The

n e w e ng l a n d j o u r na l

of

m e dic i n e

Case Records of the Massachusetts General Hospital

Founded by RichardC. Cabot
EricS. Rosenberg, M.D., Editor
JoAnneO. Shepard, M.D., Associate Editor
SallyH. Ebeling, Assistant Editor

NancyLee Harris, M.D., Editor

AliceM. Cort, M.D., Associate Editor
EmilyK. McDonald, Assistant Editor

Case 40-2015: A 40-Year-Old Homeless

Woman with Headache, Hypertension,
and Psychosis
DerriL. Shtasel, M.D., M.P.H., Oliver Freudenreich, M.D.,
and TravisP. Baggett, M.D., M.P.H.

Pr e sen tat ion of C a se

Dr. Alex S. Keuroghlian (Psychiatry): A 40-year-old woman with a history of psychosis
was admitted to this hospital from a homeless shelter because of headache and
hypertension.
One week before admission, the patient had accepted placement in a homeless
shelter, after spending the previous 4 years sleeping in a public building. During
that time, she had repeatedly declined assistance from outreach workers in finding
shelter; she maintained that it was her mission from God to stay outside and watch
over people. On evaluation at the shelter, she was disheveled and had disorganized
speech and thought content that was focused on spiritual themes. She attributed
her impairments to a traumatic brain injury that she had incurred in a motor vehicle accident more than 12 years earlier. She did not think she had a psychiatric
illness and refused psychiatric medications but agreed to see an on-site primary
care internist at the shelter. A limited physical examination revealed extensive
tinea pedis and venous stasis dermatitis of the legs.
On the morning of admission, the patient reported a severe headache that had
begun the night before. She permitted a nurse to measure her vital signs; the
blood pressure was 180/110 mm Hg. Emergency medical services were called; on
evaluation, the systolic blood pressure measured 212 mm Hg. She was brought by
ambulance to the emergency department of this hospital.
The patient reported feeling off and intermittently said she had a frontal
headache; she did not report visual symptoms, chest or abdominal pain, nausea,
or vomiting. She had a history of hypertension and a psychotic illness of more than
12 years duration that was characterized by somatic, paranoid, grandiose delusions, a disorganized thought process, and poor self-care. Five years before this
admission, she was admitted to a psychiatric hospital; as an inpatient, she had
brief symptomatic improvement while she was receiving olanzapine. After discharge, she did not pursue follow-up psychiatric care or continue to take olanzapine. She had taken hydrochlorothiazide 4 years before this admission but cur-

From the Departments of Psychiatry

(D.L.S., O.F.) and Medicine (T.P.B.), Mas
sachusetts General Hospital, and the De
partments of Psychiatry (D.L.S., O.F.)
and Medicine (T.P.B.), Harvard Medical
School both in Boston.
N Engl J Med 2015;373:2563-70.
DOI: 10.1056/NEJMcpc1405204
Copyright 2015 Massachusetts Medical Society.

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

2563

n e w e ng l a n d j o u r na l

The

Table 1. Laboratory Data.*

Reference Range,
Adults

On Admission

Hematocrit (%)

36.046.0 (women)

30.4

Hemoglobin (g/dl)

12.016.0 (women)

9.0

150,000400,000

414,000

80100

67

Mean corpuscular hemoglobin

(pg/red cell)

26.034.0

19.9

Mean corpuscular hemoglobin

concentration (g/dl)

31.037.0

29.6

Red-cell distribution width (%)

11.514.5

18.2

4,000,000
5,200,000

4,500,000

Variable

Platelet count (per

mm3)

Mean corpuscular volume (m3)

Erythrocyte count (per mm

3)

Smear description

2+ anisocytosis,
3+ hypochromasia,
3+ microcytosis

Reticulocytes (%)

0.52.5

1.7

Ferritin (ng/ml)

10200

Iron (g/dl)

30160

23

Iron-binding capacity (g/dl)

230404

327

* To convert the values for iron and iron-binding capacity to micromoles per li
ter, multiply by 0.1791.
Reference values are affected by many variables, including the patient popula
tion and the laboratory methods used. The ranges used at Massachusetts
General Hospital are for adults who are not pregnant and do not have medi
cal conditions that could affect the results. They may therefore not be appro
priate for all patients.

