown to be most effective, whereas quetiapine, ziprasidone and haloperidol displayed a relatively short time to discontinuation.

Consistent with previous comparative studies of antipsychotic effectiveness in routine clinical settings 8 , 11 , 14 , we also found that clozapine has the longest time to medication discontinuation. Close inspection of these results, however, shows that clozapine is overwhelmingly superior to other antipsychotics in our sample than studies in Western populations. For example, one study by Ascher-Svanum reported that the median time to discontinuation for clozapine and olanzapine was 302.8 and 266 days, respectively 8 , which differed from our results (1233 and 119 days, respectively). These differences could be attributed to our longer follow-up period than in previous studies. It has been well documented that long-term maintenance therapy with clozapine is successful 24 ; hence, the longer follow-up may have led to greater differences in time to discontinuation for clozapine and other antipsychotics. Another possible explanation may lie in the interethnic differences in the pharmacodynamics of clozapine. Several studies have suggested that Asian patients can be effectively and safely treated with lower doses of clozapine than Caucasian patients 18 , 25 . Our results indicating clozapine’s superiority over time to discontinuation extend the findings of previous studies from Western countries and highlight the usefulness of clozapine in long-term maintenance therapy, especially in the Asian population.

Findings from survival analysis illustrate the ranking of the antipsychotic medications in the following descending order: clozapine, aripiprazole, paliperidone, olanzapine, amisulpride, risperidone, quetiapine, ziprasidone, and haloperidol. In line with many previous studies 8 , 10 , we also observed that second-generation antipsychotics (SGAs) were generally more effective in terms of treatment continuation than first-generation antipsychotics (FGAs). Following correction for multiple comparisons, some SGAs (aripiprazole and clozapine) maintained their initial significant differences from haloperidol, which is FGAs. Interestingly, paliperidone was more effective than risperidone in antipsychotic treatment. Since paliperidone is the primary active metabolite of risperidone 26 , it is believed that paliperidone and risperidone have similar efficacy. However, the comparative effectiveness of paliperidone and risperidone is not well known because few studies have been designed to directly compare the two medications 27 , 28 . Therefore, our finding that the real-world effectiveness of paliperidone is higher than that of risperidone is meaningful. It seems possible that this result is due to the nature of paliperidone with extended-release formulation, which provides more stable plasma concentrations 29 . However, this result should be interpreted with caution because of the statistically significant difference ( p  = 0.01) between paliperidone and risperidone is lost after Bonferroni correction (required p -value < 0.0014).

With respect to the incidence of discontinuation, clozapine was the most effective antipsychotic drug, followed by aripiprazole. As with the survival analysis for time to discontinuation, clozapine and aripiprazole were the top ranked. Taken together, our results indicate that aripiprazole is particularly effective among SGAs. This finding is consistent with a previous study of Japanese patients 9 , in which aripiprazole had a significant or trending longer time to discontinuation than the other five SGAs (olanzapine, risperidone, blonanserin, quetiapine, or perospirone). Surprisingly, these results have not been observed in European and Western/American populations. A possible reason for the superior effectiveness of aripiprazole, especially in Asian populations, may be related to ethnic differences in pharmacological properties. Although there is no significant difference with regard to ethnicity in the treatment response to aripiprazole 30 , some evidence has suggested more favorable safety profiles in Asian patients than in Caucasian patients 19 , 31 . Since effectiveness takes into account the parameters of efficacy and safety/tolerability, an inter-ethnic difference in the vulnerability for the development of side effects may lead to differences in the effectiveness of aripiprazole. However, these comparisons of the effectiveness of antipsychotics reported in studies in different countries must be interpreted with caution because of differences in the study methodologies, medication variables (e.g., usual dosage and local prescription traditions) and other confounding factors 32 . For example, antipsychotic doses for patients with schizophrenia, the proportion of antipsychotic polypharmacy, and the use of concomitant medications differed across countries/territories 33 , 34 . Furthermore, a recent large-scale observational study reported that clozapine plus aripiprazole resulted in a better outcome than any other antipsychotic treatment 35 . Considering the findings of this previous study, the higher rank of the time to discontinuation of aripiprazole in our study may also be a consequence of its use in combination with clozapine. Our additional analysis of the comparative effectiveness for antipsychotic monotherapy, however, showed that aripiprazole was still the top-ranked antipsychotic monotherapy among other antipsychotics without the combined use of clozapine. These results seem to suggest that aripiprazole could be recommended as the first-line choice of antipsychotic medication in Asian populations.

Our findings regarding the comparative effectiveness (as measured by all-cause time to discontinuation) of antipsychotic drugs differed somewhat from previous studies conducted in Western countries 14 , 36 , 37 . Although we have already discussed that these differences may be explained by ethnicity, other factors contributing to these differences should also be considered. For example, the CATIE trial reported that olanzapine was more effective than other antipsychotic medications in patients with chronic schizophrenia 13 . Furthermore, one study by Bitter et al. 36 compared the efficacy of olanzapine with clozapine in patients with treatment-resistant schizophrenia and found that olanzapine displayed similar efficacy to clozapine and represented a safe alternative in the management of patients with refractory schizophrenia. In contrast to these findings, a naturalistic study 37 examining the effectiveness of antipsychotics used to treat first-episode psychosis showed that the ranking of the longest time to discontinuation was risperidone, quetiapine, aripiprazole, and olanzapine. Our analysis including all patients with schizophrenia, regardless of the illness stages or treatment resistance, revealed that olanzapine exhibited a moderate level of effectiveness among the medications studied. The reason for this difference between our results and some published studies may be related to the stages of illness and responsiveness to antipsychotic medication 38 . A further study with more focus on these possible factors is therefore suggested.

Our results showing the proportion of concomitant medication use are generally consistent with a previous pan-Asian study reporting frequent prescriptions of antidepressants (11.7%), mood stabilizers (13.7%), benzodiazepines (27.8%) and anticholinergics (45.6%) along with antipsychotics 33 . The results from our study also showed differences in the use of concomitant medications among antipsychotic groups. In accordance with previous studies 39 , clozapine was the most frequently used with mood stabilizers and antidepressants. Because clozapine is considered to be the gold standard for treatment-resistant schizophrenia 40 , patients taking clozapine usually have a high disease severity and comorbid illness 41 . Therefore, the use of concomitant medications such as mood stabilizers to treat comorbidities is higher in patients on clozapine than in other antipsychotics. On the other hand, it is remarkable that anticholinergics/propranolol was the most frequently used with haloperidol among antipsychotic drugs. This is consistent with previous studies, which reported that FGA-treated patients had more extrapyramidal side effects and used more adjuvant anticholinergics 42 , 43 .

