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CHAPTER TWO

The Really Tough Cases

Let’s highlight some difficult patients. I’ve seen my share of tough cases of Anxiety Disorders, Depression, Bipolar Disorder, and ADD/ADHD. Even though some cases are easier to resolve, and some are more perplexing, I love the challenge. I enjoy figuring out intricate puzzles, and the human being is the living puzzle I most enjoy solving. It is exciting to see people who have long struggled quickly get their lives back. Many patients arrive in desperate state. Some don’t want to live any longer if it means living the same way. Many have seen several doctors without getting to the root causes of their problems. I want to be the one who finds answers and gets them on track. I want them to thrive, not just survive. When I see their excitement, I’m elated. It’s humbling when they share how much their lives have improved and have discovered true happiness and joy.

PTSD

PTSD is a mental health condition triggered by experiencing or witnessing a terrifying event. Many have heard of it as something soldiers from war go through. I’ve had the pleasure of working with many veterans, evaluating and treating them for PTSD. I have profound respect for those who’ve risked their lives to preserve the moral ideals and values the United Statesrepresents. I’m sure to thank each of them for their sacrifice and service. There are other examples of traumas and terrors leading to PTSD, such as victims of violent crimes such as armed robbery, rape, domestic emotional and physical abuse, through natural disasters and other lifethreatening scenarios. PTSD leaves impactful, long-term damage. Thankfully, treatments exist to help them to move on and thrive.

Bruce After spending many years in the VA system, Bruce was referred to me by another veteran. A Marine who’d served in Vietnam in the 1960s and 1970s, Bruce spent time near the front lines in active combat. After reviewing his intake form and VA hospital records, I was struck by his considerable amount of trauma. Bruce had difficulty talking about the war. He got choked up. “I’m sorry,” he said. “It’s still so present in my mind.” “You have absolutely nothing to apologize for,” I said. “I need to know every detail about what traumatized you.” “When I was at the base, a supposedly safe space, we were attacked by rockets and mortars day and night. We slept with our boots on and our guns by our side. When the watchman yelled ‘Incoming’ we’d drop to the floor to try and find some shelter. You can’t ever relax because you’re in constant fear of dying.” I kept listening. “I saw many of my fellow soldiers dying or severely wounded. I saw a couple of people blown up when they couldn’t avoid an incoming rocket and the horrible aftermath. I’ll never forget one soldier who was obviously dying, pleading with me to help, but there was nothing I or anyone could do.” “That’s a lot to carry,” I told him. “I killed several of our enemy. I’m not sure how many and I don’t want to know. I get that they were the enemy, and I was just doing my job, but I can’t stop thinking about them having families that’d never see them again. As much as I wish they weren’t, those thoughts haunt me every day.” He had several classic symptoms of PTSD. Before the war, he never had any mental health issues. That changed since coming back home. He was bitter at the response from some Americans, who called them names such as baby killers and other vile names. Bruce suffered insomnia. “I sometimes don’t want to sleep because I have vivid nightmares … flashbacks of what I went through. I wake up screaming. I don’t recognize my wife at first.” His dreams haunted him, causing a lack of sleep, leading to fatigue, lack of focus and concentration, and reducing his motivation and drive. Amy, his wife, chimed in. “I’m concerned about his reduced memory, especially for recent events. He gets angry and irritable. Bruce isn’t like the man I knew before the war.”