rently took no medications; she reported an allergy

to nifedipine, which had caused palpitations.
She was born in a Caribbean country and had
immigrated to the northeastern United States
many years earlier. She smoked intermittently and
did not use illicit drugs but reported being injected in the thigh with an unknown substance
in the past. The family history was unknown.
On examination, the patient was obese, malodorous, disheveled, and wearing multiple layers of clothing. The blood pressure was 208/118
mm Hg; a repeat measurement was 240/130
mm Hg. The pulse was 95 beats per minute, the
temperature 36.4C, the respiratory rate 16 breaths
per minute, and the oxygen saturation 99% while
she was breathing ambient air. She had a systolic ejection murmur (grade 1/6) at the right
upper sternal border, without rub or gallop.
Both legs had 2+ pitting edema to the knees,
with changes related to chronic stasis and thickening of the skin. The patients attitude was
pleasant and cooperative; eye contact was good,
2564

of

m e dic i n e

with no abnormal movements. Her speech had a

low volume and a fast rate. She described her
mood as fine, and she appeared to be euthymic, with a blunted affect. Her thought process
was disorganized, and the content included hyperreligious and grandiose delusions. She reported
auditory hallucinations involving the voices of God
and Satan, as well as visions that she believed
were messages from God. She reported no suicidal or homicidal ideation; her insight and judgment were poor. The remainder of the general
examination was normal.
The white-cell and differential counts, results
of renal-function and coagulation tests, and urinalysis were normal, as were blood levels of
electrolytes, calcium, phosphorus, magnesium,
glucose, troponin T, N-terminal proB-type natriuretic peptide, vitamin B12, and folate. Tests
for troponin I and urinary human chorionic
gonadotropin were negative. Other test results
are shown in Table1. An electrocardiogram, a
chest radiograph, and a computed tomographic
(CT) scan of the head (obtained without the administration of contrast material) were all normal. Intravenous labetalol and oral captopril
were administered; the blood pressure decreased
to 187/111 mm Hg. The patient was admitted to
this hospital.
Additional doses of labetalol and captopril
were administered, as were acetaminophen,
dalteparin, ferrous sulfate, omeprazole, folic
acid, thiamine, and a multivitamin. The blood
pressure decreased to 141/65 mm Hg in the left
arm and 141/62 mm Hg in the right arm, and
the headache gradually resolved. Screening of
the urine for toxins was negative. The patient
declined an influenza vaccination. She was discharged to the shelter on the third hospital day,
with a plan to receive blood-pressure monitoring
on site. Medications on discharge were lisinopril, thiamine, a multivitamin, folate, omeprazole, and ferrous sulfate. The patient was advised to follow up in the medical walk-in clinic
in 1 week.
Management decisions were made.

Differ en t i a l Di agnosis
Dr. Oliver Freudenreich: All the discussants are
aware of the diagnosis in this case. This 40-yearold homeless woman with untreated psychosis
presented to the emergency department with

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

Case Records of the Massachuset ts Gener al Hospital

severe hypertension. In this patient with both

psychiatric and medical illnesses, it is critical to
create a list of the most likely diagnoses to prioritize workup and treatment. In the absence of
an organized longitudinal history, a certain degree of diagnostic uncertainty must be tolerated.

Table 2. Differential Diagnosis of Psychosis.

Secondary psychosis
Delirium
Dementia
Medical illness (including neurologic diseases)
Substance use

Psychosis

In constructing a differential diagnosis for possible causes of psychosis in this patient, it is

helpful to distinguish between primary and
secondary psychosis (Table2). Primary psychoses are the result of psychiatric illness, whereas
secondary psychoses are the result of medical or
surgical illness or substance use.