Several limitations to this study need to be acknowledged. First, we were unable to determine the extent to which individuals defined as having discontinued antipsychotic treatment from our data warehouse actually continued pharmacotherapy at other centers because of relocation or other reasons. This is the inherent limitation of research using electronic databases 10 . Our database also did not include information about potential confounders (e.g., treatment history and duration of illness) associated with medication adherence 44 . Second, we did not limit the antipsychotic episodes to monotherapy; thus, we could not distinguish between the augmenting and augmented antipsychotic medication. Despite the potential for underestimation of time to discontinuation for antipsychotics frequently used as augmenting drugs, it is important to determine the true comparative effectiveness that represents complex treatment regimens in real-world practice. Fortunately, the current main findings were generally consistent with those of further analysis of antipsychotic episodes for monotherapy only. Third, LAIs were not included in the current study. Because LAIs, by their nature, appear to lead to an improvement in treatment continuation 45 , a comparison of the effectiveness between oral antipsychotics and LAIs on the same line may not be adequate. For example, all LAIs except clozapine showed a lower risk of treatment failure than oral antipsychotic medications 14 . Therefore, this study is meaningful in that it excluded the confounding effects that can be caused by differences in drug formulations. Last, our data were derived from a single urban tertiary care hospital and therefore may have limited generalizability to other facilities or countries.

In conclusion, this study extends our knowledge of the comparative effectiveness of antipsychotic treatments in the Asian population. Based on time to discontinuation, clozapine was the most effective antipsychotic medication, as has been shown in Caucasian subjects. In addition, our results suggest that aripiprazole had a significantly longer time to discontinuation than other antipsychotics except clozapine, which indicates that aripiprazole may be the most recommended first-line antipsychotic in Asian patients with schizophrenia. Such information could be used as an aid to develop Asian guidelines for the pharmacotherapy of schizophrenia. However, a further research involving many different Asian countries needs to be undertaken before providing guidelines suitable for Asians.

Study design, sample, and data sources

This naturalistic retrospective study at the Seoul National University Hospital (SNUH) compared the effectiveness of oral antipsychotic medications in patients with schizophrenia. SNUH is a large urban tertiary hospital in Seoul, South Korea. Data were obtained from a Clinical Data Warehouse (CDW) totally synchronized with the electronic medical records (EMR) system generated as part of the usual clinical practice. The SNUH CDW encompasses all routine clinical information, such as the demographics, diagnosis, medication profiles, and laboratory results, from each visit since 2001. Approval from the Institutional Review Board at SNUH was obtained prior to collecting and analyzing the data. Written informed consent is not required for CDW-based studies using anonymized data.

The study population included all patients who were treated in the inpatient and/or outpatient setting at SNUH from 1 March 2005 to 28 February 2014, with a diagnosis of schizophrenia or schizophreniform disorder ( International Statistical Classification of Diseases and Related Health Problems, Tenth Revision [ICD-10] codes: 20, 200, 201, 203, 205, and 208). For the homogeneity of the study population, patients with schizoaffective disorder or bipolar disorder ( ICD-10 codes: 25, 25X, 30, 30X, 31, and 31X) were excluded. From this sample, we selected patients prescribed any one of the following antipsychotic medications: amisulpride, aripiprazole, clozapine, haloperidol, olanzapine, paliperidone, quetiapine, risperidone, and ziprasidone. Here, we included only the oral form of the above drugs and not the LAI formulation.

Using the treatment episodes approach, we defined an antipsychotic episode as the sustained prescription period of any antipsychotic medications during the study. A patient could have several antipsychotic episodes, with the possibility of overlap between these antipsychotic episodes throughout the 10-year study. This treatment episode approach provides overall information on a variety of treatment courses per patient from the perspective of the longitudinal treatment of the illness 8 .

All patient prescription data derived from the SNUH CDW were handled by bioinformatics experts using Python programming. Medication information was extracted according to the generic name of drugs instead of the brand names or different prescription codes because all medications have different drug codes depending on the dose of the drug.

The primary outcome measure in this study was the discontinuation of antipsychotic medication. All-cause discontinuation, namely, treatment discontinuation for any cause, including a lack of efficacy, intolerable side effects, and the clinician’s decision to stop the medication 46 , was used in our analysis. We defined discontinuation as the period longer than 56 days during which the patients did not have any medication supply. Time to discontinuation was calculated as the duration (in days) of the antipsychotic medication episode, a continuous period of medication supply from the day of its first prescription until the date of discontinuation or the end of the study period.

Other outcomes were the incidence rate of antipsychotic discontinuation and proportion of concomitant medication use. The incidence rate measured the occurrence of discontinuation in each antipsychotic group per unit of time (person-years) of follow-up. On the other hand, we measured concomitant medications used more than once during a continuous period of each antipsychotic possession (i.e., time to discontinuation of antipsychotic medication). Concomitant medications belonging to the following four categories were used for the analysis: mood stabilizers, antidepressants, anxiolytics/hypnotics, and anticholinergics/propranolol.

Statistical analyses

We first calculated descriptive statistics about sample characteristics, antipsychotic prescription patterns over time, and the proportion of concomitant medications. Second, we estimated the median time to discontinuation for each antipsychotic medication using Kaplan–Meier survival curves. To determine the effectiveness of antipsychotic treatments, we compared the survival curves of each antipsychotic drug by applying log-rank tests for significance. The results from the log-rank tests were corrected for multiple comparisons using Bonferroni correction. The Bonferroni-corrected p -value corresponding to a statistical significance level of 0.05 with 36 pairwise comparisons was 0.05/36 = 0.0014. Additional analyses were conducted to see whether the results would be consistent under the condition after removing the polypharmacy effect. For this, we eliminated all antipsychotic episodes where the prescribed antipsychotics overlapped and then performed a survival analysis with only the remaining antipsychotic episodes corresponding to monotherapy. Third, the incidence rate was calculated using the number of patients with antipsychotic discontinuation divided by the total time of follow-up of each patient. Statistical analyses were performed with R (×64, 3.53 version).

Reporting summary

Further information on research design is available in the Nature Research Reporting Summary linked to this article.

Data availability

The data that support the results of this study are available from the corresponding author upon reasonable request. The data are not publicly available because they contain information that might compromise the privacy of the research participants.

Code availability

The MATLAB and R scripts for data processing and statistical analysis respectively in this study are available from the corresponding author upon reasonable request.