Bruce obviously exhibited symptoms of anxiety and depression. “He’s become more withdrawn and doesn’t participate in things he enjoyed before,” Amy said. “Bruce startles easily and hates loud noises. He doesn’t like depictions of wars on TV, movies, or books. He hates the Fourth of July, same as our dogs.” “I’m surprised your PTSD hasn’t been adequately diagnosed and treated” I said to Bruce. “You’ve been to some individual and group therapy, but the medical treatment was woefully inadequate.” To be fair, he was offered medical help but refused it. “I know there’s a stigma for vets. That soldier mentality of not complaining and being tough— don’t show signs of weakness. It’s counter to a soldier’s machismo image.” “I don’t understand why my life was spared while so many others died. Part of me wishes I would have died there, too,” Bruce confided. “That’s heartbreaking to hear,” I said. “You’re experiencing survivor’s guilt.” It’s hard to imagine what he went through, and the aftermath years later. “But that isn’t a weakness. It’s not your fault.” I drew him a diagram of two neurons connecting. “The trauma you experienced threw off the balance of the chemicals in your nervous system. They haven’t rebalanced since and can’t without medical help. I suggest trying psychotherapy. There’s a specialized type called EMDR, which is well known to help with all kinds of trauma including PTSD.” Bruce said, “I’m listening.” “It’s a difficult therapy. Patients can relive difficult experiences, but it’s well worth it. The results work. The idea is not burying painful memories while learning to deal with them. Only then can you move on.” My first task was balancing his nervous system. He deserved nothing less. Initially reluctant to accept my advice about starting a psychotropic medication, he soon agreed to follow through. His first intervention was an SNRI. During our next visit, Bruce was smiling. “I’m feeling so much better. My anxiety has gone way down. I’m not as jumpy. I’m sleeping better and it’s easier to focus.” “It’s a thrill hearing you report such great results,” I said. “That’s what I hope for. You’ve suffered far too long.” “Thanks, doc. Overall, I feel better emotionally and physically but there’s still some fatigue and lack of motivation. My memory’s not back to normal. There’s less nightmares but they’re still not completely gone.”

“Seeing you respond to medicine so well, let’s add Wellbutrin XL and Prazosin. Prazosin is actually a blood pressure medication, but it can help to resolve nightmares associated with trauma such as PTSD.” Two weeks later, he came in with Amy. “I can’t thank you enough for giving me my husband back. I knew him before he went to Vietnam, and we got married after he returned home.” She squeezed his hand. They looked like young kids in love again. “Bruce hasn’t felt this well for over 50 years. His energy and motivation are way better.” “That’s thanks to the Wellbutrin XL,” I said. “My focus, concentration and memory have gotten good enough that I want to get together with my friends to play cards and go golfing. Also, the Prazosin at bedtime seems to have taken away the nightmares. My dreams are actually now peaceful,” Bruce said. At his one-month and three-month checkups, Bruce continued to live the life he deserved. Some of the most satisfying results come from patients suffering from PTSD. The stories of veterans and others suffering traumatic events affecting the nervous system are heart-wrenching and have, at times, brought me to tears. They don’t deserve what’s happened. Thankfully, treatment allows them to return to a normal quickly. Results can last the rest of their lives when appropriately treated with the amazing array of readily available psychotropic medications.

Eating Disorders

Abnormal or disturbed eating habits characterize eating disorders. It’s a complex mental health condition requiring psychological and medical attention. Consisting of many elements including psychological, medical, hormonal, and mental/psychiatric components, they’re often present in those with a history of severe trauma, such as PTSD. Common in Westernized countries, who are preoccupied with thinness and body shape, they’re not as significant an issue in other countries. There are many different types of eating disorders. We’ll describe the three most common and well-known throughout this section. FURTHER READING: A more comprehensive discussion appears in Chapter 12: Eaten Alive by Eating Disorders in volume one of my Healing the Mind and Body: The Trilogy.

Anorexia Nervosa

This condition generally develops during adolescence and young adulthood and tends to affect women more than men. They perceive themselves as overweight, even if they’re dangerously underweight. They are obsessive about monitoring their weight, counting calories, and knowing the fat content of each food they consider eating. Their self-esteem revolves around their weight and body shapes. They have a distorted body image and deny being seriously underweight. I think of eating disorders as an obsessive-compulsive behavior similar to OCD, but the obsessions revolve around food, especially about the lack thereof for anorexics. Anorexia Nervosa can be damaging to the body, especially the brain. They can experience bone thinning similar to osteoporosis. Hair and nails go brittle. Menstrual cycles become irregular and can lack menses. Anorexia can lead to infertility, electrolyte abnormalities, and death.

Bulimia Nervosa

Like Anorexia Nervosa, which also tends to develop during adolescence and early adulthood, Bulimia Nervosa is more common in women. Both conditions also are common in certain sports, such as gymnastics, dancing, and wrestling for boys. It tends to affect athletes who focus on weight. People with bulimia frequently eat unusually large amounts of food over a specific period of time, progressing until the person is painfully full. On the flip side, there are others who purge small amounts of food. They cannot stop eating or control the quantity. This is the obsessive-compulsive behavior bulimics have difficulty controlling. Common purging behaviors include forced vomiting, laxatives, diuretics, enemas, and excessive exercise. As opposed to Binge Eating Disorder, they tend to maintain a relatively normal weight. Their self-esteem is overly influenced by their body shape. They have an intense fear of gaining weight. Symptoms include an inflamed, sore throat, swollen salivary glands, worn tooth enamel, tooth decay, acid reflux, abdominal irritation, dehydration, and hormonal disturbances. In severe cases, they can also develop electrolyte abnormalities concerning sodium, potassium, and calcium. This can lead to serious cardiac issues, sometimes fatal.