Alcohol and sedatives

Illicit drugs (e.g., hallucinogens, cannabinoids, stim
ulants, phencyclidine, synthetic designer drugs)
Medications (e.g., glucocorticoids)
Primary psychosis
Schizophrenia spectrum disorders
Schizophrenia
Schizoaffective disorder

Secondary Psychosis

The four main categories of secondary psychosis

to consider are delirium, dementia, medical conditions (including neurologic diseases), and substance use (including use of alcohol or illicit
drugs or medication-induced toxidromes). The
initial goal is to identify potential causes of the
patients mental state without making a premature diagnosis. To keep this task manageable,
the selection of laboratory tests should be tailored to the clinical situation and should be focused on ruling out life-threatening causes of
psychosis (e.g., delirium) and identifying treatable causes (e.g., hyperthyroidism or vitamin B12
deficiency). It is important to select tests judiciously, because false positive and false negative
results become more likely if too many tests or
the wrong tests are ordered.1 Although many
tests are not needed in an emergency situation,
all tests should be considered when acute care is
being provided, especially if subsequent outpatient follow-up is unlikely.
The following studies are indicated in all
patients: measurement of vital signs, a physical
examination, a test of the blood glucose level, a
complete blood count, a differential count, and
a comprehensive metabolic panel that includes
testing for electrolytes (plus calcium) and liver
and kidney function. Lumbar puncture, imaging
studies of the head, and electroencephalography
should be performed on the basis of clinical
concerns for encephalitis, structural brain abnormalities, or seizures, respectively. Screening
should be considered for treatable conditions,
such as thyroid disease (thyrotropin test), immune and inflammatory diseases (measurement

Schizotypal personality disorder

Delusional disorder
Acute and transient psychotic disorders
Psychotic mood disorders (e.g., bipolar disorder, recur
rent depression)
Psychosis-like experiences
Borderline personality disorder
Post-traumatic stress disorder
Autism spectrum disorder
Attenuated psychosis syndrome (e.g., schizophrenia
prodrome)
Obsessivecompulsive disorder
Body dysmorphic disorder
Paranoid personality disorder
Malingering

of the erythrocyte sedimentation rate and test

for antinuclear antibodies), vitamin B12 deficiency (tests for vitamin B12 and folate), and infections, including human immunodeficiency
virus (HIV) and neurosyphilis.
Delirium, which is accompanied by psychosis
in about 50% of cases,2 is unlikely in this case,
because the patients psychiatric symptoms were
neither acute nor characterized by a waxing and
waning course. The onset of her illness and her
history argue against a neurodegenerative disorder, but her previous traumatic brain injury is
relevant because it could suggest that her presentation includes apathy. Severe hypertension
can cause mental-status changes with psychosis,
but I would expect encephalopathy with confusion and other end-organ involvement to be

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

2565

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

present. Another concern associated with hypertension is stroke, which can result in psychosis,3
but the normal CT scan of the head and the
nonfocal neurologic examination in this case
make this diagnosis unlikely. The urine drug
screening was negative, but this test does not
measure all psychoactive substances of abuse.
Vitamin B12 deficiency was ruled out, but a thyrotropin test is still needed, and tests for neurosyphilis and HIV should be strongly considered,
since all these conditions are treatable and associated with psychosis. However, unless the
result of one of these tests is abnormal, secondary causes of psychosis appear to be unlikely.