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Acknowledgements

This research was supported by the Brain Research Program and the Basic Science Research Program through the National Research Foundation of Korea (NRF), funded by the Ministry of Science, ICT & Future Planning (Grant Nos. 2017M3C7A1029610, 2019R1A2B5B03100844, and 2020M3E5D9079910).

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Oh, S., Lee, T.Y., Kim, M. et al. Effectiveness of antipsychotic drugs in schizophrenia: a 10-year retrospective study in a Korean tertiary hospital. npj Schizophr 6 , 32 (2020). https://doi.org/10.1038/s41537-020-00122-3

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8 Clinical Cases of Schizophrenia (Extremes)

Knowing the 8 cases of schizophrenia that I will show you in this article article will help you to better understand this mental illness; Its symptoms, characteristics and the people who have it.

The schizophrenia Is a chronic mental disorder that affects approximately 1% of the population. When it appears it is characterized by hallucinations, delusions, disorganized thinking, altered language, attention problems, lack of motivation and emotional distress (American Psychiatric Association).

The tendency to develop schizophrenia is inherited genetically and may or may not arise depending on many more factors, such as lifestyle, personality or experiences.

Currently there is no cure for this condition, but it can be greatly improved if adequate therapy is found for each person, including always pharmacological treatment (usually antipsychotics or neuroleptics).

For a better understanding of the symptoms of this disease, I recommend reading these 8 real cases:

1. The case of Stuart

It all started in 1991, when Stuart traveled to Moscow to go to a march against communism. It was a rather tense moment in history, as the communists were attempting to stage a coup against Mikhail Gorbachev, the president of the Soviet Union at the time.

Stuart claims that a very angry Russian man called him that night at dawn. The unknown man cursed and shouted at him, asking him why he had gotten into his affairs. Stuart, very frightened, hung up the phone.

From that moment on, he began to feel fear because he could not stop thinking that he was being investigated. When he returned to London, he was always stressed because he felt persecuted, over time developing a depression .

Stuart lost his job shortly before his first psychotic outbreak, which he described as: "It was horrible, I think it appeared out of sheer stress and anxiety. I was lying on the bed when suddenly I felt a pressure on my head, and then, a total darkness. It was as if my own mind had aspired to me, losing all sense of reality. I screamed, and suddenly I went back to my room with that strange feeling in my head."

Later he moved a couple of times, in order to flee from those who were supposedly chasing them. Desperate, one day he went to the family doctor, who did not hesitate to send him quickly to a psychiatric team.

He was diagnosed with schizophrenia, and after testing several treatments, they found a drug that helped him. Stuart stopped experiencing the symptoms: he discovered that no one was chasing him, it was only the result of his illness. He felt much better, with new life plans and goals, like climbing Everest.

He wants to convey to the world that, despite what they say, recovering from schizophrenia is possible.

2. The man who feared being homosexual

The origin of this history can be located in 1972, when a patient with 23 came to consult for fear of being homosexual. He indicated that he was very scared since he heard voices that spoke to him of the subject.

He was diagnosed homosexual panic and paranoid schizophrenia, and a treatment was started to eliminate his fears and hallucinations. Over time, he managed to accept his homosexuality, presenting a double identity: masculine and feminine, which fluctuates according to the time in which he is. Sometimes he would dress in women's clothes or wear women's underwear, surprising why people did not look at him from the street.

Subsequently, he began to have promiscuous relationships with homosexuals, drug addicts, thieves and exploiters. One day, while he was drunk, he pushed one of these into the void from his house, dying on the spot. He was detained for 6 months. However, they declared it unimpeachable.

This patient had problems with alcohol, and although he received financial aid, he had numerous debts because he spent much more than he received.

He spent most of his time writing about the"Principality of Naranjo Bay,"a place he claimed existed. He keeps a daily record of what was happening in the principality and gave it to the doctor after each consultation to be kept in the library of the Psychiatric Institute. The objective of this patient was to demonstrate that, within 100 years, psychiatrists read and confirm that he does not have schizophrenia.

The curious thing about this case that surprised the psychiatrists was the absence of hallucinations and the predominance of inventions, fantasies and delusions. In addition, he reasoned adequately on any subject that was not related to his delusions. For this reason, many classified it as a rare form of schizophrenia called schizophrenia, or Paraphrenia .

It seems that this man remained in treatment, with stable results.

3. Antonio, the boy who thinks he's an alien

At age 14 Antonio appeared in consultation accompanied by his parents. They said the beginning was when Antonio, 12, started talking to his friends about aliens.

From then on they began to see him sad, frightened and suspicious; And before long he was convinced that both he and his family were aliens. For this reason, he received medication , Although his obsession with UFOs remained.

He presented a rather strange way of speaking, which is associated with schizophrenia: unorganized language, jumping from one subject to another that has nothing to do with it, difficulty in finding the word he wants to say, or not responding concretely to what he is told Question.

In addition, it is not expressive, does not usually look at the face, and has A very low self-esteem .

Together with this, Antonio began to develop a Obsessive compulsive disorder , Which can be identified through"manias"and rituals. For example, washing your hands continuously, watching your body a lot, thinking that something terrible is going to happen if you do not turn off the lights or close the door to your room... which sometimes does not leave you To fall asleep .

He was diagnosed with disorganized type schizophrenia, establishing a treatment with his family to strengthen ties, Cognitive therapy , Training in social skills , Techniques to avoid relapse, Neuroleptic medications Y Antidepressants , among others.

4. Jack's Case

Jack graduated from high school and got a job at a video store. After six months of being there, he began to hear voices telling him that he was not doing things right.

In addition, he began to think that his boss was placing small cameras in the movies that clients returned to verify if he did his job well. Thus, Jack was becoming more worried and anxious in his work, especially the days when the store was fuller.

Little by little he began to talk strangely to clients, even told one of them that he could not book the movie he wanted because he had pictures of him that the CIA was reviewing.

A year later Jack could not stand it anymore and quit his job, shouting to his boss that he was sick of watching over all the screens in the store and even in his own house.

He returned to live in the house of his parents, and a while later he was admitted to the hospital. They tried to treat him with various drugs, but he was not persistent, since they had many side effects.

During the next 7 years he was hospitalized 5 times, until he found a treatment that was able to help him.

Finally, he began attending a club for people with mental illness 3 times a week, attending the telephone and participating in the local newspaper. In addition, he feels totally qualified and motivated to look for a work related to the cinema.

5. Susana, the girl of the robots

Susana is a 15 year old girl who her teachers describe as difficult, violent, underperforming in school, and who often interrupts in class telling stories and making animal sounds.

It seems that the problem manifested itself from the age of 12, having been from a girl something different from the others. Since going to the movies to watch Star Wars, he has a great obsession with robots, so he spends the day talking about related topics and drawing futuristic spaceships and inventions.

