Help diagnose 60 year old mother with schizophrenia-like symptoms

Family
1

What could be the diagnosis and best treatment course for the following person?

60 year old mother. Never had any psychotic symptoms before.

At the end of last year she had one psychotic episode with paranoid delusions (including being watched sensation), visual hallucinations, false memories and thought withdrawal. The same day started 10 mg Zyprexa (olanzapine). Within two weeks symptoms began to improve. Much sleeping and sedation while on it. One month later abruptly stopped Zyprexa. Then another month later relapsed with paranoid delusions and the same being watched sensation. Started on 5 mg this time for two months with improvement, but later developed insomnia. Now on 10 mg since that time for three months now, with no paranoid delusions and other schizophrenia-like symptoms, but with insomnia with depression-like worrying thoughts being the greatest complaint now. She accepts she has an illness.

Got an MRI with bright signals in T2 weight image and FLAIR at bilateral frontal, right parietal and occipital cerebral.
Glucose, cholesterol, and blood pressure normal.
No memory problems.

Has seen two psychiatrists. One says MRI result must be responsible for psychosis. Other denies this. One other neurologist also denies this.

My questions:

  1. If schizophrenia at this age (60 years) is not common, what other diagnosis could be possible?
  2. Depression-like symptoms in schizophrenia are common? The fact is that she was not having any depression symptoms before her psychotic episode.
  3. Does the result of MRI has anything to do with her psychotic symptoms?
  4. Why Zyprexa was causing sedation and too much sleeping at first, and now there is insomnia even when taking the same dose? Does it have to do with stopping Zyprexa in the middle?
  5. Is six months of taking antipsychotics enough to see if they are affective?
  6. How about olanzapine/flouxetine combination? Will that help?
  7. Is coming off (gradually, of course) of Zyprexa at this time a good idea? Could Zyprexa be causing insomnia and depression-like symptoms?
  8. What could be the best medication for her condition?

I’m sorry if I sound like as though I’m in psychiatrist office, but I’m sure I’ll get more help from the wonderful people at this forum than any doctor’s office. I don’t want my mother to go on taking anti-psychotics for life when she didn’t need them. Please ask any additional questions to clarify any point.

2

a) Alzheimers, right off the bat, even despite the lack of memory loss. (Alz hits really suddenly, and doesn’t always come with memory loss at the outset.)

b) Other organically caused early onset dementias. I’d look into those at MayoClinic or NIMH online to see if she presents other confirming or disconfirming symptoms.

c) Any number of environmentally induced (eg as from new meds for some physical malady, OTC cold remedies for sure, alcoholism or pill addiction, a bad diet, bug spray or dirty a/c ducts) psychoses.

d) And finally… delayed onset, complex PTSD stemming from collections of events that may have occurred decades ago but were re-triggered by something that began to happen recently. We’re seeing a lot of this now in among the boomers, especially those who used psychedelics years ago and/or were severely abused in childhood.

They can be, but I’m sort of pushing my chips out on a non-sz psychosis here, as you can see.

Possibly. And moreover, if the MRI is not picking up attendent brights in the medial pFC (though the over-general notation on the “bilateral frontal” may include that area) owing to attempts to “manage” the “heat” elsewhere. If they didn’t pick up a lot of glucose metabolizing in the limbic system with her behavior, I’m a little surprised (unless she was sedated for the session). Truthfully, static MRIs are never as useful as active-reactive fMRIs for this stuff, anyway.

Pretty likely (I’ll say 75%) because she’s not “organically” psychotic, and the med is therefor not a useful intervention.

It’s always a possibility. This stuff is complex as h##l.

Yup. Probably 98% of the time.

Maybe, but if the psychosis is not induced in the manner that sz or bipolar is induced, probably not. Oh… has she been scanned for tumors or stroke infarctions? (Duh. Wake up, here, notmoses.) Because this is starting to sound like that. Does she have any previous oncologic history? I’d look into this for sure if her neurologist hasn’t already ruled it out.

I don’t have enough data here to make a good rec, but I’d probably look at a switchover to another sedating anti-P like Seroquel quetiapine to see if it works. In no small part because there’s a genetic rift about Seroquel and Zyprexa. One often works when the other makes a mess of things.

Might not be a med at all, but if so, there are numerous alternatives in the dopamine-blocking anti-P group like Seroquel, Abilify, Latuda, Invega, Geodon, etc.

I just have to say that at least statistically, and on the sole basis of what you reported, this is probably not sz but some other form of psychotic expression related to organic or environmental (including late life epigenetic, though that’s a real stretch) factors.

BUT… I’m only offering opinions on the basis of what I read in your post.

3

I can only help with a bit of this from my family’s experiences.