lead us to revise the diagnosis of schizophrenia

if it turns out that the patient had a more episodic course of illness, with psychosis only during periods of mood disturbance, or a medical
condition that better explains her symptoms.
The patient should be treated with antipsychotic and antihypertensive medications. To better
understand her cognitive impairments, I would
recommend neurocognitive testing and magnetic resonance imaging (MRI) of the head to
look for evidence of previous strokes or encephalomalacia due to traumatic brain injury. Given
her probable cognitive impairment associated
with schizophrenia, complex verbal instructions
should be avoided. This patient should ideally be
Primary Psychosis
followed longitudinally by one outpatient proWhen considering a diagnosis of psychosis due vider who is trusted by the patient and could
to psychiatric illness, the main distinction to assist in obtaining these studies and in monitormake is between schizophrenia spectrum disor- ing her response to treatment.
ders and psychotic mood disorders. The absence
of clinically significant mood symptoms argues
Dr . Ol i v er Fr eudenr eichs
against a diagnosis of psychotic mood disorders.
Di agnosis
In contrast, this patient has the characteristic
symptoms of schizophrenia. Her positive symp- Schizophrenia, probable cognitive impairment
toms include delusions, auditory hallucinations, associated with schizophrenia, hypertension, and
and a disorganized thought process. She has a homelessness.
blunted affect, which is a core negative symptom; other negative symptoms include impaired
Discussion of M a nagemen t
social relationships and decreased motivation.
The chronic course of her illness is typical of Dr. Travis P. Baggett: I first met this patient 1 week
schizophrenia, and she appears to have poor before her admission to this hospital. After
social functioning.
sleeping in a public place and declining social
The patients lack of insight into the nature of services for several years, the patient agreed to
her illness is common in schizophrenia and of- accompany an outreach worker on a tour of a
ten points toward higher-order cognitive prob- shelter where I conduct a weekly primary care
lems. Indeed, functionally relevant cognitive clinic as a physician for the Boston Health Care
impairment develops in 85% of persons with for the Homeless Program (BHCHP). I was asked
schizophrenia4 and particularly affects working to see her because of swollen legs.
memory, verbal memory, and executive funcMy primary goal during the first encounter
tion.5 This condition, which is known as cogni- was to earn her trust and not to turn her visit
tive impairment associated with schizophrenia, to the shelter into a formal medical encounter.
is persistent and does not respond to treatment I did not measure her vital signs or perform a
with antipsychotic medications.6
comprehensive physical examination. Instead, I
Although schizophrenia is a diagnosis of ex- soaked her feet and trimmed her toenails. This
clusion, the diagnosis is nevertheless based on is a nonthreatening way to introduce physical
observable clinical features and history. On the contact for patients with serious mental illness
basis of the information available at the time of who may be reluctant to accept care. It also meets
this patients presentation, the probable diagnosis a tangible need while providing a window into a
is schizophrenia that is most likely associated persons mental health and social circumstances.
with cognitive impairment and is perhaps exac- This patient had elongated toenails that wrapped
erbated by her previous traumatic brain injury. underneath her toes, suggesting a chronic course
Collateral information and further testing might of psychiatric illness with limited insight. Her
2566

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

Case Records of the Massachuset ts Gener al Hospital

feet were macerated and foul-smelling and had

extensive changes consistent with tinea infection, indicating that she had infrequent opportunities to remove her shoes and socks. The leg
swelling with venous stasis dermatitis that was
seen in this relatively young woman is common
among persons who sleep upright on chairs or
public benches for prolonged periods.
The patient accepted placement at the shelter
a few days later, and she was admitted to this
hospital shortly thereafter because of a hypertensive episode. After discharge, she was unable
to obtain her prescribed medications because she
lacked a green card and other identifying documents and was ineligible for coverage under the
Massachusetts Medicaid program. A shelter-based
multidisciplinary team collaborated to address the
patients health and social service needs, including obtaining identification and a green card.
Although the patient lacked insight about her
mental illness and declined psychiatric care, she
was willing to engage in primary medical care.
During the subsequent 2 years, the patient
made more than 60 visits to my shelter-based
primary care clinic. Her concerns usually focused on physical symptoms that predominantly
affected the left side of her body; these included
headaches and chest, abdominal, and arm pain,
as well as light-headedness, nausea, and fatigue.
Her descriptions of these ailments were often
disorganized and interspersed with delusional
thought content and perceptual disturbances.
She attributed many of her symptoms to having
struck the left aspect of her forehead in a car
accident 12 years earlier. A CT scan of the head
that had been obtained at another hospital on
the day of the accident showed a soft-tissue hematoma, without skull fractures or acute intracranial sequelae, and a repeat CT scan that was
obtained at this hospital was normal.
In the outpatient setting, I controlled the patients blood pressure with lisinopril and hydrochlorothiazide; she obtained the treatments with
subsidies from BHCHP and the Massachusetts
Department of Mental Health. MRI of the head,
which was performed because of persistent headaches, was normal. After a neurologic consultation, therapy with topiramate was started for
migraine headaches. She declined neuropsychological testing. HIV testing was negative. The
thyrotropin level was normal. Her iron level and
hematocrit normalized after iron supplementa-

