Recovery and reintegration
The case that accompanies “Recovery from Schizophrenia: Fact or Fiction” does not reflect the typical patient with schizophrenia. The affective symptoms, onset at age 15, and the fact that Ms. J was effectively maintained on lamotrigine, 300 mg/d, and olanzapine, 5 mg/d, suggest that she suffered from bipolar disorder. Paranoid delusions can appear in the context of mania.
Also, Ms. J had been taking haloperidol, 50 mg/d, which is excessive regardless of diagnosis. Insufficient or excessive dosing is detrimental, and overmedication can impede recovery. Ms. J was lucky to have avoided tardive dyskinesia.
Some thoughts about the role of vocational rehabilitation: Rule of thumb is that during recovery from schizophrenia, vocational goals should be set one step below the achievement or the potential that existed before illness onset. When onset occurs before the patient fulfills his or her vocational potential—as often happens—potential may have to be substituted for achievement.
Joseph More, MD
Attending psychiatrist, forensic division
Connecticut Valley Hospital
Dr. Martens responds
Ms. J’s symptoms were consistent with schizophrenia, bipolar type. Vocational goals for schizophrenic patients in remission might be set one step below the achievement or potential that existed before onset. Medication might enhance or hinder the patient’s creative, cognitive and intellectual abilities. Increased responsibilities, work stress, and career promotion can increase psychotic symptoms; relapse should be avoided by reducing vocational activities.
Willem HJ Martens, MD, PhD
Director, W. Kahn Institute of Theoretical Psychiatry and Neuroscience
Elst (Utrecht), The Netherlands