Objective: A 21-year-old man who presented with a 17-month history of unremitting anxiety associated with panic attacks

was studied.

Result: The anxiety with panic attacks did not abate with escitalopram 15 mg nocte and alprazolam 0.5 mg tds. At month 3,

the patient reported low mood and unexplained sexual arousal in addition to the unremitting anxiety symptoms. His condition

fairly improved with addition of quetiapine. At month 17, transition to psychotic disorder occurred when the patient experienced

hallucinations for the first time. Quetiapine was increased to 500 mg nocte and the anxiety symptoms improved tremendously

before he relapsed 6 months later due to poor compliance.

Conclusion: Unremitting anxiety with depression can be a dominant feature during the schizophrenia prodrome. Atypical

antipsychotic quetiapine is an interesting treatment option due to its status as approved adjunctive treatment for major depressive

disorder and promising efficacy for generalized anxiety disorder

Husain, Maruzairi

Jaapar, Sharifah Zubaidiah Syed

Othman, Zahiruddin

Yasin, Mohd Azhar Mohd

Objective: A 21-year-old man who presented with a 17-month history of unremitting anxiety associated with panic attacks 
was studied. Result: The anxiety with panic attacks did not abate with escitalopram 15 mg nocte and alprazolam 0.5 mg tds. At month 3, the patient reported low mood and unexplained sexual arousal in addition to the unremitting anxiety symptoms. His condition fairly improved with addition of quetiapine. At month 17, transition to psychotic disorder occurred when the patient experienced hallucinations for the first time. Quetiapine was increased to 500 mg nocte and the anxiety symptoms improved tremen-
dously before he relapsed 6 months later due to poor compliance. Conclusion: Unremitting anxiety with depression can be a dominant feature during the schizophrenia prodrome. Atypical antipsychotic quetiapine is an interesting treatment option due to its status as approved adjunctive treatment for major depressive disorder and promising efficacy for generalized anxiety disorder

Sharifah Zubaidiah Syed Jaapar

Maruzairi Husain

Mohd Azhar Mohd Yasin

NEUROSURGERY ENTHUSIASTIC WOMEN SOCIETY

Use of Queatiapine in Treatment of Unremitting Anxiety: A Case Report of Schizophrenia Prodrome