tion for menorrhagia. Serologic testing for celiac

disease was negative. She eventually underwent
Papanicolaou testing, which was negative. She
accepted the indicated vaccinations.
I devoted most of our encounters to simply
listening to her talk in an effort to build rapport
and understand her narrative. Although she had
profound symptoms of psychosis, she generally
did not view these as problematic. She disputed
the diagnosis of schizophrenia by showing me a
passage from a spirituality book she was reading
that contained this quote from Lily Tomlin:
Why is it that when we speak to God we are
said to be praying but when God speaks to us we
are said to be schizophrenic?
At the 19th office visit, the patient first mentioned bothersome cognitive symptoms, including poor memory and difficulty with reading,
performing arithmetic, thinking, and concentrating. I introduced the idea of medications to
target these symptoms, but she declined. During
the ensuing 6 months, I gently reiterated the possibility of a medication trial through frequent
low-pressure office visits during which we also
discussed her medical issues. At the 33rd visit,
the patient agreed to start low-dose olanzapine,
which I offered to her with the input of collaborating psychiatrists at BHCHP and this hospital
who were familiar with her case. I increased the
dose slowly over a period of several months,
with incremental improvement in her positive
symptoms of hallucinations and delusions. She
gradually accepted care from an outreach psychiatrist who had known her for years. Together,
the psychiatrist and I gradually switched the
treatment from olanzapine to lurasidone, because the patient had weight gain and sedation
while she was taking olanzapine. The patient is
now in a group home, and I continue to follow
her for routine primary care.
Homelessness and Schizophrenia

Dr. Derri L. Shtasel: Why had this patient been

homeless? She had many of the developmental
complications of schizophrenia. Usually diagnosed in late adolescence or early adulthood,
schizophrenia impedes educational, vocational,
and interpersonal development. The core symptoms hallucinations, delusions, paranoia, diminished curiosity and motivation, and impaired executive functioning create challenges
in meeting the demands of adult life. As a result,

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

2567

The

n e w e ng l a n d j o u r na l

of

m e dic i n e

many adults with schizophrenia are underemTable 3. Professionals Involved in the Virtual Health
ployed or unemployed, socially disaffiliated, and
Home.
disconnected from family, as this patient had
Boston Health Care for the Homeless Program
been; many are homeless.
Primary care physician
After 4 years on the street, being in a shelter
Nurses
was a remarkable step for this patient. Sixty
years ago, a patient such as this one would probNursing students
ably have been cared for in an institution. Since
Case managers
that time, a shift away from long-stay state hosMassachusetts General Hospital Psychiatry Department
pitals in favor of community-based systems of
Attending psychiatrists
care means that we often encounter such pa7
Chief residents
tients in an outpatient setting. With this shift,
Postgraduate year 2 residents
the threshold for admission to acute psychiatric
hospitals is now related to level of danger rather
Psychologists
than severity of illness, and the focus of hospiMassachusetts Department of Mental Health
talization is often on crisis stabilization. Despite
Transitional shelter staff
improvement during an inpatient psychiatric
Outreach team for homeless persons
hospitalization 5 years earlier, this patients illSocial workers
ness relapsed when she declined both outpatient
Nurses
care and medication continuation. We do not
Case managers
know why she stopped taking antipsychotic medication, but this commonly occurs. Early hopes
Psychiatrists
that pharmacotherapy for the treatment of schizoCommunity
phrenia would be curative have not been realized.
Community-based rehabilitation teams
Instead, these medicines modify only some symptoms, do not necessarily improve functioning,
and often cause side effects. Discontinuation enabled the development of a network of on-site
rates are high.
mental health care, primary care, and recoveryoriented services targeting the multifaceted needs
of this and similar patients. Integrated models, in
Assertive Community Treatment
Although community-based treatment for pa- which multiple health and wellness services are
tients with serious mental illness is clearly desir- focused on behavioral health care delivery, have
able, most outpatient mental health services are received increasing attention in the movement
designed for people who can navigate complex toward creating specialty medical homes for
systems, have reliable sources of support and patients such as this one.9
transportation, and keep appointments. Such
services often do not work for patients such as Housing and Recovery
this one. This patient needed treatment and ser- Available evidence also suggests that permanent
vices to be brought to her. Assertive community supported housing should be a core component
treatment8 by a nonoffice-based multidisci- of this patients care. In particular, Housing
plinary outreach team is an established ap- First appears to be a promising strategy for
proach for doing just that. Although assertive promoting long-term housing tenure in people
community treatment was not initially available with serious mental illness.10 In contrast to linto this patient, several components of this ap- ear housing paradigms, which require a person
proach were deployed in her care. In the 60-bed to have sequential engagement in services and to
shelter of the Massachusetts Department of demonstrate clinical stability before moving into
Mental Health where this patient was staying, a independent housing, the Housing First11 model
novel collaboration among social workers, nurs- allows a person to move directly into indepenes, psychiatrists, internists, and rehabilitation dent housing, with clinical and social services
and peer specialists representing government, available as adjuncts. Although this patient deacademic, and community sectors (Table3) had clined antipsychotic medication and formal psy-