To help with some of your questions:

  1. I can’t answer this, other than to say, my father’s sz has worsened since he had a stroke, and his psychiatrist has seen some cognitive breakdown which could indicate dementia. As sz and dementia symptoms can mirror each other quite closely, it can be hard to tell the two apart. Like I said, I can only speak from personal experience, not actual knowledge. In elderly persons, old-age illnesses can often make diagnosis much more difficult for the treating dr.

  2. Yes, depression like symptoms are common in certain subtypes of sz. My father actually deviates from one extreme (depression) to elation and over-activity quite regularly, as one might with bi-polar. This has always been the case. He smoked as well, so that habit did also create some of his insomnia, however he has been off that 6 years and is still a light sleeper.

  3. Zyprexa (the brand name for olanzapine) is what my father has been on for 30+ years. Yes, it can cause sedation. The insomnia may not be controlled by that drug but I am not sure that it would directly cause it either. My father is in an assisted living home and they report that he walks the halls most of the night, sleeping 3-4 hours on average. The offset is, he gets “flat” and sleeps a lot during the day. I am sure body clock and what people are used to also plays a part. My father was never a good night time sleeper, but it has worsened with age.

  4. It’s difficult to tell as it varies so much from person to person. I would imagine you would start to see some results before then however. I know with anti-depressants, it can take several weeks to feel the effects but those are different to anti-psychotics. My dad was on them long before I was born so someone else may have more info on that.

  5. Fluoxetine is a common SSRI anti-depressant. It may help treat the depression if the Zyprexa is treating the psychosis. It’s not uncommon for Drs to prescribe two classes of medications like this. My dad takes Zyprexa in conjunction with Epilim (sodium valproate, a mood stabilizer) and does well on that combination. But like I said, even though he has been on these for many years, the onset of stroke and dementia has exacerbated his sz symptoms regardless.

Only a dr can really tell you the best combination. It is very difficult because it takes a lot of trial and error to find what works best for each person. It can wear down a person and decrease their motivation to try new meds, leading to non-compliance. I’d persevere a little longer if you can. From my experience, not being on medications is more harmful than good.

Best of luck.

4

Or temporal lobe epilepsy

5

She hasn’t said anything about seizures, but, yeah, ya gotta throw it into the mix of possibilities.

6

Thank you everyone of your responses.

It seems more visits to psychiatrists and neurologists are needed to arrive at a definite diagnosis. But with chronic diseases like these it does not hurt to experiment a bit.

Although Alzheimer’s is possible but it seems to me less likely because she hadn’t any of its early hallmark symptoms so why would be the first symptom be psychosis which affects just 30% to 40% of those with Alzheimer’s? Anyway, more investigation is needed in this area (along with dementia) because continuing taking antipsychotics while having Alzheimer’s is dangerous.

And no, no tumors or seizures. Yes, a neurologist mentioned infarcts based on the MRI and probably caused by silent strokes (she hadn’t any stroke symptoms), but he didn’t think it likely to be causing psychotic symptoms. He prescribed Aspirin.

Anyway, for now the biggest problem is not psychotic symptoms (as they are well under control on Zyprexa) but it is the depression and insomnia, so I’m thinking of taking the next step by doing any one of the following:

  1. Increase the dosage of Zyprexa (currently taking 10 mg). Maybe abruptly stopping it in the middle had caused depression and insomnia and so it might help to increase it to 15 or 20 mg for some time and then slowly returning to 10 mg or even less (older people are more sensitive to anti-psychotics and their psychosis is even less severe so 5 mg would be enough).

  2. Keep taking Zyprexa 10 mg but along with fluoxetine 20 mg. I hope the latter can be easily discontinued later without the depression relapsing. Also, here I can experiment with decreasing the dose of Zyprexia while taking fluoxetine.

  3. Switching from Zyprexa to something better for depression and insomnia like Abilify (though how would I go about it? Is coming off of Zyprexa slowly and completely necessary before starting a different anti-psychotic?)

I’d appreciate any input as regards the best course of action.

7

Is there any danger in decreasing the dosage for someone who has taken antipsychotics for merely months? If there is no harm in this, then why it is said that the sooner antipsychotics are started on seeing first symptoms of schizophrenia or related mental disorder, the better the outcome? Does the disease progress in someone who is not on any antipsychotic?

I’m asking this for my mother who has taken it for 3 months continuously now, but before that she had suddenly stopped taking it after taking it for one month, and while it was working great and causing sedation and sleepiness in that one month, now after stopping it suddenly she has developed insomnia and depression and even having taken the dosage for 3 months continuously.

I am thinking of getting her off of it gradually this time, but will it make any difference or not I don’t know, and I keep fearing that she might progress even more into the disease than she is currently now.

8

I think the research suggests that there is higher risk of relapse when you lower the medication dose. Stopping it suddenly is definitely a very bad idea and does cause problems.