Susana explains that she has an incredible gift that no one has yet discovered. She says that she makes robots with pieces of computers, and that she once almost caused a catastrophe with one of them, although she managed to stop it in time.

However, when asked how it works or how it was built, it does not know how to respond accurately. She begins to relate random mathematical procedures that make no sense, considering herself as a genius. In psychology, this is called delirium .

In addition, he presumes to have the gift of hearing voices that no one hears and speaks with beings from another world. Experts rate this as Auditory hallucinations .

However, the family did not clearly appreciate the problem and thought they were minor children's stories.

A pharmacological intervention, cognitive therapy, psychoeducation, family intervention and social skills Surely the state of Susana improved.

6. Eva, a girl with paranoid schizophrenia

Eva was 10 when she claimed she could hear voices. The voices told her she was going to die soon because other people have committed crimes because of her.

And he also thinks that, through his breathing, he is able to handle other people. On the other hand, he believes that they record it on video continuously with the aim of putting them on sale.

To make matters worse, she is convinced that others can read her mind, look at her and pursue her. This gives you discouragement and sadness.

Eva presented problems from the age of two, more specifically, developmental delay and communication disorder.

As for her family, her mother apparently had schizophrenia, and when Eva was five, her parents separated and a new family welcomed her. At this age developed many phobias, problems to relate to others, developmental delay and hypersexual behaviors for their age. Surely that form of upbringing was not healthy for the little girl.

After being diagnosed paranoid schizophrenia , A very complete treatment was carried out which probably made her improve in all aspects.

7. Schizophrenia is discovered in a boy who demanded therapy for pain in the shoulder

A 19-year-old boy was referred to physical therapy because of chronic pain in the shoulder, elbow and wrist. It seems that he had bruises since in his spare time he used to skate, snowboard, and break dance, as well as weight training.

In the past, he had gone more than 10 times to the same clinic of sports medicine, diagnosing a great amount of physical affections provoked by the sport.

The pain was real, however, this indicated that the discomfort was due to an electronic device that the United States government had implanted two years ago to control him. He was convinced that the electromagnetic impulses of the device had caused them to fall and injure.

In addition, he said that when he was doing something that the government did not like (according to the patient, his sports activities), his joints cooled or began to hurt. On the other hand, he began to hear voices ordering him to harm his friends or relatives, but he blamed it on the electrical device.

He also thought that other people around him had implants similar to his own to be controlled. He indicated that these people emotionally abused him, gesturing to him to make him understand that they were being watched.

The therapist was able to identify that it was a mental condition and immediately sent it to the psychiatrist. He was diagnosed with schizophrenia and prescribed Risperdal , a known Antipsychotic medication .

Through this case, Shah and Nakamura (2010), insist on the importance of all health professionals to know the signs and symptoms of schizophrenia and other mental health problems. And of course, they stress the importance of in-depth interviews in patients with musculoskeletal discomfort.

8. Álvaro, a young man with behavior problems

Did you know that schizophrenia also alters the way you talk, gestures and movements?

These are the main symptoms of schizophrenia presented by Alvaro, a 17-year-old boy who came to Mental Health for behavioral disorders. For example, he was so aggressive with his mother that she had to call the police several times.

Álvaro left the studies and seems to be a young retired, distrustful and of lost look.

What appeals to the psychiatrist is his gestures: he presents Stereotyped movements (Repetitive movements that are not useful, such as touching clothes, or any part of the body, or swinging). In addition to involuntarily imitating the movements of the people around him ( Ecopraxia ) And making strange grimaces.

Other symptoms of schizophrenia that it presents are reduced language, with phrases made and, above all, to repeat what the examiner says (what is called echolalia).

• Escobar M, Enrique, & Barra C, Bernardo. (2011). History of a case with schizophrenia, or fantastic and systematized paraphrenia. Revista chilena de neuro-psiquiatría, 49 (2), 177-181.
• Childhood schizophrenia. Clinical cases. (S.f.). Retrieved on October 28, 2016, from Paidopsychiatry Portal.
• Rose, M. (s.f.). Schizophrenia: Case study. Retrieved on October 28, 2016, from Collin College.
• Schizophrenia - Stuart's story. (S.f.). Retrieved on October 28, 2016, from NHS Choices.
• Shah, N., & Nakamura, Y. (2010). Case Report: Schizophrenia Discovered during the Patient Interview in a Man with Shoulder Pain Referred for Physical Therapy. Physiotherapy Canada, 62 (4), 308-315.
• What Is Schizophrenia? (S.f.). Retrieved on October 28, 2016, from the American Psychiatric Association.

Recent Posts

20 Famous Schizophrenics

• By Kristen Fescoe: BA Psychology; MS Clinical and Forensic Psychology
• Published November 25, 2015
• Last Updated February 7, 2024
• Read Time 24 mins

Famous People With Schizoaffective Disorder and Schizophrenia

Schizophrenia is a severe, chronic mental health disorder that affects the brain and behavior in about 1 percent of the general population. The diagnosis is a heritable trait that is passed down through DNA. Throughout history, this seriously debilitating disease has affected people of all walks of life. People with schizophrenia often report hearing voices, seeing things that are not really there and having delusional thoughts. They may believe other people are reading their minds, controlling their thoughts, or plotting to harm them or someone they love. Schizophrenics that do not receive treatment can become withdrawn or agitated as a result of their disease. In some cases, people with schizophrenia may not make sense and in some cases may even sit for hours without moving or talking (catatonic schizophrenia). At other times people with schizophrenia may appear to be perfectly “normal” until they express their delusional thoughts.

Schizophrenia affects millions of people from all walks of life. This disease affects the rich, the poor, men and women, and even the famous. There are even celebrities with schizophrenia . What famous person has schizophrenia ? This list outlines 20 famous people with schizophrenia who battled the disease throughout their lifetimes. Some of these people are known to have battled the mental illness, while others may be more surprising. Medications and treatments can mitigate the affects of the disease and allow an individual to appear more “normal.” In some cases these individuals were famous for what seemed to be eccentricities but, were in reality, symptoms of schizophrenia. Here are some celebs with schizophrenia .

Lionel Aldridge – 1941-1998

Professional football player.