Binge Eating Disorder

Bing Eating is one of the most common eating disorders. Binge eaters characteristically eat unusually large amounts of generally unhealthy foods over short periods. The feelings are uncontrollable— they key element of their obsessive-compulsive behavior. They don’t restrict calories and don’t engage in purging behaviors, such as vomiting, excessive exercise, or the others. Often done secretly, until they’re uncomfortably full, binge eaters do so despite not feeling hungry. They often feel distress, shame, disgust, or guilt, when thinking about their binge eating behavior. They tend to be overweight, with some morbidly obese. They may have medical complications such as type 2 diabetes, hypertension, heart disease, and increased stroke risk.

Jennifer 

Jennifer’s psychologist referred her when she was 25 years old. She was the third therapist Jennifer had seen, along with a handful of medical doctors, all seeking answers. She filled three pages of details in her patient intake form. The average is two. From the form, I diagnosed her with a severe eating disorder along with other related, coexisting diagnoses. My process is to block out an hour for a new patient. I could have used more for Jennifer; there was a lot to address. While getting a patient’s history, I allow the patient to talk as long as possible without interruption. This provides all the information they deem important. It’s the most vital information to hear in order to figure out how to best help. It’s essential to pay attention to all the numerous details and clues. After establishing their baseline, I ask them to start at the beginning. “Tell me about their childhood, adolescence, and adulthood. Start back when you felt your best. How would you like to feel again, if possible?” “I’m not sure,” Jennifer said, lost. “I can’t remember a time I wasn’t stress-free. I’ve had anxiety since I was a kid. I was shy, except around my parents and close family members. I had bad separation anxiety when my mother dropped me off at school. I’d cry for quite a while after she left. I’d wear myself out and stop.” She shook her head. “I had a few friends growing up but liked being alone. Other people made me anxious.” She continued and I listened. “One thing I loved was eating, which calmed my nerves. My small group of friends discovered endless types of junk food we loved. That being said? I still preferred being alone so no one could see what I was doing. My parents were concerned by middle school. Going into high school, I became overweight. I got teased a lot. Kids in high school were brutal.” Jennifer was open to change. “My parents were concerned and sent me to a nutritionist to teach me proper eating habits. After hearing what the nutritionist said, paid attention to the details of the foods ate. I was horrified by I saw and read online. My eating habits completely violated ever dietary rule. I learned what foods contained fat, what the different carbohydrates were, and how sugars affect the metabolism. I counted calories and watched fat content. I lost the weight I originally wanted, but it wasn’t enough.”

