Hypersensitivity Psychosis and Lack of Compliance in the Penitentiary Environment

In French prisons, outpatient psychiatric care can only be delivered with the patient’s consent.¹ This report describes the difficulties encountered in daily practice regarding therapeutic compliance in an incarcerated patient with schizophrenia.

Case Report

A 32-year-old man imprisoned for several years is followed for heboidophrenia or pseudo-psychopathic schizophrenia. The psychiatric history reveals several hospitalizations without consent for acute psychotic decompensation due to the patient stopping   psychotropic treatment without informing his psychiatrist, as well as a suicide attempt by hanging at the start of his incarceration. The addiction history reveals active tobacco dependence syndrome, cannabis dependence syndrome currently weaned, and misuse of psychotropic treatments weaned for several years. The only reported somatic history is arterial hypertension. Since the beginning of his psychiatric care in prison, we have observed progressive difficulties in obtaining remission of psychotic symptoms, which resulted in numerous changes in antipsychotic treatments (risperidone, olanzapine, and clozapine in particular). Indeed, due to a lack of insight, the patient fails to comply with the drug treatment a few days after leaving the hospital, which results in the reappearance of an essentially positive psychotic symptomatology, including associating attitudes of listening, soliloquies, agitation, experience of hostility that can lead to hetero-aggressive acting out, and delusional ideas of persecution associated with ideo-behavioral disorganization. This psychotic symptomatology appears a few days after stopping drug treatment. To date, the patient is receiving haloperidol 25 mg/d. The other treatments prescribed are mirtazapine 30 mg/d, lorazepam 10 mg/d, and levomepromazine 150 mg/d. A negative syndrome associating social withdrawal, blunting of affect, and psychomotor slowing remains. The treatment is well tolerated neurologically and metabolically. According to our clinical assessment, the patient presents the diagnostic criteria for hypersensitivity psychosis as proposed by Chouinard et al in 2017.²

Discussion

Conceptualized in 1978, hypersensitivity psychosis corresponds to the emergence of a psychotic disorder appearing in patients who have taken D₂ antagonists over a prolonged period in the months following the cessation of treatment.^2–4 As a result, some studies² have shown a prevalence of hypersensitivity psychosis of 30% in schizophrenia patients and more than 70% in those with resistant schizophrenia. Consequently, hypersensitivity psychosis often requires an increase in the dosage of antipsychotics. Furthermore, in 50% of patients with schizophrenia, we find a lack of insight, which can create difficulties in adhering to treatment, expose them to therapeutic ruptures, and therefore generate the appearance of hypersensitivity psychosis.^5,6 In France, although the organization of psychiatric care for detainees tends to follow that which is offered in the community, it is illegal to compel a patient to receive outpatient treatment.^1,7 This specificity therefore raises the question of what strategies can be  implemented in the management of incarcerated patients presenting with a schizophrenia disorder, a lack of compliance with outpatient treatment, and hypersensitivity psychosis. As the use of long-acting antipsychotic by injection to ensure compliance is in the present case not accepted by the patient, one of the answers could be to offer care in partial hospitalization within the Services Médico-Psychologiques Régionaux (SMPR), which provides drug delivery several times a day as well as the implementation of therapeutic activities to maintain or promote the conditions for psychosocial rehabilitation. However, admission to the SMPR remains conditional on the patient’s consent. A second option would be to support these patients in requests for adjustment or suspension of their sentence for psychiatric reasons to allow them to receive psychiatric care in the community.

Article Information

Published Online: June 29, 2023.
© 2023 Physicians Postgraduate Press, Inc.
Prim Care Companion CNS Disord 2023;25(3):22cr03381
To Cite: Da Costa J, Gervais E, Audouin L, et al. Hypersensitivity psychosis and lack of compliance in the penitentiary environment. Prim Care Companion CNS Disord. 2023;25(3):22cr03381.
Author Affiliations: Unité Hospitalière Spécialement Aménagée, Pôle de Psychiatrie et Conduites Addictives en Milieu Pénitentiaire, Centre Hospitalier Gérard Marchant, Toulouse, France (Da Costa, Gervais, Audouin, Billot); Centre Ressources pour les Intervenants auprès des Auteurs de Violences Sexuelles Midi-Pyrénées, Pôle de Psychiatrie et Conduites Addictives en Milieu Pénitentiaire, Centre Hospitalier Gérard Marchant, Toulouse, France (Da Costa); Espace de Psychiatrie Légale, Pôle de Psychiatrie et Conduites Addictives en Milieu Pénitentiaire, Centre Hospitalier Gérard Marchant, Toulouse, France (Da Costa); and Centre de Ressources Régionale en Santé Mentale, Centre Hospitalier Gérard Marchant, Toulouse, France (Billot).
Corresponding Author: Julien Da Costa, MD, Pôle de Psychiatrie et Conduites Addictives en Milieu Pénitentiaire, Centre Hospitalier Gérard Marchant, 134, route d’Espagne–BP 65714. 31057 Toulouse Cedex 1, France (julien.da-costa@ch-marchant.fr).
Relevant Financial Relationships: None.
Funding/Support: None.
Patient Consent: Consent was received from the patient to publish the case report, and information has been de-identified to protect anonymity.