http://neuro.psychiatryonline.org/cgi/content/full/17/1/36
J Neuropsychiatry Clin Neurosci 17:36-44, February 2005
© 2005 American Psychiatric Press, Inc.
Clozapine Reduces Violent Behavior in Heterogeneous Diagnostic Groups
John E. Kraus, M.D., Ph.D. and Brian B. Sheitman, M.D.
How the fuck can I argue against a 'treatment' for this sort of behaviour?
I'm strongly against the use of antipsychotics as a chemical cosh or
straight jacket in pill form because it allows them to be used for
pretty much anything and clozapine will contribute to the individual's
mortality. I don't agree that violent behaviour should be treated by
medication but there seems to be no alternative. I really hope there are
psychologists out that that could read the description of Mr.C and have
some compassion for the human being who is lost in life and twisted by
the internal maelstrom. This description shows none of the humanity and
I bet he had a good side. But I'm wrong on so many things.
"
Case 3. Mr. C was a 30-year-old African American male who presented to
the hospital on petition secondary to medication noncompliance and
aggression toward other clients at the group home where he had been
living. Mr. C had been diagnosed with schizoaffective disorder in
adolescence and had multiple prior hospitalizations. He was considered
treatment refractory in that he had persistent delusions and thought
disorganization even with optimal treatment. He had a prior trial of
clozapine but did not have significant improvement in his positive
symptoms of psychosis and was ultimately switched to a potentially less
toxic medication. At the time of the current admission, his
antipsychotic medications were haloperidol decanoate 100 mg
intramuscular every 4 weeks, oral haloperidol 5 mg each evening, and
ziprasidone 80 mg orally twice a day. For mood lability, divalproex
sodium 1500 mg orally each evening had been prescribed. Mental status
examination on admission was notable for paranoia (e.g., the medications
were poison), delusions (e.g., the patient believing he was a
psychiatrist and was married to a billionaire), disorganization of
thought and behavior, and his attending to internal stimuli. He was also
described as "slightly belligerent" and "uncooperative." Early in his
admission, Mr. C required forced medications due to persistent
medication refusals. His ziprasidone was discontinued but haloperidol
and divalproex sodium treatment continued. The oral dose was increased
to haloperidol 5 mg twice a day, and haloperidol decanoate was increased
to 150 mg every 4 weeks. Mr. C required seclusion and restraint on
multiple episodes and had several transfers to a high-management crisis
unit. Six weeks into his hospitalization, haloperidol was increased to
10 mg orally twice a day. Four months into his hospitalization, Mr. C
still required episodes of forced medication secondary to noncompliance
and aggressive behaviors. In the 3 months prior to clozapine treatment,
he had nine episodes of violent behavior and required seclusion and
restraint nine times. These episodes included hitting staff with a chair
and attempting to stab staff with a broken comb. Coinciding with his
violent behavior were increased sexual preoccupation and associated
hypersexual behavior. Mr. C experienced penile soreness secondary to
excessive masturbation. Just prior to clozapine treatment, Mr. C
assaulted a nurse, grabbing her buttocks, pushing his body into hers
"belly to belly," and "grinding" his groin into her. Mr. C was again
transferred to the high-management crisis unit and clozapine was started
the following day, while haloperidol was discontinued. His final dose of
clozapine was 175 mg/day with a serum level of 356. While on clozapine,
he did not have further violent episodes nor did he require seclusion
and restraint. He was able to leave the high-management unit and return
to the general hospital population. Along with improvement in his
violent behavior, his sexual preoccupation diminished greatly, and he
was no longer medication noncompliant. Despite the improvement in these
target behaviors, he remained delusional with moderate to severe thought
disorganization. However, he improved enough behaviorally to be
discharged to a group home in the community.
"
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