Her parents enrolled her in gymnastics for her to exercise regularly and teach discipline. “I liked it but spent most my time comparing my body to the other gymnasts. The other girls were thinner. I had to change that, so I restricted more until I was so weak, I couldn’t compete.” Jennifer returned to her nutritionist who told her she was taking things too far and she needed a more balanced diet. “I didn’t like hearing that because all I heard was I how much weight she’d gain if I followed her recommendations.” She did not want to stay in gymnastics because she didn’t like believing she didn’t look as good as the other girls. Her parents relented, knowing gymnastics wasn’t for her. No matter what they did for her, Jennifer wasn’t satisfied. They demanded she needed to find some type of exercise to replace gymnastics. She exercised solo by power walking and jogging but didn’t increase her dietary needs accordingly. By high school, she was tired of working so hard and still not being happy. Jennifer decided to break her dietary habits and go back to comfort eating. She gained weight, which upset her mother. “I felt my daughter was moving backward,” her mother said. Her older brother and father teased her. Her father pinched her on the side and told her she needed to, “Do something about this.” Her mother took a banana out of her hand she was going to peel and eat because the outside was brown, which meant it contained too much sugar. “A girl in high school told me about purging. I could eat whatever I wanted and get rid of it in secret,” Jennifer said. “Another girl in high school told me about purging.” Because she didn’t lose enough weight by purging, she took long walks or jogged for 2 to 3 hours. She used laxatives when she was too full or constipated. Her friends and family observed her as being more withdrawn. She hid her anxiety attacks and learned how to eat and exercise for relief. While she hid her binging and purging, she found cutting her forearms made her feel better, too. She hid the gouges by wearing longsleeved blouses and sweaters. She avoided people. Her mother took her back to the nutritionist who confirmed Jennifer seemed to have transitioned from an anorexic to a bulimic condition. Her glands swelled and she showed symptoms of acid reflux, along with abdominal pain and bloating. Her dentist noticed her teeth and gums showed signs of overexposure to stomach acid. She required extensive dental work to fix the damage. Her friends were talking behind her back, so she avoided them. She Grateful to graduate and go off to college, Jennifer left her friends and former life behind. She majored in psychology, believing she’d discover some truths about herself. She didn’t get much exercise, since she spent a lot of time in her room studying and eating, getting rid of it when she ate too much. With only one roommate her first two years, she hid her habits. Junior and senior years where easier as she had her own room: her safe space. Over time, she learned how much to eat in order to maintain a weight that wasn’t as thin as she’d have hoped but was comfortable with. She was lonely and sad but didn’t trust others who might discover her secrets. “I didn’t let anyone get close. I had some short-term boyfriends, but I was ashamed. I thought I was fat. I was tired all the time and had zero motivation. I stopped exercising and just watched TV or did my schoolwork. I was most comfortable when I was alone.” Jennifer began treatment with me during her third year of graduate school, getting a Ph.D. to become a psychotherapist. She was well aware she had a mixed eating disorder. Remarks and teasing from those closest to her contributed to the underlying factors leading up to her eating disorder. As her mother also struggled with weight, there was also a genetic factor. “These get worse from middle school to high school since this is when puberty occurs. It’s also when kids tease,” I said. “What can start as a jest can sometimes lead to bullying. Neurochemicals can start going out of balance at that age, contributing to obsessive thinking, fluctuating moods, and body feelings.” “You’re spot on,” she said. “Any stressors you think may be contributing to your condition?” Jennifer said, “Grad school is challenging, and I was I was in a healthy relationship, but I’m not feeling stable enough for that to be possible.” She’d purge daily, less than she used to. She used strong mouthwash mixed with hydrogen peroxide to prevent damaging her teeth. “I’d wait until night to binge sugars and carbohydrates. I couldn’t help the cravings. I was out of control and felt guilty and ashamed.” To regain control, she saw a new psychologist and made some progress. The doctor offered medical treatment. Jennifer tried a couple of medications: an SSRI and Wellbutrin XL, though not together. She didn’t like how antidepressants felt. The SSRI made her tired, and the Wellbutrin made her anxious, so she stopped them. “I’m nervous to take another medication after that,” she said. “The only way to fix this problem for good is by addressing the underlying problem and treating it in a supportive and curative way.” She seemed intrigued. I drew a diagram of two neurons connecting. “I suspect you have three imbalances: serotonin, dopamine, and GABA. Psychotropic medications work by attaching to the nerve cells and redirecting traffic, which forces the chemicals to move in the right direction. This results in a re-creation, for the first time in years, a feeling of normality and feeling of self, with true inner happiness and joy.” I started her on a low dose the SSRI Prozac and titrated slowly to a higher range. Why did I not choose an SNRI, my usual first choice? Because I didn’t suspect that norepinephrine was a key factor. With eating disorders serotonin is usually a significant factor. Patients with anorexia nervosa usually require a low dose, while people with bulimia nervosa typically need a dose in the higher range of normal. The medicine would help her obsessive thinking and calm her anxiety. She’d feel tired and apathetic, but it’d be temporary and would signal it’d be time to add the second medication. A few weeks later I added Wellbutrin XL to boost dopamine. I checked a full lab panel to ensure her electrolytes were normal and she was stable for treatment. Adding the Wellbutrin XL boosted her energy and motivation and resolved her depression. When adding it to the SSRI, it didn’t cause anxiety like it had on its own. Wellbutrin is usually better as an add-on agent rather than an initial treatment. Adding Topamax in the early evening balanced her GABA. Titrating it over four weeks to the optimal dose resolved her cravings for sugars and carbohydrates, stopping her from binging and purging. It helped her anxiety, headaches, and neck, shoulder and upper back pain. “My whole body just feels better.” Jennifer was all smiles during her third visit she showed off her beautiful white teeth. It was exciting to see her transformation. “I’m not obsessing over food and I’m actually eating a proper well-balanced diet throughout the day.” She looked healthy and full of energy and motivation back. She exercised regularly and reasonably. “Psychotropic medications don’t control a person—they help a person be in control. You couldn’t help what you went through since eating disorders are so persistent and difficult to resolve. There are so many factors at play, with genetics, upbringing, hormonal changes, and situational stressors all out of one’s control.” A few months later, she had another surprise. “I’m in my first really healthy relationship that’s lasted more than a month or two. I shared her story with Brad. I was both surprised and relieved when he accepted me for who I am and didn’t judge me for her past. He actually thanked me for telling him, since he wanted to know everything about me.” Grad school was doing much better since she had more drive and determination to put the work in and get better grades. “I made peace with my family,” she said. “I understand where they were coming from. They couldn’t help certain things, either. By the way? I referred my mom to you after telling her how you helped me.” During her mom’s first appointment, she asked, “Can you help me like you helped my daughter?” “Of course. I’d be honored to,” I told her. She’s doing well now, too. The Corona Protocol works.

