This report describes the use of acupuncture as an add on treatment for a patient with chronic schizophrenia. The 63-year-old woman suffered from persistent hallucinations and even physical pain as a result of the hallucination of a black bird that kept pecking her back. The patient received 12 weekly acupuncture treatments. A clinical diagnostic interview and psychological testing (on sleep quality, depression, and on positive and negative symptoms) were conducted before, immediately after and 3 months after the acupuncture treatment. The results of the diagnostic interview gave important insights into the treatment effects. The patient experienced improved daily functioning and noticed a change in hallucinations. Although the hallucinations still occurred, she felt less disturbed by them. Interestingly, pain decreased markedly. In addition, the results showed that the overall score of the positive and negative symptoms did not change immediately; however, a decrease in symptoms occurred 3 months after acupuncture treatment. Moreover, the patient described an immediate improvement in sleep; this was confirmed by a daytime sleepiness questionnaire. The patient was not able to complete a (longer) test on sleep quality beforehand but did so after the treatment period. Finally, a delayed improvement in the depression scale was found. Although larger clinical intervention studies on acupuncture and schizophrenia are needed, the results of this case study indicate that acupuncture may be beneficial as an add on treatment tool in patients with schizophrenia.
Trial registration number 3132.
- Complementary Medicine
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Acupuncture is increasingly used in Western medicine as an add on treatment for various psychiatric diseases,1 particularly in the treatment of patients with depression.2 However, the use of acupuncture in patients with schizophrenia is rare.3 We report a case from a large German psychiatric clinic. We were interested in examining if acupuncture was helpful as an add on treatment in a patient with schizophrenia, and assessed which psychological tests were suitable to capture the effects of the acupuncture treatment.
In November 2003, our patient (aged 56 years) experienced compulsory admission to a psychiatric clinic for the first time. This was necessary to prevent danger to the patient and others due to severe delusions. The psychotic symptoms were disrupted only after she was compulsorily injected with a high dose of neuroleptics. After she left the psychiatric clinic she received regular treatment as an outpatient for several years, and her situation was continually characterised by significantly decreased performance, exhaustion, increased psychophysical vulnerability, reduced concentration and reduced attention. She showed increasing periods of extreme tiredness, and mentioned pain in the back, legs, shoulders and ribs in particular. She described the pain as resulting mainly from one of her hallucinations: a black bird that kept pecking at her back, which caused the pain. Moreover, she spoke of the bird that continually sat next to her and kept swearing and calling her names.
As a result of her continued suffering, the patient decided to participate in an acupuncture project. The study was approved by the ethics committee of the Ärztekammer Nordrhein. The patient drank approximately 2 L of coffee a day (sometimes more) and smoked heavily.
The patient was on medication during the whole of the study period. She used melperone 75 mg at night, risperidone 3 mg daily dose (1 mg in the morning, afternoon and evening) and risperidone 37.5 mg every 14 days.
To measure the severity of her schizophrenic symptoms, the Positive and Negative Symptom Scale (PANSS)4 was used (including the cognitive component).5 The results showed that the patient was suffering from serious positive and negative symptoms and from general psychopathology at the start of the study. The Epworth Sleepiness Scale,6 which measures subjective experience of daytime sleepiness, revealed that she was very sleepy during the day. Before treatment, she was not able to complete the Pittsburgh Sleep Quality Index (PSQI)7 that measures sleep quality and possible disturbances in sleep patterns during the previous month. She was too disturbed by her increasing hallucinations and asked whether it was possible to skip the test. Finally, the severity of depressive symptoms was measured using Becks Depression Inventory II.8 The patient's score was 27, showing that she was suffering from moderate depression at the beginning of the study.
Treatment and outcome
The patient was given individualised acupuncture treatment once a week for 12 weeks, and points were punctured bilaterally. The needles used were 0.25×25 mm or 0.20×15 mm stainless steel (depending on the place of needling) single use needles (AcuPro C, Wujiang City Cloud and Dragon Medical Device Co Ltd, China) and were placed according to Traditional Chinese Medicine principles.1 De qi was obtained, and the needles were not stimulated after that, but left in place for 1 h.
Acupuncture diagnosis and point selection
Due to the thin, (mostly) pale, flaccid, (mostly) moist tongue with many cracks and hardly any coating, and the weak and sometimes rapid pulse, a Qi and Blood deficiency was diagnosed. From time to time, local stagnation of Qi and Blood presented as a purple colour of the tongue and lips (and an increase in pain related to hallucinations) together with some heat symptoms (noticeable foremost in the pulse in the spleen/stomach position and then in the stronger pulse). Although she mostly presented with symptoms of depletion, there were also symptoms of excess (phlegm misting the mind or even at some point fire harassing the mind). In addition, years of heavy medication (continuing during treatment), and coffee and cigarette consumption were taken into consideration, as also reported by others.9 A careful individual diagnosis (at each treatment) was conducted by a licensed oriental medical practitioner with more than 5 years of clinical experience.1
Figure 1 provides an overview of the acupuncture points used (and the frequency). Treatment was based on the following primary points: LI4, LI11, ST8, ST36, SP6, SP9, BL67, KI3, LR3, GV20 and EX-HN1 (Sishencong) (detailed justification for point selection can be obtained from the author).
