When the Side Effect Is Really the Symptom
Am Fam Physician. 2002 Nov 15;66(10):2008-2013.
For some time I have had a patient with schizophrenia. Despite our friendly physician-patient relationship, she refuses to take the medications necessary to alleviate her symptoms of paranoia and anxiety. She says that such medicines have “side effects,” and that they poison her body. She sometimes agrees to take risperidone, but after only a day or two, the sensation that she is being “poisoned” kicks in, and she stops taking it. How can I convince this patient that the medication is safe and that it will make her more functional, less fearful, and more at ease in the world?
This case scenario addresses a difficult and common problem. Schizophrenia is a severe, chronic disorder that occurs in about 0.5 to 1 percent of the population and accounts for 10 percent of permanent disability cases.1 New medications offer hope for improvement in symptoms and reduction of side effects, but in many cases, they have not resulted in improved compliance with medication regimens.2 Up to 80 percent of outpatients do not follow their medication regimens, resulting in high relapse rates.3 Multiple factors influence patients' perceptions of medications and their decisions to take them.
To improve compliance with medication regimens, the following recommendations, based on recent developments in the treatment of schizophrenia, may be useful.
Cognitive Behavioral Therapy (CBT)
Two methodologically sound meta-analyses of CBT for schizophrenia reveal meaningful clinical effects on measures of positive and negative symptoms.4,5 Effects are independent of medication compliance, are related to altered beliefs about the illness, and exceed those of adjunctive therapies.
Additional benefits include enhanced medication compliance and positive patient satisfaction rates of up to 80 percent, much higher than satisfaction with medications. However, if CBT is to be successful, the patient must have intact verbal memory, flexibility in thought, and the ability to reason hypothetically.
Goals of CBT include guided exploration of beliefs about the illness; identification of cognitive errors; decreasing overreaction to symptoms; and the ability to challenge the authenticity of hallucinations and delusions. Therapeutic dialogue might consist of review of evidence and generation of alternatives. If a delusion persists, the therapist will work within it, developing management strategies such as distraction or relaxation techniques. Homework exercises are assigned to “check out” assumptions and practice skills.
The following is a progression of suitable questions that might help the physician in this case use CBT principles to explore the patient's beliefs about medication. The questions begin with issues that are less controversial or emotionally loaded.
Is the patient capable of doing research on medications to better understand their side effects? If not, why?
Would she be willing to accept help in finding accurate information on her medications?
What is it like for her to have schizophrenia? Is she ashamed of taking these medications?
Is she capable of experimenting with techniques such as diversion, distraction, self-reassurance, or relaxation to manage “thoughts” about her medication? Could she report how well these techniques work? Could she distinguish even slight improvement resulting from use of these techniques? What beliefs might prevent her from trying these techniques?
Is she particularly anxious or nervous about something? If so, is it possible that she has attributed this anxiety to her medication?
Does she believe that the medication has malevolent intent toward her? How could this happen? What types of evidence could disprove this for her?
Several studies have supported the importance of physician-patient relationships on medication compliance in patients with schizophrenia.3,6 This finding may be somewhat surprising, because relational abilities in schizophrenia have been compared to those in autism, and paranoia is diagnosed in 80 percent of cases of schizophrenia. One study found that the single best predictor of medication compliance was the patient's perception of the physician's interest in him or her as a person.3 Another study found that 74 percent of patients with fair or poor therapeutic alliances failed to comply fully with medication regimens.6 Conversely, only 26 percent of patients with a good alliance with their doctor were noncompliant.
Although it seems that a supportive relationship exists between the physician and the patient in this case, the following points should be considered in determining how to build an alliance from which the physician may further encourage treatment.