2568

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

Case Records of the Massachuset ts Gener al Hospital

chiatric care, she was permitted to stay for

nearly 2 years in a unique transitional shelter
that had many of the characteristics of a Housing First approach.
Finally, an emphasis on recovery should be
central to the care of this patient. In 2003, the
New Freedom Commission on Mental Health
defined recovery as a process of change through
which individuals improve their health and wellness, live a self-directed life, and strive to reach
their full potential.12 The goal of recovery is to
help persons to move away from the stigma,
powerlessness, and hopelessness that accompany serious mental illness and to move toward
rebuilding purpose, reclaiming hope, and reconnecting with family, friends, and community. In
a manner consistent with a recovery framework,
this patient (and not her providers) set the priorities and goals (Table4).13
Why did this patient get better? After the
patients hospital admission for a hypertensive
episode, members of numerous agencies (Table3)
collaborated to address her medical, psychiatric,
social, and personal needs by bringing services
directly to her in a transitional shelter. We tolerated medical and psychiatric uncertainty, striking a balance between our sense of urgency and
the patients pacing and hierarchy of needs. Her
primary care provider prioritized their relationship, used numerous visits to promote trust, and
maximized the patients input in treatment decisions. He collaborated closely with psychiatrists
regarding her mental health care. Ironically, the
slowness of reestablishing the patients legal
status and obtaining entitlements created a luxury of time: she had no documentation, no income, and no means to get permanent housing,
so there was nowhere for her to go. This afforded the time to create a virtual health home
that linked housing, medical, psychiatric, and
social services with community outreach and
rehabilitative teams. The patient is now living in
a community-based group home. She has reconnected with her mother and her children, and
she has been off the street for more than 2 years.
Dr. Nancy Lee Harris (Pathology): Is this patient
representative of those who live at this shelter?
Is her recovery unusual, or do most patients get
better and live independently?
Dr. Shtasel: With appropriate treatment and
support, the majority of previously homeless

Table 4. Guiding Principles of Recovery.*

Recovery emerges from hope: The belief that recovery is real provides the
essential and motivating message of a better future that persons can
and do overcome the internal and external challenges, barriers, and ob
stacles that confront them.
Recovery is person-driven: Self-determination and self-direction are the foun
dations for recovery as persons define their own life goals and unique
paths.
Recovery occurs on many pathways: Persons are unique, with distinct needs,
strengths, preferences, goals, cultures, backgrounds, and experiences
that affect and determine their pathways to recovery. Abstinence is the
safest approach for those with substance use disorders.
Recovery is holistic: Recovery encompasses a persons whole life, including
mind, body, spirit, and community. The array of services and supports
available should be integrated and coordinated.
Recovery is supported by peers and allies: Mutual-support and mutual-aid
groups that allow for the sharing of experiential knowledge and skills and
for social learning play an invaluable role in recovery.
Recovery is supported through relationships and social networks: An impor
tant factor in the recovery process is the presence and involvement of
people who believe in the persons ability to recover; who offer hope, sup
port, and encouragement; and who also suggest strategies and resources
for change.
Recovery is based on and influenced by culture: Culture and cultural back
ground in all of its diverse representations including values, traditions,
and beliefs are keys to determining a persons journey and unique
pathway to recovery.
Recovery is supported by addressing trauma: Services and supports should
be informed about any trauma in order to foster safety (physical and
emotional) and trust, as well as promote choice, empowerment, and
collaboration.
Recovery involves individual, family, and community strength and responsi
bility: Individual persons, families, and communities have strengths and
resources that serve as a foundation for recovery.
Recovery is based on respect: Community, systemic, and societal acceptance
and appreciation for people affected by mental health and substance use
problems which includes protecting their rights and eliminating dis
crimination are crucial in achieving recovery.
* Data are from Sheedy and Whitter.13

people with schizophrenia can live stably in the

community, as this patient is now doing.