Age of Diagnosis: 33

Individual History: Lionel Aldridge was an All-Skyline tackle and co-captain of the Utah State Aggies. He was drafted in 1963 after a standout college career at Utah State. Lionel Aldridge was among the few rookies to start for coach Vince Lombardi. Aldridge, defensive end, enjoyed an 11-year career in the NFL playing for the Green Bay Packers and the San Diego Chargers. As a Green Bay Packers player, he played a role in three straight NFL Championships (1965-66-67) and in Green Bay Packers victories in Super Bowls I and II. Traded to the San Diego Chargers, Lionel Aldridge played two seasons in San Diego before retiring from professional football in 1973. Upon his retirement he worked as a sports analyst until being diagnosed in the late 1970’s with paranoid schizophrenia — a sub-type of schizophrenia and the most common type. His diagnosis led to him becoming homeless and he eventually regained some sense of mental health. He became an advocate for the homeless and the mentally ill until his death in 1998. His advocacy work included serving as a board member for the Mental Health Association of Milwaukee and working as a speaker for the National Alliance on Mental Illness. Lionel Aldridge is one example of modern celebrities with schizophrenia .

Syd Barrett – 1946 – 2006

Musician and founder of pink floyd.

Age of Diagnosis: Unknown

Individual History: Syd Barrett is another example of famous people with psychosis . He was an English songwriter, guitarist and artist, most notably the founder of the rock band Pink Floyd. Barrett was the lead singer, guitarist and principal songwriter in the band’s early years and is credited with naming the band. Barrett was excluded from Pink Floyd in April 1968 after David Gilmour took over as their new frontman. He left amidst stories of him having mental illness coupled with serious drug abuse. There were many reports that Barrett was schizophrenic, although he never publicly admitted this. He eventually suffered a severe burnout and cut out all social aspects of his life while remaining in constant isolation. With time Barrett stopped contributing to music and avoided conversation about his association with Pink Floyd. In 1978, when his money ran out, he moved back to Cambridge to live with his mother. He returned to live in London again in 1982, but lasted only a few weeks and soon returned to Cambridge for good. He lived with serious diabetes for several years, and died at his mother’s home in Cambridge on in July of 2006 at the age of 60. The cause of death was pancreatic cancer.

Charles “Buddy” Bolden – 1877-1931

Jazz music pioneer.

Age of Diagnosis: 30

Individual History: One of the most historic cases of famous schizophrenic people is Buddy Bolden. While there is a great deal of first hand oral history about Bolden, facts about his life continue to be lost amongst colorful myth. There have been stories saying that he was a barber by trade or that he published a scandal-sheet called the “Cricket.” However, much of this has been refuted. What is known about him is that he is regarded by music contemporaries as a key figure in the development of a New Orleans style of rag-time music, or Jass, which later came to be known as jazz. He was referred to as King Bolden and a king of Jazz. His band was a top draw in New Orleans from about 1900 until 1907. He left no known recordings He was known for his very loud sound and constant improvisation. Bolden suffered an episode of “acute alcoholic psychosis” in 1907 at the age of 30. Upon further investigation of this diagnosis he was given the full diagnosis of dementia praecox (now known as schizophrenia). He was admitted to the Louisiana State Insane Asylum at Jackson, where he spent the rest of his life.

Eduard Einstein – 1910-1965

Son of albert einstein.

Age of Diagnosis: 20

Individual History: Eduard Einstein was born in Zürich, Switzerland, the second son of famous physicist Albert Einstein and his first wife Mileva Marić. Albert Einstein and his family moved to Berlin in 1914 shortly after the parents separated.  Marić returned to Zürich, taking Eduard Einstein and his older brother Hans Albert with her. His father remarried in 1919 and in the 1930s emigrated to the United States under the threat of the German Nazi regime. Eduard Einstein was extremely intelligent and a successful student throughout his education. During his youth Eduard wanted to be a psychoanalyst but was began showing signs of schizophrenia by the age of 20. This led to him to be institutionalized several times. Eduard Einstein died in an asylum at age 55 and his family lineage has been used to raise public awareness of schizophrenia.

Zelda Fitzgerald – 1900-1948

Writer, dancer, artist, wife of writer f. scott fitzgerald.

Individual History: Zelda Fitzgerald is included on this list of famous people with schizophrenia, in large part due to her fame as the wife of the F. Scott Fitzgerald. F. Scott Fitzgerald is the author of The Great Gatsby. She was an American novelist, dancer, and socialite. She became iconic in the 1920s after being dubbed by her husband as “the first American Flapper.” After the success of his first novel, This Side of Paradise (1920), the Fitzgeralds became celebrities. Zelda Fitzgerald was known to go into fits of paranoia, especially regarding her husband’s alleged unfaithfulness. In 1930, she was diagnosed with schizophrenia at the age of 30. After years as the face of the Jazz Age, the Roaring Twenties, and the Lost Generation, Zelda Fitzgerald posthumously gained further celebrity with the publication of Nancy Milford’s best-selling Zelda: A Biography in 1970. Milford’s biography portrayed Zelda Fitzgerald as a victim of an overbearing husband, and she soon became a feminist icon.  In April 1930, Zelda Fitzgerald was admitted to a sanatorium in France where, after months of observation and treatment, she was diagnosed as a schizophrenic. She was initially admitted to a psychiatric hospital outside Paris, then later moved to a clinic in Switzerland. As her psychological symptoms progressed, she was moved to a psychiatric facility in Prangins on the shores of Lake Geneva. She was released in September 1931, and Zelda and F. Scott Fitzgerald returned to Montgomery, Alabama, where her father was dying. By February 1932, she had returned to living in a psychiatric clinic.

Peter Green – 1946 –

Guitarist and founder of fleetwood mac.

Age of Diagnosis: 31

Individual History: Peter Green, founder of Fleetwood Mac, is a British blues-rock guitarist. Fleetwood Mac is an American band. Peter Green played lead in Peter Bardens’ band, Peter B’s Looners, in 1966. After a three-month stint, he had the opportunity to fill in for Eric Clapton in John Mayall & the Bluesbreakers for three gigs. Upon Clapton’s permanent departure not long after, he was hired full-time. He was inducted into the Rock and Roll Hall of Fame in 1998 for his work with the group. Peter Green has written such songs as “Albatross”, “Black Magic Woman”, “Oh Well” and “Man of the World.” The songs have been recorded by artists such as Santana, Aerosmith, Status Quo, Black Crowes, Midge Ure, Tom Petty, Judas Priest and Gary Moore. Green’s playing was noted for its idiomatic string bending and vibrato and “economy of style.” Peter Green was ranked 38th in Rolling Stone’s list of the “100 Greatest Guitarists of All Time.” Along with a lifetime of success has come a lifetime of struggling with mental illness. Peter Green was eventually diagnosed with schizophrenia and spent time in psychiatric hospitals undergoing electroconvulsive therapy during the mid-1970s.

