We present a 33-year-old Black male with schizoaffective disorder - bipolar type, generalized anxiety disorder, stimulant use disorder (methamphetamine type), phencyclidine use disorder, and cannabis use disorder. The patient's illness at baseline includes residual auditory hallucinations but no suicidal or homicidal ideations. Two months before admission, the patient's outpatient medication regimen consisted of valproic acid 1000 mg daily, buspirone 15 mg three times a day, trazodone 50 mg daily, gabapentin 900 mg daily, quetiapine 300 mg daily, and paliperidone palmitate 156 mg intramuscular injections every 4 weeks. The patient's outpatient team reported that the patient frequently nasally ingested his buspirone and had a history of difficulty with medication adherence.
Prior to admission, the patient had abandoned his domicile and 4 days later was found with alcohol intoxication by police and making suicidal statements. The patient was placed on an involuntary psychiatric hold while receiving a medical evaluation. Admission labs were unremarkable except for urine toxicology positive for amphetamines and tetrahydrocannabinol. He was endorsing bizarre and paranoid delusions, such as believing people surrounding him were aliens and demons. Furthermore, he began refusing hospital food, believing that it was poisoned.
On admission to the inpatient psychiatric unit, the patient developed increasing agitation and was offered oral haloperidol 5 mg, lorazepam 2 mg, and diphenhydramine 50 mg. Still, he refused and then later received them via intramuscular injections after escalating violence. The patient was offered oral risperidone 2 mg daily to target ongoing psychotic symptoms with diphenhydramine 25 mg nightly; however, the patient refused to accept those medications. He later accepted treatment with oral chlorpromazine 150 mg daily and showed some decrease in agitation.
On the 7th day of hospitalization, the patient requested that his home medication regimen be restarted and complained of uncontrolled anxiety. The patient was initiated on valproic acid 1000 mg daily and buspirone 5 mg three times a day. After 48 h of initiating buspirone, the patient exhibited increased bizarre and paranoid delusions, agitation, homicidal ideations, and disorganized thinking. The patient began refusing his oral medications, claiming he was abducted by aliens and had frequent verbal outbursts toward staff. Chlorpromazine dosage was titrated up to 300 mg daily; however, the patient continued to refuse doses frequently, and his antipsychotic medication was switched to quetiapine XR (extended-release) 300 mg. Valproic acid was also discontinued due to the patient's inability to cooperate with laboratory monitoring. Quetiapine XR was titrated up to 800 mg and then discontinued due to a lack of therapeutic response. The patient was then started on oral haloperidol and titrated to a dose of 10 mg twice daily. After 8 days, buspirone was discontinued as the patient was found to be hiding buspirone in his mouth and later admitted to reserving it for nasal ingestion. Two days after the discontinuation of buspirone, the patient was calm, in behavioral control, and cooperative with the treatment team.
The patient was on a regimen of haloperidol 30 mg daily and benztropine 4 mg daily while awaiting discharge to a locked psychiatric rehabilitation center. During that time, the patient's average daily meal intake was 76%, and his medications were switched from haloperidol to a trial of oral Risperdal and, finally, the administration of long-acting injectable paliperidone palmitate 234 mg.
On hospital day 62, the patient insisted on restarting buspirone for anxiety, which was re-initiated. Two days later, the patient's paranoid delusions about his food being poisoned returned, and his oral intake began to decline significantly. The patient only accepted pre-packaged food during that time, which was a behavioral change compared to the previous. After 4 days, the patient exhibited an increase in aggression. Clinical Global Impressions Severity scale (CGI-S) scored 6 (severely ill) at that time. Buspirone was discontinued on hospital day 72. Over the course of 10 days that the patient received buspirone, his oral intake averaged 32% daily, and he required high amounts of behavioral prompting for feeding. It was noted in behavioral notes during that time that the patient had been found to be nasally ingesting buspirone again. One day after buspirone was discontinued, the patient's meal intake increased to 83%, with adequate oral intake for the remainder of psychiatric hospitalization. In addition, the patient's Clinical Global Impressions Improvement scale (CGI-I) scored 2 (much improved). Ultimately, the patient responded well to paliperidone palmitate 234 mg intramuscular every 4 weeks, which was continued throughout the remainder of his hospital course. Buspirone was avoided for the remainder of the hospitalization, and the patient was discharged to a psychiatric rehabilitation center.