Fina l Di agnosis
Schizophrenia, cognitive impairment associated
with schizophrenia, hypertension, and homelessness.
This case was presented at Psychiatry Grand Rounds.
Disclosure forms provided by the authors are available with
the full text of this article at NEJM.org.
We thank Drs. Jonathan Alpert, Maurizio Fava, Gregory Fricchione, John Herman, Jerrold Rosenbaum, Theodore Stern, and
Louisa Sylvia (Department of Psychiatry) for assistance with organizing the conference; and the Massachusetts Department of
Mental Health for its commitment to persons with serious mental illness.

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.

2569

Case Records of the Massachuset ts Gener al Hospital

References
1. Freudenreich O, Schulz SC, Goff DC.
Initial medical work-up of first-episode
psychosis: a conceptual review. Early Interv Psychiatry 2009;3:10-8.
2. Meagher DJ, Moran M, Raju B, et al.
Phenomenology of delirium: assessment
of 100 adult cases using standardised measures. Br J Psychiatry 2007;190:135-41.
3. Hackett ML, Khler S, OBrien JT,
Mead GE. Neuropsychiatric outcomes of
stroke. Lancet Neurol 2014;13:525-34.
4. Kahn RS, Keefe RS. Schizophrenia is
a cognitive illness: time for a change in
focus. JAMA Psychiatry 2013;70:1107-12.
5. Heinrichs RW, Zakzanis KK. Neurocognitive deficit in schizophrenia: a
quantitative review of the evidence. Neuropsychology 1998;12:426-45.

6. Keefe RS, Bilder RM, Davis SM, et al.

Neurocognitive effects of antipsychotic

medications in patients with chronic
schizophrenia in the CATIE Trial. Arch
Gen Psychiatry 2007;64:633-47.
7. Torrey EF. Out of the shadows: confronting Americas mental illness crisis.
New York:John Wiley, 1997.
8. Dixon L. Assertive community treatment: twenty-five years of gold. Psychiatr
Serv 2000;51:759-65.
9. Alakeson V, Frank RG, Katz RE. Specialty care medical homes for people with
severe, persistent mental disorders.
Health Aff (Millwood) 2010;29:867-73.
10. Goering P, Veldhuizen S, Watson A, et
al. National At Home/Chez Soi Final Report. Calgary, AB:Mental Health Com-

mission of Canada, 2014 (http://www

.mentalhealthcommission.ca).
11. Tsemberis S, Eisenberg RF. Pathways
to housing: supported housing for streetdwelling homeless individuals with psychiatric disabilities. Psychiatr Serv 2000;
51:487-93.
12. Substance Abuse and Mental Health
Services Administration. Recovery and
recovery support. 2014 (http://www
.samhsa.gov/recovery).
13. Sheedy CK, Whitter M. Guiding principles and elements of recovery-oriented
systems of care:what do we know from
the research? HHS publication no. (SMA)
09-4439. Rockville, MD:Center for Substance Abuse Treatment, 2009.
Copyright 2015 Massachusetts Medical Society.

Lantern Slides Updated: Complete PowerPoint Slide Sets from the Clinicopathological Conferences
Any reader of the Journal who uses the Case Records of the Massachusetts General Hospital as a teaching exercise or reference
material is now eligible to receive a complete set of PowerPoint slides, including digital images, with identifying legends,
shown at the live Clinicopathological Conference (CPC) that is the basis of the Case Record. This slide set contains all of the
images from the CPC, not only those published in the Journal. Radiographic, neurologic, and cardiac studies, gross specimens,
and photomicrographs, as well as unpublished text slides, tables, and diagrams, are included. Every year 40 sets are produced,
averaging 50-60 slides per set. Each set is supplied on a compact disc and is mailed to coincide with the publication of the
Case Record.
The cost of an annual subscription is $600, or individual sets may be purchased for $50 each. Application forms for the current
subscription year, which began in January, may be obtained from the Lantern Slides Service, Department of Pathology,
Massachusetts General Hospital, Boston, MA 02114 (telephone 617-726-2974) or e-mail Pathphotoslides@partners.org.

2570

n engl j med 373;26nejm.org December 24, 2015

The New England Journal of Medicine

Downloaded from nejm.org at UAB LISTER HILL LIBRARY on December 25, 2015. For personal use only. No other uses without permission.
Copyright 2015 Massachusetts Medical Society. All rights reserved.