Darrell Hammond – 1955 –

Comedian and saturday night live actor.

Age of Diagnosis: During Childhood

Individual History: There are also schizophrenic actors . Darrell Hammond is an American actor, stand-up comedian and impressionist. He was a Saturday Night Live cast member from 1995 to 2009, one of the longest-standing actors in the show. Darrell Hammond was a regular member of “The Not Ready For Prime Time Players Company” on Saturday Night Live from 1995 to 2009, the longest tenure of any cast member in the show’s history. When he left the show at the age of 53 he was the oldest cast member in the show’s history. Darrell Hammond made more SNL appearances than any other cast member and impersonated more than 107 celebrities, with Bill Clinton as his most frequent impression. On September 19, 2014, Darrell Hammond became the new announcer of SNL, replacing Don Pardo, who had died the month before. What is lesser known about the comedian is that he is on the list of famous people with schizophrenia. During an 2011 interview with CNN, Darrell Hammond revealed that his mother had brutally abused him throughout his childhood. Darrell Hammond stated that this trauma from abuse led to cutting, several hospitalizations due to psychiatric issues, and diagnoses that include bipolar disorder , schizophrenia, and borderline personality disorder. Hammond is among famous actors with schizophrenia .

Tom Harrell – 1946 –

Composer and jazz musician.

Age of Diagnosis: In His 20’s

Individual History: Tom Harrell is an American composer and arranger and a jazz trumpeter and flugelhornist. Harrell has won awards and grants, including multiple Trumpeter of the Year awards from Down Beat magazine, SESAC Jazz Award, Broadcast Music Incorporated Composers Award, and Prix Oscar du Jazz. He received a Grammy nomination for his big band album, Time’s Mirror. Harrell’s success is quite a story, given that he is a famous person with schizophrenia. His disability profoundly affects his life when off stage. He suffers from paranoid schizophrenia, which affects every aspect of his life. On stage he stands away from the microphone, off to the side, his head bowed and his hands clutching his trumpet. When called upon to play, he walks slowly to the microphone, head still lowered, raising it only to play. When finished, he bows his head and resumes his original place. He has been recorded on over 260 albums. He continues to compose, record and tour around the world.

John Hinckley, Jr. – 1955 –

Failed american assassin.

Individual History: John Hinckley, Jr. was the man who attempted to assassinate U.S. President Ronald Reagan in 1981, making him one of the most infamous people with schizophrenia. He shot Reagan with a revolver as the president left the Hilton Hotel in Washington, D.C., after he addressed an AFL-CIO conference. The act was said to be the culmination of an effort to impress actress Jodie Foster. Reported to have been driven by an obsessional fixation on Foster, Hinckley’s lawyer claimed he was schizophrenic and he had been diagnosed with schizoid personality disorder. Hinckley is a famous person with schizoid personality disorder . The disorder has many of the same symptoms as schizophrenia. Hinckley was found not guilty by reason of insanity, and remained under institutional psychiatric care since then. Public outcry over the verdict led to the Insanity Defense Reform Act of 1984. The Act altered the rules for consideration of mental illness of defendants in federal criminal court proceedings in the United States. Hinckley was confined at St. Elizabeth’s Hospital in Washington, D.C. He was released from St Elizabeth’s Hospital in Washington, D.C. in 2016.

Jack Kerouac – 1922-1969

Novelist and poet.

Age of Diagnosis: 21

Individual History: Jack Kerouac was a American novelist and poet. He’s the author of the classic On the Road. Kerouac is recognized for his method of spontaneous prose. His writing covers a wide range of topics such as Catholic spirituality, jazz, promiscuity, Buddhism, drugs, poverty, and travel. He became somewhat of a quiet celebrity and, along with other “beats”, became a founding member of the hippie movement. Kerouac spent a short time enlisted in the United States military. During his stint a Navy doctor diagnosed him with what was then called “dementia praecox,” today known as schizophrenia. His enlistment lasted just 10 months and Kerouac left the military to start his career as one of the greatest writers of the Beat Generation. When he was discharged from his service the diagnosis was formally changed and noted that he might display some “schizoid tendencies.” He died on October 20, 1969 from an internal hemorrhage caused by cirrhosis of the liver. It was the result of a lifetime of heavy drinking. Some say the drinking was a type of self-medication to stop hearing voices, which are often heard by most schizophrenics.

Veronica Lake – 1922-1973

Film noir actress.

Individual History: Veronica Lake was a famous film noir actress in the 1940’s. She was diagnosed with schizophrenia as a child. Veronica Lake was known for some dramatic and even violent outbursts in adulthood. She won acclaim for her role in Sullivan’s Travels and for her femme fatale roles in noir films with Alan Ladd. Veronica Lake was also well known for her “peek-a-boo” hairstyle. By the late 1940’s, her career began to decline largely due to her struggles with mental illness and alcoholism. Veronica Lake made only one film in the 1950s but appeared in several guest-starring roles on television. Veronica Lake returned to the screen in 1966 in the film Footsteps In the Snow, but the role did not revitalize her career. Veronica Lake died in July 1973 from hepatitis and acute kidney injury at the age of 50.

Mary Todd Lincoln – 1818 – 1882

Wife of abraham lincoln and first lady of the united states.

Individual History: Mary Todd Lincoln, first lady, was the wife of America’s 16th President Abraham Lincoln.  Abraham Lincoln was highly motivated to pursue his increasingly successful law career. Mary Todd Lincoln had the same fierce ambition for success. She was a member of a large, wealthy Kentucky family. She was well educated. Before she married Lincoln, Mary was courted by his long-time political opponent Stephen Douglas. She and Lincoln had four sons together, only one of whom outlived her. In February 1862 her son Willie died at the age of 11 years old. After his death Mary Todd Lincoln spent a considerable amount of money to pay for mediums and spiritualists to try and contact her dead son.  Mary Todd Lincoln supported her husband throughout his presidency. She witnessed his fatal shooting when they were together in the President’s Box at Ford’s Theatre on Tenth Street in Washington. The First Lady had a history of migraines, mental illness, mood swings, fierce temper, public outbursts throughout Lincoln’s presidency, as well as excessive spending. Many historians and psychologists speculate that Mary suffered from bipolar disorder and/or schizophrenia.

Rufus May – 1968 –

Clinical psychologist.