Schizophrenia

Schizophrenia is a serious mental disorder in which reality is interpreted abnormally. It may present through combinations of hallucinations, delusions, and extremely disorganized thinking and behavior, impairing daily functioning. Some with schizophrenia are high functioning, while others can be completely disabled. This chronic diagnosis needs long-term treatment, which can dramatically improve the condition and improve their long-term outlook. Delusions are false beliefs not based in reality. Some feel they’re being followed, or harassed, and are suspicious of others. They may misread gestures and comments, taking them personally. Hallucinations involve seeing or hearing things that don’t exist. They believe they’re real. Hallucinations can happen through any of the senses; hearing voices is the most common and classic type. Disorganized thinking displays as disorganized speech. They may not answer questions directly and put together words that don’t make sense to anybody except themselves. This is referred to as a word salad. Disorganized and abnormal motor behaviors include unpredictable agitation, along with childlike silliness. Their behaviors aren’t goal oriented. Their body movements may be inappropriate, bizarre and display excessive movement. The symptoms thus far are referred to as positive symptoms. Negative symptoms refer to basic functioning, such as neglecting personal hygiene. They may appear to lack of emotion and may avoid eye contact. They tend to freeze their facial expressions and speak in a monotone. They may lose interest in everyday activities, become socially withdrawn, and lack the ability to experience pleasure. There may be periods when they do better, while at other times they’re worse. In men, Schizophrenia typically starts in the early to mid20s, though it can start in the teens. In women, it typically starts in the latter 20s. It’s rare to first see it in children or middle age. Schizophrenia is a severe diagnosis, but thankfully, we have serious treatments that work extremely well.

