Abstract
Prakash S. Gangdev, Tairawhiti Healthcare, Gisbourne, New Zealand:
In a recent article [1], it was pointed out that a number of patients with schizophrenia have coexisting anxiety disorders and that in routine practice these anxiety disorders do not get addressed. Traditionally, serious mental illnesses such as schizophrenia take precedence over other illnesses. The upshot of this is that anxiety disorders and other comorbid conditions are either totally missed or they are considered to be part and parcel of schizophrenia. This has far-reaching implications on both the appropriate management and the outcome.
It is well known that a number of people with schizophrenia do not make full recovery and they are left with either residual symptoms or have ongoing acute symptoms that may not respond to any medications. Thus, by itself schizophrenia does result in deficits.
Similarly, people with anxiety disorders of moderate to marked severity such as social phobia, obsessive-compulsive disorder, panic disorder, post-traumatic stress disorder and so on also experience a lot of distress and impairment and sometimes these also may prove difficult to manage. There is no rule which says that people with antecedent anxiety disorders cannot develop schizophrenia at a later stage. This is also true for people with (residual) attention deficit disorder who may be significantly impaired. It is quite possible that some adults may have (residual) attention deficit and then develop schizophrenia.
Furthermore, given the high life-time prevalence of hypnogogic/hypnopompic hallucinations, it is possible that these may coexist in patients with schizophrenia. If that happens, and the clinician does not routinely enquire about them, there is a risk of hypnic hallucinations confounding the outcome. For instance, it is possible that the nocturnal hallucinations may not respond to neuroleptics and the patient may continue to report ‘hallucinations’, leading the clinician to consider higher dose or atypical neuroleptics.
Thus, in the scenarios described above, it is very easy to focus on schizophrenia and the comorbidities may be totally ignored. Both anxiety and other morbidities, as well as schizophrenias, have an ability to independently cause impairments. Therefore, the possibility exists that in a patient with comorbidity, the schizophrenia may be treated appropriately but the patient continues to have deficits due to the comorbidity. There is a risk here that these deficits may be attributed to schizophrenia and as a result the patient might possibly get a diagnosis of resistant or residual schizophrenia rather inappropriately. The upshot of this is that he may receive increasing doses of neuroleptic medication and also be placed on atypical antipsychotics, and also not receive appropriate treatment for comorbidities. Thus, it is very important that all patients with serious mental illnesses be also assessed routinely for antecedent comorbidity such as anxiety disorders, dissociative disorders and attention deficit disorder, as well as for hypnic hallucinations. Research is, thus, needed in ascertaining as to what proportion of people with resistant or residual schizophrenia have pseudo-resistance due to the comorbidities. Research is also needed to measure outcomes in individuals who receive appropriate treatment for comorbidities and schizophrenia as well.