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International Medical Journal Vol. 23, No. 6, pp.  624 -  625 ,  December  2016PSYCHOLOGICAL  MEDICINEUse of Queatiapine in Treatment of Unremitting Anxiety: A Case Report of Schizophrenia ProdromeZahiruddin Othman,  Sharifah Zubaidiah Syed Jaapar, Maruzairi Husain,   Mohd Azhar Mohd YasinABSTRACTObjective: A 21-year-old man who presented with a 17-month history of unremitting anxiety associated with panic attacks was studied.Result: The anxiety with panic attacks did not abate with escitalopram 15 mg nocte and alprazolam 0.5 mg tds. At month 3, the patient reported low mood and unexplained sexual arousal in addition to the unremitting anxiety symptoms. His condition fairly improved with addition of quetiapine. At month 17, transition to psychotic disorder occurred when the patient experi-enced hallucinations for the first time. Quetiapine was increased to 500 mg nocte and the anxiety symptoms improved tremen-dously before he relapsed 6 months later due to poor compliance.Conclusion: Unremitting anxiety with depression can be a dominant feature during the schizophrenia prodrome. Atypical antipsychotic quetiapine is an interesting treatment option due to its status as approved adjunctive treatment for major depres-sive disorder and promising efficacy for generalized anxiety disorder.KEY  WORDSdepression, prodrome, pseudoneurotic, early intervention, quetiapineReceived on July 1, 2014 and accepted on December 10, 2015Department of Psychiatry, School of Medical Sciences, Universiti Sains MalaysiaKubang Kerian, 16150 Kelantan, MalaysiaCorrespondence to: Zahiruddin Othman(e-mail: zahirkb@usm.my)624INTRODUCTIONSchizophrenia is chronic debilitating mental disorder that involves tremendous direct and indirect costs to the patients, their families and society. Interest in identification of prodromal phase of schizophrenia is increasing as the focus now shifts to the prevention of mental illnesses. Recent findings in patients with an emerging psychotic disorder suggest that schizophrenia may present with significant neurotic symptoms. Meta-analysis of 1683 high-risk subjects showed that baseline preva-lence of comorbid depressive and anxiety disorders is respectively 41% and 15%1). In a local study, 55% of the subjects with sub-threshold attenuated psychotic symptoms (APS) had associated depression and/or anxiety2). Here, we report a case of schizophrenia presenting with prom-inent unremitting anxiety symptoms.CASE The patient was a 21-year-old student living with his mother and elder sister. He was referred to the psychiatry clinic via the family phy-sician, having presented with unremitting anxiety associated with panic attacks. The first episode was 2 month before which was described as sudden onset of burning epigastric pain which was treated as gastritis. Another episode occurred while he was talking with his friend during Friday prayer. The panic attack which lasted about half an hour was characterized by a discreet episode of sudden onset of palpitation, short-ness of breath, chest tightness, numbness of extremities, burning epigas-tric pain and sense of impending blackout. He was also worried that he might be having a brain tumor or other neurological conditions. He searched for information regarding his symptoms and possible diagno-ses from the internet and would discuss about it with the doctors. Both his father and brother were under psychiatric treatment with a diagnosis of schizophrenia and obsessive-compulsive disorder, respectively. The patient was diagnosed as panic disorder. He was treated with escitalo-pram and alprazolam which were titrated up to 15 mg nocte and 0.5 mg tds respectively. After 3 months of treatment, he continued to have frequent and severe panic attacks at 1 to 3 episodes per day for almost every day resulting in very frequent visits to the emergency department. The patient slept around the hospital compound to ease him getting the med-ical attention whenever panic attack occurred. In addition, he stated that he was likely to become sexually aroused during sleep at home which he attributed to jin. He postponed his study incapacitated by the severe anxiety and low mood. Differential diagnosis of major depressive disor-der was considered at this stage. In view that the patient was also at high risk for schizophrenia, quetiapine XR 50 mg nocte was started to aug-ment the escitalopram3,4). His condition improved resulting in less fre-quent visits to the emergency department. The compliance to treatment, however, was not very good.Seventeen months after the initial presentation, he described hearing voices of people talking about him and reciting verses from the Quran at night for the first time. The quetiapine XR was increased to 100 mg nocte. Two weeks later, the voices became more prominent and com-manded him to kill himself leading to two week admission in psychiat-ric ward. Quetiapine XR was increased up to 500 mg nocte. His diagno-sis was revised to schizophrenia. After 2 months, he experienced mini-mal anxiety, depressive and psychotic symptoms. He went to work in Kuala Lumpur for about 6 months. However, the symptoms recurred after his default of treatment for which quetiapine XR 500 mg was restarted and his condition had improved since then.   