But there is also research that suggests that the longer term outcomes are better if you can keep the dose as low as possible, so as to minimize side effects. Work closely with the doctor on this and keep the monitoring very frequent if you do it.

Part of the issue also is that the more relapses a person has the worse the long term outcomes are - the psychosis actually damages the brain (perhaps through very high stress hormones that take place when a person is psychotic).

Here are some references:

and on suddenly stopping medications:

RESULTS:

A growing number of studies demonstrate high rates of relapse when medications are discontinued in patients suffering from mood disorders, schizophrenia, and anxiety disorders. Abrupt cessation of psychotropics is especially dangerous, leading to a greater chance of destabilization. Discontinuation syndromes, with prominent physical symptoms, may also result from sudden psychotropic cessation. Conversely, continuing home psychotropic medication may cause adverse effects due to drug-drug interactions or changing pharmacokinetics.

source:

Also - you have to be careful with depression treatments / medications when a person has psychosis / schizophrenia - it can have very negative effects. Therapy has lower risks, but ideally both therapy and medications would be used for depression. Again - talk with the doctor.

Some relevant, recent discussions on this topic:

and:

and

and

and

9

Yes antipsychotics for older people can be dangerous.

Schiz usually shows up when you’re young.
To diagnose it at 60 is very unusual. Get a second opinion or two from different psychiatrists.

10

By the way - you should talk to your doctor about the addition of estrogen to your mother’s treatment program. There is a lot of evidence that it can help. Here are some recent studies:

and

and

and

http://forum.schizophrenia.com/t/a-placebo-controlled-study-of-raloxifene-added-to-risperidone-in-men-with-chronic-schizophrenia/25884

11
12

Can you run her personality stuff down to me as she was before the onset of the current symptoms? You might get some clues, btw, from looking at Teddy Millon’s website at http://www.millon.net/taxonomy/index.htm. I think @firemonkey may be onto something here, but I’m not sure because I don’t have a handle on her progression.

13

I had looked up Paraphrenia before as well - basically it is just schizophrenia for older people but with less severity. If she has this then shouldn’t 10 mg of olanzapine everyday be working especially considering the fact that old people are more sensitive to antipsychotics?

Also, the first time when she stopped taking the med, 2 or 3 days later she had near-psychotic episode (not full-fledged) like thinking someone stole something, but then she was okay the next three weeks, and THEN she started complaining of insomnia and depression and having that “being watched” feeling. Now, does this mean she can’t remain without taking the med, or could it be the abrupt withdrawal symptoms from the med? It is for this reason I want to gradually wean her off the med so as to see if the psychotic symptoms return or not.

As for her personality before the current symptoms, the only noticeable thing was she was more suspicious of some particular person (a relative) living in the same house. 2 or 3 weeks before the first episode she started having paranoid delusions that someone was harming her and family.

By the way, did I say she had depression 20 years ago? Not sure if related to her current symptoms.

If schizophrenia is causing depression and if she is already taking 10 mg of olanzapine then what should be done to alleviate the distressing symptoms and insomnia? Increase the dosage? Add an SSRI? Stop taking antipsychotic? And what to do with the MRI result? Is it relevant to her symptoms? I am at my wits’ end as to what to do now.

14

Tell me where you live, and I’ll see what I can come up with vis getting to the best people in the field in that area.

15

Thank you, but I’m not from the U.S. I’ve started giving her 20 mg flouxetine to see if it works. I wonder how many weeks will pass before any improvement is seen. In the meantime, I’ll visit a few more psychiatrists and neurologists for second opinions.

16

If you’re in the UK, Ozland or Canada, you can find specialist locators through the psychiatric associations in those countries. Not so sure about other countries.

17

You might find this new research of interest:

Reducing antipsychotic dosage feasible, effective among patients with late-life schizophrenia

Results from an open-label, single-arm prospective study indicate that reducing dosage of antipsychotics is feasible among patients with late-life schizophrenia and can improve extrapyramidal symptoms, hyperprolactinemia and other symptoms related to increases in dopamine D2/3 receptor occupancies.

“Schizophrenia is a life-long illness that typically requires maintenance antipsychotic treatment throughout an individual’s life… Clinical guidelines developed by expert consensus recommend the use of lower doses of antipsychotics in older patients with schizophrenia. However, empirical data on age-specific antipsychotic dosing are limited,” study researcher Ariel Graff-Guerrero, MD, PhD, of the Centre for Addiction and Mental Health in Toronto, and colleagues wrote.

Read the full story here:

18

8 weeks is typical time to try out a new anti psychotic. If it doesn’t work in 8 weeks, try a different one. Omly cloza[pine is the exception to the rule in the sense that clozapine requires a 6 month trial.