Brian 

Brian was referred to me at 23. His parents and him filled out separate intake forms to explore both their perspectives, which can be enlightening. During his first visit, getting his perspective about what he felt was going on with him. I then had his parents come in for the second half of the visit to share their perspective regarding what they felt was going on with their son. They told me he was shy growing up and kept to himself a lot, but his parents didn’t worry about him because he was getting good grades and devoted a lot of time to his studies. He loved working with computers and spent endless hours playing video games alone in his room. His parents tried to encourage him to go out and play and be more active, but he only did the minimal amount and tried to avoid others whenever possible. He was teased at times, especially going into middle school and high school, since he came across as socially awkward, and since he did so well at school, he had been termed a nerd and a geek. His parents encouraged him to join the science club and math club at the high school, and he checked them out but didn’t feel comfortable being around that many other people. His parents gave up trying to get him involved in activities but were happy that he had such a high GPA and wanted to attend college to get a Computer Engineer degree. At college, he continued to excel academically but spent most of his time in his room or at the library, preferably by himself and far enough away from other people, so they didn’t bother him. He didn’t get involved with any of the social opportunities available on campus and spent his off time in his room playing video games for hours. He felt he was actually living within his game since the beautiful woman with the long dark hair would occasionally speak to him when he was sleeping when he was trying to think about something else. It felt so real to him when she’d join him in his dreams on certain evenings. She would also join him while she was inside the game. He could tell that she was interested in him by the way that she looked at him and treated him. He thought he could hear her whispering to him and could occasionally briefly see her in the corner of his vision, but when he looked, she’d disappear. Occasionally, teachers and other students would see him muttering to himself, and he sometimes seemed unaware of others around him. He’d graduated from college and continued to live with his parents where he felt safe, so they were able to see firsthand how his behaviors had progressed, and they were concerning to them. He spent hours in his room when he was working in his first year out of college as a computer engineer. Due to the pandemic, he could work full-time from home, so he could therefore easily avoid being around other people, which he was happy about. This resulted in Brian spending most of his time in his room, either working or playing video games. His parents were concerned he didn’t seem to shower or brush his teeth often, so they would remind him when they could see or smell that he had not been taking care of himself. There were also concerns that he seemed to be frequently talking while he was playing video games as if he was having a conversation with someone else when they knew that there was nobody else in the room with him. When they asked him who he was talking to he told them that there were other people that he played the game with, but they could hear the conversations and that didn’t make any sense to them. They knew that he wasn’t telling the truth. Brian could also hear the voices of his neighbors, so he would go out to look and see if he could catch them spying on him. His next-door neighbor’s teenage daughter would occasionally lay out in the backyard in her bikini, and he knew that she was attracted to him and that she was trying to tease him. He knew that it was wrong what she was doing, and he was ashamed about how he was thinking about her. It was her fault for tempting him. He suspected that it was more than just those neighbors, so he kept track, since he knew that he was being spied on and monitored. When he told his parents about this, they were told everything was fine and that he was just imagining this, which made him angry that they were dismissing his concerns because he knew that what he was sensing was real. He started keeping track of the license plates of the cars on the block so he could identify them in case they broke into their home. His parents noticed that he was having conversations with people that weren’t there, and the dialogue made no sense. He was also getting more withdrawn than usual. He was watching TV or playing video games all night until the early hours and then working the next day. His parents noticed he wasn’t making good eye contact with them and that he never smiled or showed any type of emotion other than anger when his beliefs were challenged. When they told him they were taking him to a psychiatrist he didn’t want to go. They told him if he wanted to continue living with them, he’d have to get assessed by a professional. He reluctantly agreed. He was diagnosed with Paranoid Schizophrenia. His parents suspected as much but were still devastated. Their son, however, didn’t seem to understand the diagnosis and felt the doctor and his parents didn’t understand him. He reluctantly tried the antipsychotic medication but didn’t like how he felt on it. It seemed to increase his appetite and it made him tired when he was working, so he stopped it without letting his parents know. He told them he was taking it, but they didn’t see any change in his behavior. By the next year, he was certain his neighbors were spying on him. He confronted them. “Stop bothering me!” “We don’t know what you’re talking about,” they’d plead. “Your daughter’s harassing me!” His accusations made them call the cops. After evaluating Brian, they gave him two options. Go into a psychiatric facility or an outpatient program. Brian wasn’t happy with either but took the latter to avoid a hospital stay. He could stay with his parents, who attended to family sessions. They were referred to NAMI (National Association for Mental Illness) to understand their son’s condition better. Brian still worked part-time from home. A new psychiatrist agreed with the diagnosis and started him on an atypical antipsychotic medication. Brian liked it one better than the first because it helped him sleep but he didn’t like feeling restless. Brian felt like he couldn’t stop moving. This side effect is akathisia. He started a second mood stabilizer: Lithium. He didn’t enjoy the way it made him feel, either. So, he stopped taking them, but didn’t tell his parents or doctor. He kept his thoughts and feelings to himself to hide his decision. He made it through the program and was discharged. He learned to hide his emotions and feelings and didn’t share the suspicions and paranoia. Brian knew he was right and didn’t care what anybody else thought. He knew his neighbors were getting away with their surveillance, so he kept an eye on them but didn’t engage since he didn’t want to go back to a treatment program. He hated discussing his feelings or answering questions during individual or group sessions. This was private information he wanted to keep to himself. It was nobody’s business. He didn’t like getting controlled by the doctors and therapists, he felt, so he just said and did the minimal to get by and leave as soon as possible. “I tried to hide that I’d stopped taking my meds by taking a large dose of lithium prior to getting my blood drawn,” Brian admitted. “I thought I’d outsmarted them.” “Over the following month, we knew he’d fallen back into the patterns of isolating, muttering, ignoring his hygiene, avoiding eye contact, and showing little emotion,” his mom said. “We met folks at NAMI meetings who gave us your name. After we looked into you, we decided to make an appointment,” his dad said. Brian didn’t want to see yet another doctor but relented when he learned it was mandatory to continue living with them. During our initial visit, I asked Brian, “Can you tell me about the voices?” “I hear from the different women I like. They like me, too,” he said. “They’re from my video games.” “Do you think they’re real?” He looked embarrassed. “Yes. I know it sounds like I’m lying, but there’s a mutual attraction. No one understands.” “Tell me more.” “Sometimes I hear the neighbors’ voices, especially the man and his teenage daughter. They’re spying on me.” “Why would they do that?” I asked. “I’m not sure,” Brian said. “There’s definitely an ulterior motive, though.” “What do you think about the medications you’ve taken?” He was prescribed atypical antipsychotic medications and lithium. “I don’t like what I found on the internet,” he said. “Researching on the internet without guidance isn’t a great idea,” I explained. “You need proper training and knowledge. If we turn it around, I could never do what you do on the computer. I just don’t have engineering or computer knowledge.” Brian smiled for the first time. “I just didn’t like the idea of taking medications because it doesn’t seem like there’s anything wrong with me. They make me feel terrible. I don’t think they’re necessary.” Reviewing his symptoms showed his sleep was disrupted. “I can’t shut my brain down at night. I stay up and watch TV or play video games. On weekends when I’m not working, I catch up on sleep before work on Monday.”