Age of Diagnosis: 18

Individual History: An interesting inclusion on the list of famous people with schizophrenia is Rufus May, a British clinical psychologist. He is most widely known for using his own experiences as a psychiatric patient to promote alternative recovery approaches for those experiencing psychotic symptoms. Upon completion of his clinical psychology training, he disclosed that he had spent time in the hospital due to a diagnosis of schizophrenia. He was diagnosed with schizophrenia in 1986 at age 18 and was compulsorily detained in a psychiatric hospital on three occasions. What makes May so interesting is his personal understanding of psychotic experiences as a reaction to experiences of emotional loss and social isolation. In his teens he reports to have begun day dreaming intensely and became preoccupied with the worlds he was imagining. He also began to experience sleep serious deprivation. He developed ideas he was an apprentice spy for the British secret service. He also experienced messages from the radio and television. This eventually led to three admissions to Hackney Hospital within 14 months. After a year of receiving psychiatric drug treatment May decided to stop being involved with psychiatric services and stop taking the drugs he was being prescribed. He then used exercise, creative activities, social relationships and voluntary work to regain his wellbeing. He currently works as a clinical psychologist in an assertive outreach team in Bradford, England. He is actively involved in consumer recovery groups such as the Hearing Voices Network and the Bradford mental health discussion and campaign group, Evolving Minds.

John Nash – 1928 – 2015

American mathematician.

Individual History: John Nash is an American mathematician working in differential geometry, game theory and partial differential equations. The nationally acclaimed Hollywood movie “A beautiful Mind” was made representing John Nash’s life and was nominated for 8 Oscars. The movie was based on his mathematical genius and his struggles with Schizophrenia. He was often rejected by his classmates and would typically laugh it off with practical jokes and intellectual superiority. John Nash viewed everyday life as little more than distractions from his scientific work. John Nash’s work has provided insight into the factors that govern chance and decision-making inside complex systems found in daily life. His theories are used in economics, computing, evolutionary biology, artificial intelligence, accounting, computer science, games of skill, politics and military theory. Serving as a Senior Research Mathematician at Princeton University during the latter part of his life, John Nash shared the 1994 Nobel Memorial Prize in Economic Sciences with game theorists Reinhard Selten and John Harsanyi. In 2015, he was awarded the Abel Prize for his work on nonlinear partial differential equations. John Nash was awarded the John von Neumann Theory Prize for his invention of non-cooperative equilibria, now called Nash equilibria. Between 1945 and 1996 he had published a total of 23 scientific studies. Nash’s mental illness first began to manifest in the form of paranoia, his wife later describing his behavior as erratic. John Nash seemed to believe that all men who wore red ties were part of a communist conspiracy against him. He was admitted to McLean Hospital in April 1959, staying through May of the same year. There, John Nash was diagnosed with paranoid schizophrenia.

Ingo Schwichtenberg – 1965-1995

Individual History: One of the many sad tales of famous people with schizophrenia is the short life of Ingo Schwichtenberg. He was a German-born drummer and one of the founding members of German power metal band Helloween. Schwichtenberg was known throughout the international music community for his high-energy drumming and ear-to-ear smile. His driving rhythm and proficiency on the drums has been imitated by many power metal bands throughout the 1990s to present. Schwichtenberg was fired from the band in 1993 during the tour of the album Chameleon. The dismissal was reportedly due to Schwichtenberg’s dependence on alcohol and drugs (most notably cocaine and hashish). Schwichtenberg also suffered from schizophrenia, and his refusal to take his medication would lead to bizarre episodes such as uncontrollable sobbing, which made it impossible for him to perform on stage. After his ejection from the band, Schwichtenberg slid further and further into his schizophrenic episodes, culminating in his suicide in 1995 by jumping in front of a subway train.

Skip Spence – 1946 – 1999

Musician and singer songwriter.

Age of Diagnosis: 23

Individual History: Alexander Lee “Skip” Spence was a Canadian-born American musician and singer-songwriter. He began his career as a guitarist in an early line-up of Quicksilver Messenger Service, and was the drummer on Jefferson Airplane’s debut album, Jefferson Airplane Takes Off. He was one of the co-founders of Moby Grape, and played guitar with the group until 1969. He released one solo album, Oar, and then withdrew from the music industry. His career was plagued by drug addiction and mental health problems. In the late 1960s, Spence became delusional after taking too much acid. He was found marching around his hotel room with an axe, bashing down doors and claiming he was the anti-Christ. At that point he was taken to Bellvue Hospital where he was formally diagnosed as schizophrenic. Spence died in 1999 from lung cancer, two days before his 53rd birthday.

Gene Tierney – 1920 – 1991

American actress.

Individual History: Gene Eliza Tierney was an American film and stage actress. She was acclaimed as a great beauty and became established as a leading lady in a short period of time. Tierney was best known for her portrayal of the title character in the film Laura (1944). She was nominated for an Academy Award for Best Actress for her performance as Ellen Berent Harland in Leave Her to Heaven (1945). There were several difficult events in her personal life. She struggled for years with episodes of what was thought to be manic depression or schizophrenia. In 1943, she gave birth to a daughter who was deaf and mentally disabled, the result of a fan breaking out of rubella quarantine and infecting the pregnant Tierney while she volunteered at the Hollywood Canteen. In 1953, she suffered problems with concentration, which affected her film appearances. She consulted a psychiatrist and was admitted to Harkness Pavilion in New York. After being in New York, she went to The Institute of Living in Hartford, Connecticut. After some 27 shock treatments, intended to alleviate severe depression, Tierney fled the facility. She was caught and returned. She later became an outspoken opponent of shock treatment therapy, claiming it had destroyed significant portions of her memory. Tierney died of emphysema in 1991 in Houston.

Vincent van Gogh – 1853 – 1890

Individual History: Vincent van Gogh was a famous artist with schizophrenia. Among the most famous schizophrenic people is world renowned artist Vincent van Gogh. Van Gogh was a Post-Impressionist Dutch painter, whose work had a far-reaching influence on 20th-century art. His work included portraits, self portraits, landscapes and still life of cypresses, wheat fields and sunflowers, and Starry Night. He was reported to have drawn as a child but did not paint until his late twenties. He completed many of his best-known works during the last two years of his life. In a short period of time, he produced more than 2,100 works of art, including 860 oil paintings and more than 1,300 watercolors, drawings, sketches and prints. The artist lived in a time when schizophrenia had not yet been identified as a disorder, but many medical professionals today believe Vincent van Gogh suffered from it. His unstable moods and a  eccentric personality led 150 doctors to hypothesize a posthumous diagnoses. Vincent van Gogh had recurring psychotic episodes in the last two years of his life, and at age 37, he committed suicide by shooting himself in the chest with a revolver.

Wesley Willis – 1963 – 2003

Singer songwriter.