Genuineness, unconditional positive regard, and empathy are prerequisites for such an alliance. The physician should monitor feelings experienced about the patient. Patients with schizophrenia seem to have an uncanny ability to sense how their physicians really feel about them. Instead of discussing this issue directly, patients instead may have symptoms, including ones similar to those in our case scenario. The physician's positive regard for a patient should not hinge on compliance. This may in fact worsen the patient's symptoms. Instead, the physician should empathize with the patient about the distress and fright that accompany her sensations and about her belief that she is being poisoned.
Antipsychotic Side Effects
Perhaps the physician has overlooked some of the side effects possible with antipsychotic medications. The basic desire to avoid side effects is a frequent cause of noncompliance, and in this case the patient may be misinterpreting merely bothersome side effects as something harmful to her. Side effects are less frequent with newer antipsychotics but differ among the various medications.7
Common side effects of both older and newer antipsychotic drugs include akathisia—an experience of motor restlessness and jitteriness—and anticholinergic effects, such as sedation and delirium. Such side effects could be misconstrued as results of poisoning.
General Compliance Factors
Finally, a number of factors that can affect compliance should be considered. Family and social support are perhaps the most important factors.3 Positive interactions in these spheres, with manageable levels of emotion, predict compliance.
The Health Belief Model (HBM) has been shown to be applicable to medication compliance in patients with schizophrenia and can lead to a better understanding of patient issues.8 According to the HBM, compliance is related to patients' perceptions of susceptibility to their illness, the severity of the illness, the efficacy and costs of treatment, and patients' ability to influence the course of their illness. Accepting that one has schizophrenia and its associated burdens, and understanding the perceived cost-benefit of taking medications, are significantly associated with medication compliance.
In applying the HBM, this physician and patient should determine if they agree on the diagnosis and its severity, and if the delusions and hallucinations constitute a burden from the patient's perspective. The physician should also explore previous medication experiences that may increase the subjective cost of pharmacologic treatment. The patient may have had medications forced on her, suffered a highly tranquilized state, or witnessed a person with tardive dyskinesia. If she has had any of these experiences, she may have significant fears that she is unable to express directly. Other factors to consider include the difficulty of her medication regimen and environmental resistance to improvement.
The following sites may be helpful to physicians attempting to educate patients about this disorder:
1. Black DW, Andreasen NC. Schizophrenia, schizo-phreniform disorder, and delusional disorder. In: Hales RE, Yudofsky SC, eds. The American Psychiatric Press Synopsis of Psychiatry. Washington, D.C.: American Psychiatric Press, 1999:393–437.
2. Geddes J, Freemantle N, Harrison P, Bebbington P, the National Schizophrenia Guideline Development Group. Atypical antipsychotics in the treatment of schizophrenia: systematic overview and meta-regression analysis. BMJ. 2000;321:1371–6.
3. Battaglia J. Compliance with treatment of schizophrenia. American Psychiatric Association: 53rd Institute on Psychiatric Services, day 2, Oct 11, 2001. Retrieved October 24, 2002, from: www.medscape.com/viewarticle/418612 [requires (free) registration before viewing].
4. Gould RA, Mueser KT, Bolton E, Mays V, Goff D. Cognitive therapy for psychosis in schizophrenia: an effect size analysis. Schizophr Res. 2001;48:335–42.
5. Rector NA, Beck AT. Cognitive behavioral therapy for schizophrenia: an empirical review. J Nerv Ment Dis. 2001;1895278–87.
6. Frank AF, Gunderson JG. The role of the therapeutic alliance in the treatment of schizophrenia: relationship to course and outcome. Arch Gen Psychiatry. 1990;47:228–36.
7. Nockowitz RA, Rund DA. Psychotropic medications. In: Doland JJ, et al., eds. Emergency medicine: a comprehensive study guide. New York: McGraw-Hill, 2000:1918–20.
8. Oehl M, Hummer M, Fleischhacker WW. Compliance with antipsychotic treatment. Acta Psychiatr Scand Suppl. 2000;10240783–6.
Please send scenarios to Caroline Wellbery, MD, at firstname.lastname@example.org. Materials are edited to retain confidentiality.
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