Approximately 50% of patients diagnosed with Delusional Disorder-Persecutory type show an insufficient response to antipsychotic therapy. This was the case in a 43-year old male patient, single, high education level, current symptom severity 2 (delusions and negative symptoms). The onset of the disorder was at the age of 27, followed with chronic course, on permanent antipsychotic therapy with inadequate clinical response, side effects and poor psychosocial functioning.

As previous treatments with various antipsychotics (flufenazine, haloperidole, risperidone and clozapine) gave inadequate clinical response and produced side effects, we decided to switch to a weight neutral agent, which does not appear to cause metabolic syndrome.

To switch to ziprasidone to enhance clinical response and improve tolerability.

The switching strategy was a gradual cross-titration and tapering of clozapine (300mg/d) over a 6-week period. Ziprasidone was started at 80 mg/d and was then raised to the maximum dose of 160 mg/d, as the patient developed EPS and activation. The patient’s mental state and metabolic parameters (BMI, total cholesterol level, triglycerides) were compared before, and 6 weeks after therapy switching.

Mental state and metabolic parameters before therapy switching: symptom severity 2 (delusion and negative symptoms); Metabolic parameters: BMI=38.7, total cholesterol 6.38mmol/l, triglycerides 2,32mmol/l. Parameters status after switching to ziprasidone: symptom severity 1 (delusions); BMI=37.1, total cholesterol 4.72mmol/l (in range), triglycerides 2.41mmol/l. The patient was ‘awakened”, with reduced body weight, sedation and negative symptoms.

Despite the persistence of central delusion themes, switching to ziprasidone improved negative symptoms and metabolic state.