Case presentation:
a 22-year-old male patient, was referred to our Early Intervention in Psychosis (EIP) team by his General Practitioner (GP) doctor. He progressively developed persistent feelings of sadness, a tendency to isolation, a decay in self-care, loss of appetite, significant weight-loss, and suicidal ideation.
Medical history:
- He experienced the presence of distressing auditory-verbal hallucinations, mainly in the form of second person voices making depreciative comments and commanding him.
- Furthermore, he presented non-systematized persecutory delusions involving friends and colleagues and self-referential delusions of erotomaniac content about a famous rap singer, who allegedly sent him messages about their relationship through the lyrics of his songs.
- He also mentioned that a photo was published in a social network in which apparently both he and the famous rap singer appeared together, although he then admitted they had never been close to each other in any situation.
- Along with these psychotic symptoms, he developed symptoms of avolition with reduced interest in spending time with family or friends or performing pleasurable activities, leading to progressive social withdrawal.
Family history:
- Unidentified
Clinical Exam
- general biochemistry, hemogram, coagulation, vitamin B12, folic acid, TSH, T4, autoimmunity panel), cranial CT, and EEG reports were normal.
- a psychometric evaluation using the Positive and Negative Symptom Scale (PANSS) and the Global Clinical Impression–Severity (CGI-S) scale for symptom and clinical assessment and the Personal and Social Performance scale (PSP) for functional assessment was performed.
- The PANSS total score was 94 (Positive subscale =24; Negative subscale =26 general Psychopathology subscale =44), CGI-S global severity score was 5 (Markedly ill), and the PSP score was 45.
Preliminary treatment:
- Risperidone was prescribed by the general practitioner, which presented a good clinical response with a reduction of psychotic symptoms but developed significant side effects of somnolence, bradykinesia, superior limb pill-rolling tremor, and hypotension.
- It also led to worsening psychotic symptoms.
Treatment:
- Cariprazine was prescribed in a rapid titration scheme up to 4.5 mg/day.
- A follow-up evaluation was performed after 6 weeks. There were no psychotic symptoms.
- When screened for possible treatment side effects he denied having any.
- He also exhibited improvement in his mood and emotions and reported having started to spend more time with family members and friends, doing physical exercise, and undertaking driving lessons for getting a license as a long-haul driver.
Clinical evaluation:
- There was a reduction in PANSS total score to 50 (Positive subscale =10; Negative subscale =14; General Psychopathology subscale =25), a CGI-S score of 3 (Mildly ill), and a PSP score of 81