I explained the role of genetics since his father’s uncle was believed to be schizophrenic and his mother’s grandmother had been institutionalized for several years. She was treated with electroconvulsive therapy as part of the treatment and died at a relatively young age. “Genetics seem to be the key factor in your case,” I told him. Brian’s age of onset was typical and consistent for the condition. I prescribed Seroquel, a dopamine antagonist that helps shut down dopamine. When taken at bedtime, it can dramatically help sleep patterns. I titrated it to a relatively high dose. When Brian returned to my office, he was doing better. He showed a consistent sleep pattern and better daytime functioning. He wasn’t completely healed. He still had some delusional thinking. “It makes sense that some of the voices aren’t real,” he said. A good step forward. Brian appeared more lucid and made more sense. Eye contact improved. His parents were thrilled with the progress, but we weren’t done. “With his level of mental illness, it’s doubtful a single medication is enough. The rational polypharmaceutical approach is the best technique for this disorder.” I added Depakote ER, which modulates GABA and glutamate, titrating it to a high level. By the visit a few weeks later, Brian appeared significantly better. He seemed to understand the voices weren’treal but still struggled with for it to make sense. “Exercise is important. Eat a well-balanced diet so as not to gain weight,” I said. If he’d been obese and struggled with overeating, adding Topamax would be appropriate to help control his appetite and lose weight. If Seroquel had been too sedating, he’d be switched to a less sedating antipsychotic medication. A few months later he was still doing much better. Brian’s parents were thrilled with his progress and were happy he was engaging more with them and other family members. He met people through work and socialized. He preferred to be alone but made an effort to get out. Work was going well and was praised by his supervisors as a diligent worker. I have seen many cases of Schizophrenia that are not nearly as high functioning as Brian’s, which is sad. Many cannot function in a work setting and there’s a high incidence of drug addiction, homelessness, and suicide. Some can be violent and cause significant and permanent damage to others. Some smoke, eat poorly and adopt other unhealthy habits such as not exercising, which can lead to an increased risk of obesity, diabetes, cardiovascular disease, and early death. They are at increased risk of ending up in jail due to drug use, often going hand-in-hand with crime. Prisons are our modern psychiatric hospitals, the vast majority struggle with mental illness. Those in and out of prison and involved in the courts are notoriously noncompliant with treatment. An excellent option available are monthly injections of antipsychotic medications. These are monitored and mandated by the courts. This helps keep these patients walking on a good path. In contrast, most civilian patients can be managed with oral medications. This is why Brian’s case was so refreshing and exciting. Schizophrenia is a treatable illness with many excellent medications. I like to look at the positives and not dwell on the negatives. It’s not a hopeless diagnosis but a hopeful one, as long as people in need receive the help they need. Brian and his parents couldn’t agree more. The good news is with proper treatment, compliance, family support and psychological support, Schizophrenia is a diagnosis that one can live with and, in best cases, can thrive.