C   2016 Japan Health Sciences University             & Japan International Cultural Exchange FoundationOthman Z. et al. 625DISCUSSIONThe recognition that high risk subjects for schizophrenia are charac-terized by high prevalence of anxiety and depressive disorders in addi-tion to their attenuated psychotic symptoms1) is not new. The term and concept, pseudoneurotic schizophrenia, was proposed by Hoch and Polatin in 1949 to delineate a poorly defined subgroup of schizophrenia patients who presented with prominent anxiety symptoms, which masked the underlying basic mechanisms of schizophrenia5,6). The diag-nostic term, however, is not part of current classification systems and thus has fallen out of clinical use. Pseudoneurotic schizophrenia is characterized by presence of pri-mary clinical symptoms which was thought to reflect the basic symp-toms of schizophrenia which operate even before the onset of psychotic symptoms. Significantly, this patient had low mood and unusual sexual arousal suggesting an altered sensorimotor-autonomic integration in psychosexual functioning5). Clinical presentations are often dominated by the secondary clinical symptoms, many of which can be recognized as developments of various primary symptoms, or combinations of such symptoms. The term pan-anxiety is used to designate diffuse anxiety, the presence of which is marked by special intensity, duration and per-vasiveness. The intensity may vary from vague disquietude to panic, but the subjective experience of anxiety is almost constantly present and is frequently dominating6). This patient showed, in contrast to the usual neurotic patients, an all-pervading anxiety in which everything that the patient experienced influenced this anxiety. Pan-anxiety was always manifested no matter how he tried to break through the conflict or to avoid it.The anxiety symptoms in this patient did not remit with adequate dose of selective serotonin reuptake inhibitor and benzodiazepine. Quetiapine XR was added but at a low dose 50 mg nocte. It was chosen for its low risk of extrapyramidal side effect. A recent study suggests quetiapine has acute anxiolytic effects for patients with specific pho-bia3). In another study, quetiapine XR (50-300 mg/day) monotherapy is effective in the short term in improving symptoms of anxiety in older patients with GAD, with symptom improvement seen as early as week 14). Currently, it is an approved adjunctive treatment for patients with major depressive disorder7). The dose of quetiapine remained at low dose 50 mg nocte for more than a year before the emergence of psycho-sis.Most clinicians still hesitate to prescribe antipsychotic treatment due to ethical consideration such as false-positive identification of pro-dromal phase. Additionally, antipsychotics are often associated with adverse effects that are undesirable for young people, such as pro-nounced weight gain8) making this option less attractive compared to other available psychological and pharmacological intervention9) even though randomized controlled studies have demonstrated the effective-ness of antipsychotics such as risperidone10,11), olanzapine12) and ami-sulpiride13) in reducing the conversion rate to schizophrenia. In an open-label study, aripiprazole shows a promising efficacy and safety profile for the psychosis prodrom14). CONCLUSIONAnxiety symptoms can be very prominent and may not respond ade-quately to the standard antidepressant and anxiolytic treatment during the prodromal phase of schizophrenia. Quetiapine is an interesting treat-ment option for patients at high risk for schizophrenia with prominent anxiety and/or depressive symptoms for the following reason: 1) it is atypical antipsychotics with low risk of extrapyramidal side effects; 2) it is already approved as adjunctive treatment for major depressive disor-der; 3) it shows promising efficacy for generalized anxiety disorder.REFERENCES 1) Fusar-Poli, P, Nelson B, Valmaggia L, Yung AR, McGuire PK. Comorbid depressive and anxiety disorders in 509 individuals with an at-risk mental state: Impact on psy-chopathology and transition to psychosis. Schizophr Bull 2014; 40(1): 120-131. 2) Razali SM, Abidin ZZ, Othman Z, Yassin MAM. Screening of genetic risk among rela-tives and the general public: Exploring the spectrum of the psychosis prodrome. International Med J 2013; 20(6); 747-51. 3) Diemer J, Domschke K, M lberger A, Winter B, Zavorotnyy M, Notzon S, Silling K, Arolt V, Zwanzger P. Acute anxiolytic effects of quetiapine during virtual reality expo-sure. A double-blind placebo-controlled trial in patients with specific phobia. Eur Neuropsychopharmacol 2013; 23(11): 1551-60.  4) Mezhebovsky I, Mägi K, She F, Datto C, Eriksson H. Double-blind, randomized study of extended release quetiapine fumarate (quetiapine XR) monotherapy in older patients with generalized anxiety disorder. Int J Geriatr Psychiatry 2013; 28(6): 615-25. 5) Hoch PH, Cattell JP. The Diagnosis of Pseudoneurotic Schizophrenia. Psychiatr Q 1959; 33(1): 17-43. 6) Hoch PH, Polatin P. Pseudoneurotic forms of schizophrenia. Psychiatr Q 1949; 23: 248-276. 7) Weisler R, McIntyre RS, Bauer M. Extended-release quetiapine fumarate in the treat-ment of patients with major depressive disorder: adjunct therapy. Expert Rev Neurother 2013; 13(11): 1183-200. 8) Findling RL, Mckenna K, Earley WR, Stankowski J, Pathak S. Efficacy and safety of quetiapine in adolescents with schizophrenia investigated in a 6-week, double-blind, placebo-controlled trial. J Child Adolesc Psychopharmacol 2012; 22(5): 327-42.  9) Klosterkötter J, Schultze-Lutter F, Bechdolf A, Ruhrmann S. Prediction and prevention of schizophrenia: What has been achieved and where to go next? World Psychiatry 2011; 10(3): 165-174. 10) McGorry PD, Yung AR, Phillips LJ et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sam-ple with subthreshold symptoms. Arch Gen Psychiatry 2002; 59: 921-8. 11) Phillips LJ, McGorry PD, Yuen HP, et al. Medium-term follow-up of a randomized con-trolled trial of interventions for young people at ultra high risk of psychosis. Schizophr Res 2007; 96: 25-33.  12) McGlashan TH, Zipursky RB, Perkins D, et al. The PRIME North America randomized double-blind clinical trial of olanzapine versus placebo in patients at risk of being pro-dromally symptomatic for psychosis. I. Study rationale and design. Schizophr Res 2003; 61: 7-18.  13) Ruhrmann S, Schultze-Lutter F, Maier W, et al. Pharmacological intervention in the ini-tial prodromal phase of psychosis. Eur Psychiatry 2005; 20: 1-6.  14) Woods SW, Tully EM, Walsh BC, et al. Aripiprazole in the treatment of the psychosis prodrome. An open-label pilot study. Br J Psychiatry 2007; 191(Suppl 51): 96-101.

Use of Queatiapine in Treatment of Unremitting Anxiety: A

Case Report of Schizophrenia Prodrome

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Use of Queatiapine in Treatment of Unremitting Anxiety: A Case Report of Schizophrenia Prodrome

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