The diagnostic interview gave important insights into the treatment effects of a patient suffering from schizophrenia and persistent hallucinations. She experienced better daily functioning and noticed a change in hallucinations. Although the black bird was still sitting next to her, he did not speak for the first 3 days after treatment and he did not pick her back. Her pain and suffering therefore decreased markedly during those 3 days and she was able to sleep. At the end of the 3 days, the bird started to swear again and took up his usual pecking, causing the same pain as before. This occurred in the same way, 12 weeks in a row.
Table 1 shows the results of the psychological testing. The overall score for positive and negative symptoms did not change directly after the acupuncture treatment, indicating that her psychiatrist (not involved in the project) did not notice large differences. However, 3 months after the acupuncture treatment a large effect was noted (70 vs 56), and this was the case for all three subscales of the PANSS. The most striking result was found on the PANSS negative subscale (from 16 to 10), implying that the number of negative symptoms had decreased. The PANSS positive (from 20 to 16) and PANSS psychopathology (from 34 to 30) showed similar results, implying that the number of positive symptoms decreased and the amount of psychopathology was also decreased.
Moreover, the score on the Epworth Sleepiness Scale showed less sleepiness after acupuncture; however, 3 months after the acupuncture treatment, this beneficial effect was back to the level before the acupuncture treatment. The results of the PSQI showed that our patient was not able to complete the questionnaire before treatment. She responded with increased hallucinations and could not continue filling it in. After treatment, she experienced no problems with the list and we found a total score of 8, indicating poor sleep quality (6 is increasingly seen as the cut-off score for good sleep quality).10 Three months after acupuncture treatment, however, sleep quality had decreased. The total score on the PSQI increased to 12, which can be characterised as very poor sleep quality, and the patient described this as the same as before treatment.
No differences were found on the depression scale, indicating that her depressed mood did not improve after acupuncture treatment; however, a small improvement was noticeable at follow-up.
The results of this case study indicate that acupuncture may be beneficial as an add on treatment tool for patients with schizophrenia, as a number of positive and negative symptoms decreased 3 months after acupuncture treatment and it appeared to have an effect on sleep and daytime sleepiness. The results of this case study seem to support the idea that one of the underlying treatment mechanisms of acupuncture in schizophrenia is an indirect one—namely, through improving sleep (which is what the patient described). From a Western point of view, it seems logical that when patients sleep better, their concentration improves and they feel better. Interestingly, previous neuroimaging research revealed that the ’limbic–paralimbic–neocortical network’, consisting of the amygdala, hypothalamus and default mode network, is involved in response to acupuncture. These areas are known for their role in the regulation of sleep and wakefulness; moreover, it was found that acupuncture had a modulating and normalising effect on these areas.11
However, larger studies on acupuncture and schizophrenia are needed12 in order to test the effectiveness of acupuncture in schizophrenia and to unravel the possible underlying mechanisms. To date, a systematic review13 on 13 studies showed only limited evidence for the effectiveness of acupuncture in treating the symptoms of schizophrenia. In future studies, care should be given to the type of psychological tests used to measure effects within this group. Due to hallucinations, long tests are unsuitable. Moreover, in the study design, the short term and long term effects of acupuncture should be considered. Our patient would likely have given different answers on, for example, a pain scale, during the first 3 days immediately following the acupuncture treatment compared with after those 3 days. Moreover, although the patient described having fewer problems, due to the fact that her bird sat silently, it was still there, probably causing less difference on the PANSS as she was still hallucinating.
This case report suggests that acupuncture may be a suitable add on treatment in patients with chronic schizophrenia, visible in the lower number of positive and negative symptoms, improved daytime sleepiness and improvement in mood. Acupuncture may also change the hallucinations themselves; the hallucinations still occurred, but the pain and distress caused by the hallucinations decreased markedly.
We thank the patient for her willingness to participate and for her cooperation during the whole study. Moreover, we thank the director of the LVR-Klinik Bedburg-Hau, Dr Marie Brill, who made this research possible. We also thank the trainees that tested the patient. Finally, we thank Professor Anton Coenen and Professor Gilles van Luijtelaar for their helpful comments.
Contributors PB created the study background and designed the study, together with MvdN. PB and HS took care of the therapeutic regimen. MvdN drafted the article. SL revised the article.
Competing interests None.
Ethics approval Ethics approval was obtained from the ethics committee of the Ärztekammer Nordrhein, number 2008331.
Provenance and peer review Not commissioned; not externally peer reviewed.
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