Age of Diagnosis: 26

Individual History: Wesley Willis was a singer and songwriter as well as a visual artist, appearing on widely viewed shows on MTV and on The Howard Stern Show. In 1989, Willis began hearing what he called “demons” and was diagnosed as having paranoid schizophrenia. He was institutionalized for two months after his diagnosis. He often mentioned that his demons were named “Heartbreaker”, “Nervewrecker”, and “Meansucker”. Willis is among the list of famous people with schizophrenia to use his symptoms and put them to his advantage. He called his psychotic episodes “hell rides”, and alternatively, he declared rock and roll to be “the joy ride music”. It was only after his diagnosis and honesty about his diagnosis and symptoms of schizophrenia that his career took flight. Willis gained a cult following that enjoyed his strange and comical lyrics, largely inspired by his disorder. He was diagnosed with chronic leukemia and died in 2003 at age 40.

Brian Wilson – 1942 –

Musician and member of the beach boys.

Age of Diagnosis: In His 30’s

Individual History: Brian Wilson was born in 1942 and became an American musician, singer, songwriter, and record producer best known for being the co-founder of the Beach Boys. He formed the band in 1961 and had a long string of hits. Moving beyond the cheery harmonies and catchy hooks that characterized his early music, Brian Wilson elevated himself and the Beach Boys to the status of rock legends with the release of the acclaimed album Pet Sounds in 1966. He used unorthodox approaches to song composition and arrangement and was a master of recording techniques. He is widely acknowledged as one of the most innovative and influential creative forces in popular music by critics and musicians alike. His childhood was tumultuous which led to years of battling drug and alcohol abuse and mental illness. After his father died in 1973, his addiction and mental illness took a turn for the worse and he spent nearly two years secluded in the chauffeur’s quarters of his home. He slept, abused alcohol, drugs (including heroin), overate, and exhibited self-destructive behavior. He attempted to drive his vehicle off a cliff, and at another time, demanded that he be pushed and buried into a grave he had dug in his backyard. During this period, his voice deteriorated significantly as a result of his mass consumption of cocaine and incessant chain smoking. Brian Wilson also admitted to having auditory hallucinations, meaning he hears voices, and has been diagnosed with schizophrenia. Wilson revived his career and released several solo albums in the 1990s. He was inducted into the Rock and Roll Hall of Fame in 1988. He was honored by the Kennedy Center in 2007 for lifetime contribution to the performing arts.

20 Famous People with Schizophrenia Schizophrenia is a serious mental health diagnosis that can lead to a lifetime of suffering for the individual with the diagnosis, as well as those around them. While the disease is treatable with medication and mental health treatment, it is not curable. The causes of the disease are largely unknown, with studies pointing to a genetic predisposition. This list has shown that schizophrenia affects people from all walks of life. Fame and money are often not enough to take away the seriousness of the illness. While some of these people lived healthy, traditional lives, many did not. This disease is not discriminatory and affects even those with fame and fortune as you can tell by reading about these schizophrenic celebs .

About the Author

After earning a Bachelor of Arts in Psychology from Rutgers University and then a Master of Science in Clinical and Forensic Psychology from Drexel University, Kristen Fescoe began a career as a therapist at two prisons in Philadelphia. At the same time, she volunteered as a rape crisis counselor, also in Philadelphia. After a few years in the field, she accepted a teaching position at a local college where she currently teaches online psychology courses. Kristen began writing in college and still enjoys her work as a writer, editor, professor, and mother.

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Who Relapses From Schizophrenia?

Factors that indicate risk for rehospitalizations and emergency room visits..

Posted April 29, 2024 | Reviewed by Michelle Quirk

• What Is Psychosis?
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• A study identified a large population of patients with schizophrenia and examined factors related to relapse.
• Factors of relapse had to do with race, insurance access, and medication nonadherence, among others.
• Other studies have confirmed these observations in smaller-scale populations.

A large review article recently published in Nature has revealed some perhaps long-suspected information about people living with schizophrenia and schizoaffective disorder who tend to relapse .

The authors’ methods in this study tried something a little different. Instead of relying on insurance claims data or only using small populations, they searched a system of large electronic health records (EHRs) to analyze the relationships between relapse episodes and characteristics such as race, disease, insurance status, and more. The data, which included 8119 patients, came from October 15, 2016, to December 31, 2021, and focused on patients who received care for at least 12 months.

Who Had Relapses?

What they defined as relapse was an emergency room visit or an inpatient hospitalization for their condition. Of the total patients in the study, 30.52 percent experienced a relapse, while 69.48 percent experienced no relapse. The patients were primarily male and accounted for 54.72 percent of the demographic, while 54.23 percent were white non-Hispanic or Latino.

Even though the patient population consisted mostly of white males, the study showed that those who were more likely to relapse were more likely to be Black (34.68 percent of Blacks), other Pacific Islander (58.33 percent of other Pacific Islanders), and Latino (35.36 percent of Latinos) compared to whites.

Those who relapsed also were more likely to be under Medicaid or Medicare, with a 33 percent and 22 percent increased prevalence, respectively. They were more likely, at a 33 percent increased prevalence, to have a diagnosis of substance abuse alongside their diagnosis of schizophrenia and schizoaffective disorder. They also were more likely to have more encounters with health care, indicating that those who frequent hospitals are more likely to visit them again.

These patients are more likely to be prescribed more medications than those who did not relapse, and the most common prescription written tends to be for atypical antipsychotics when typical antipsychotics haven’t worked.

Oddly, patients who relapsed were less likely to have diagnoses of obesity, hypertension, and diabetes. There were no sex differences in the likelihood of relapse episodes.

Other Findings

In a literature review that included 145 other manuscripts, similar factors were observed for determining who was more at risk for relapse.

The most common factors were nonadherence to treatments like medications, stress and depression , and substance use. Those who were more likely to relapse were also less likely to be privately insured, which may imply that those who cannot work or gain private insurance through other means like family members or spouses are more likely to relapse.

What this study confirms is an instinct many who work in the industry perhaps have already observed. Those who are more at risk for relapse episodes need more targeted treatment solutions so that people living with schizophrenia and schizoaffective disorder can reduce their interaction with substance abuse and increase their adherence to prescribed treatments.

Rivelli, A., Fitzpatrick, V., Nelson, M., Laubmeier, K., Zeni, C., & Mylavarapu, S. (2024). Real-world predictors of relapse in patients with schizophrenia and schizoaffective disorder in a large health system. Schizophrenia , 10 (1), 28.

Sarah An Myers is a writer with a Master of Arts in psychology and behavioral neuroscience from the University of Missouri-St. Louis. She researches novel computational and therapeutic methods for treating and diagnosing mental disorders.

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